Mc CY2006

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
TELL CONTRACTOR (INDIVIDUAL) NAME (print)) et A tL/ &) v 59-; CER7IFIC�pAATIONO /�t
r�'ELI. CONTRACTOR COMPANY NAME r( 54- /LJetc tin(.t,j (Iel PHONE,/ (gL 7ZSi1'YS SIB
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMIT,/
(if applicable) (ifapplicable)
1. WELL USE (Check Applicable Box): Residential Lys lyunicipal/Pubtic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: Nearest Torn: OG a Count BtN YO Topographic/LanUng
1—Wq. e CAfx ORidge ❑Slope slue;OFIat
(Sirceht Name. Numbers, Community, Subdivision, Lot No..p Curie) (check appropriate box)
Lalltudelbn gttie f It
3. OWNER: Lc72/S 41(f/1,l�ili+(CeiC
Address Sq Ape 6R,j CAfte ,t_L
CC I) Fort (stranN ) 2 87(42
City or Town Stale rip Code
Area code- Phone number
4. DATE DRILLED 4»7/0
5. TOTAL DEPTH: 72 C &j ,, / o
o we location
_5 �� e o N OSZ° 101'8(w
J (degreeshminuteslscconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D /00 ' IX, -
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 610"...
7. STATIC WATER LEVEL Below Top otcasing• 40 Fr. ,/Y® _ 7 2 C
(Use "+- if Above Top of Casing)
8. TOP OF CASING IS in Ff. Above Land Surfaces
*Top of casing terminated atfor below Ind surface requires a
variance is accordance with ISA NCAC ZC Ant
9. YIELD (gpm): 40 METHOD OF TEST /l/g
10. WATER ZONES (depth): 70 9pni e /et S-
c Amount 11. DISINFECTION: Type C ! f ( ff 02
12. CASING:
Depth
To
From D /0
From 107 To //
From //3 To //S'
13. GROUT: Depth
From To
From 0 To 2Z
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Ft.
Ft.
Ft
Wall Thickness
Di or Weight/Ft.
U 90 ``'
Q 0 %v
Material Method
Ft FL ,e( f Oin/OGL/
Diameter Slot Size Material ppp,,,,,,
FL in. in. p t
Ft. in. in. ealid4,Size Material / i7 ,5 e ,a,
DLO 6r4
Q2oS*t' fax /L-
ttA..Jt74P
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and conunon road names. ..
Ft.
Ft.
IN)
J
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION DARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
F PERSON CONS
Submit the original to the Division of Water Quality, Groan
27699-1636 Phone No. [phone], within 30 days.
UCTING THE WELL
DATE
water Section, 1636 Mail Service Center - Raleigh, NC
GW-1 REV. 07/2001

93)
WELL CONSTRUCTION RECORDS
North Carolina - Department of Environment and Natural Resources Divisionivof Water Quality - Groundwater Section
ou�a-
WELL CONTRACTOR (INDIVIDUAL)NAME (print) 9n ry 3UST la "�CERTIFICATIIOON # 7iiJ o
WELL. CONTRACTOR COMPANY NAME SOS31 eF- waLt. Vie; Ut9ty.toNE # �Zm7Zvf-r{,Sf/ 43
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential L3. Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI:
Nearcst Town: %f 4t10A) County A pt tc.
litSCOP" Addi riterCl
(Street Maine. Number , Commuunnity. Subdivision, Lot No.. Zip Cale)
•
3. OWNER: FO1.1 rvj( t-L.er-
Address 352E 5oSrAa hrasal
( Street or Route No.)
fillir(oru N c 287 S'Z-
ty or Town State Zip Code
738-4rn'
To-4rirFt.. Mr
JUG
From 9 T: DeTo tit Ft. / �iterLit
13. GROUT: Depth Material ethod
From To Et.
From_ To-n—Ft. Ili pP/
14. SCREEN: Depth Diank er Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
ea code- Plane flambe ��,,rvvlI
4. DATE DRILLED nit/rC 2 Z 06
5. TOTAL DEPTH: /ps
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LY
7. STATIC WATER LEVEL Below Top ofCasing:2j FT.
(Use"+' if Above Top ofCasing)
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): ,e) METHOD OF TEST A/%L
10. WATERZONES(depth): tqpikt 6 75
11. DISINFECTION: TypeeLOsCrA// Amount $O2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From 0
16. REMARKS:
1 DO HEREBY CERT HAT THIS WEL
CONSTRUCTION ST I`ARDS, AND T
Submit the original to the Division of Wa
27699-1636 Phone No. [phone], within
Size Material
NSTRUCTE
Topographic/La�ndf�e�tting
❑Ridge ❑Slope I�dalley ❑Flat
(check appropriate box)
3S •ti dg/7 zei pie of dinell tion
Oif r( / S$ 9 'c/
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fomtation Description
D/R>`Grot #LC
Awct
Ike 6e-A
DEPTH
From To
- ys
O
rJ
LOCATION SKETCH O•
Show direction and distance in miles from fj'east
two State Roads or County Roads. Include the road ---.
numbers and common road names.
2. tra f(�l.L
ORDANCE WITH 15A NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER
SON CONSTRUCTINCt THE -WELL
DATE
uality, Cr4indwati'r Section, 1636 Mail'Senice Center -Raleigh, NC
days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina - Dcpanment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
Wk:LL CONTRACTOR (INDIVIDUAL) NAME (print) tyn7 ti5J, C CERTIFICATiONf 2rra
'I ELL CONTRACTOR COMPANY NAME 3bc4(C€ L.,.)1 , r.SLC 1,9 PHONE a P�7Z46-yrlr$
STATE WELL CONSTRUCTION PERMITa 1
(if applicable) ASSOCIATED WQ PERMITS/
(if 8pp/ita lic)
1. WELL USE (Check Applicable Box): Residential I{X Itmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other D If Other, List Use
2. WELL LOCATIOth At
Nearest Town: J Qf: 0 N County Pik web-(/
/2 (r asses+- C 4Sr.41e D r
(Street Namc. Numbers. Community, Subdivision, Lot No., Zip Code)
3. OWNER: Mtc p Fro,c)y
Address te,m Rea rsir 44)
(Stan a Rime No.)
SitistAAn.>et $3C z I i7 7
Coy or Town State Zip Code
_)- 7913 - 7575
Area code. Plane number
4. DATE DRILLED "firC11 I O CO
5. TOTAL DEPTH; $ 6 S
6. DOES WELL REPLACE EXISTING WELL? YES i NO °
7. STATIC WATER LEVEL Below Top of Casing q0 FT.
8. TOP OF CASING IS (Use`*' if Above Top of Casing)
FT. Above Land Surface*
*Top of cuing teradoated atlor below land surface mains a
variance is accordance with ISA (CAC SC.0I1&
9. YIELD (gpm): ye METHOD OF TES, TA-id/a2 t
10. WATER ZONES (depth): 4/��A P /°t syo, e 3 be
4 So. 61 two ) asset, r >,jo LOCATION SKETCH
11. DISINFECTION: TypcCLO/CA/c. Amount g t Show direction and distance in miles from at least
G
)
Latitude/longitude source:DGPS°Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
O^ 1(o OrKe"
qs- t$7
9 2- 865-
e
8A-d S"tee
9ts4xJr
fV
12. CASIN
Wall Thickness two State Roads or County Roads. Include the road
From Depth or Wd�ft material numbers and common road names.
To FL
From O To —Ft.
Fron aC Ton Ft
13. GROLT:
From
Topo ic/Land setting
DRidge lope DValley °Flat
(check appropriate boil
Latitude/longitude of well location
3.5"6/IIM R7'it'q .Q76W
Weareesiminutesnaoods
Depth
To FL
Diameter
From O To io Ft.
14. SCREEN: Depth Dia
From To Ft.
From To FL_
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material Method
0
iPpq Posts
er Slot Size Material a
in- in.
in- in.
16. REMARKS:
0
u
DO HEREBY CERTIFY THAT THIS WELL BCONSTRUCTED
LL
CONSTRUCTION STANLftDS, AND THAT AC PY OFTHISS RECCORD HAS BEEN PROVIDED TO THE WEAC 2C. LL OWNER
SIGNATUI OF PERSON CONSTlUCFINGTHE WELL ,) DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Senice Center - Raleigh, NC
27699-1636 Phony No. [phone], within 30 days.
Gw-I REV. 07/2001

n
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (LNDIVIDUAL) NAME (print) &A//y h _ 9 U S �.
q� v 11 �CERTIFICATION # Z% 5G
mtELI. CONTRACTOR COMPANY NAME J�1S•�,LG wet L 0icl. Li tiea? PHONE # 4)2r.Ijsy,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential G✓MunicipalIPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name. Numbers. Community. Subdivision, Lot No., Zip Code) (chi' appropriate or box)
%Q[ 1�(� ` Latitude/longitude ofwell location
3. OWNER: 32(% IJ/'1 ,per, `� 35 ?8 nezo D8/' 59. 7891A/
Address (degreestmirmtes/secoads)
3S 3 / far iJa i:e i yt 1 Latitude/longitude source:OGPS❑Topographic map
(Stan w Route o )
!check boa)
DRILLING LOG
Formation Description
Q:iL7/elloScieerk
Nearest Town: /74'4y-) o N County
343 Gir,✓UAvr,) a
ge�ort yet e
in, or Toua State
g"�Z
(Rein � I�/ U ut a Zip Code
Area rode- Krone number
4. DATE DRILLED Z—J—oC
5. TOTAL DEPTH: 9 4 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0r
7. STATIC WATER LEVEL Below Top of Casing /2° 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 )a accordance with ISA NCAC ZC AI IS. WA"
9. YIELD (gpm): / METHOD OF TEST If f y
10. WATER ZONES (depth): /t/' f .itlit i %gip,.
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
From To
O- 8S
£C-'i2
11. DISINFECTION: Type flO i/ut
12. CASING:
Depth
From To
From /9 TO 9/
From Lj / To 13
13. GROUT: Depth
From To
From d To .0
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
from To
16. REMARKS:
Ft.
Ft.
Ft.
Amount e Q'Z<
Wall Thickness
Diameter or Weight/FL Material
9
I 9 9
Material
Method
FL
Ft meter / f t,ayoel
Diame'({er Slot Size Material
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 COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRRU�� cc ^�
Submit the original to the Division of Water Quality, Groundk3[etrftC �R�16elalail Sen
27699-1636 Phone No. [phone], within 30 days.
DATE
c Center - Raleigh, NC
GW-1 REV. 07/2001
MAR 08 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - DivisionLof Water Quality - Groundwater Section
W\T' 7ELL CORACTOR (INDIVIDUAL) NAME (print) A TJ.)3TI C�i
� Co , CERTIFICATION i
tl ELI. CONTRACTOR COMPANY NAME 3US%1 LL,(\I PHONE #
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERM&T#
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential 13 Municipal/Public 0 Industrial ❑ Agricultural ❑ Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: el kt) 4r4"
154 ORoo1c )_volt
FromZ To /02. Ft
From f Q2 To / bi/ Ft. _
13. GROUT: Depth aterial
From To Ft
From ti To -S Ft 1�''j}' /
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
County /11i (A ie lst
(Street Namc. Numbers. Community. Subdivision, tau No., tip Code)
3. OWNER: SC**Uemery
Address ISCJ 13rcae)je LCt4-C
/Street or Route No.)
C)LQ Apr" 1" C 2 9a7i 2.
_City or Town State Zip Code
(5a)- Nets 737o
Area code- Phone number
4. DATE DRILLED a-13 - 0 G.
5. TOTAL DEPTH: 30dr
6. DOES WELL REPLACE EXISTING WELL? YES NO 0
7. STATIC WATER LEVEL Below Top ofGa' sing. a. FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
'Top of easing terminated atlor below land surface requires a
variance in accordance with ISA NCAC ZC .61 I8.
9. YIELD (grim): 3METHOD OF TEST A' I f /S414/41
10. WATER ZONES (depth): _vl Gar 4. 00
`
Topographic/Land pttting
[Ridge ❑Slope )7Ma')ley ❑Flat
(chat appropriate box)
Latitude/longitude of well location
at
350 33 S44 u oa2•/e cj9'zW
(dtgees/minules(secondr)
Latitude/longitude source:❑GPS❑Topographic map
(chech boat
DEPTH DRILLING LOG
From To Formation Description
D- 6n D/got
ion' 7 j SA't overioe
75" $ 0 ies41 9 en.4/G✓6--
11. DISINFECTION: Type C (,o Q ; Ne Amount 48 07
12. CASING: WallThicknesS
Depth Dior Weight/FL MAlerial
From A To 82. Ft_�,LI/ 6 ad —
Method
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS
CONSTRI RTInn Via b DARDS, A `t L AT A COPY OF THIS RE
RECFIVED
MAISuQi &taiginal to
27699-1636 Phasic No. (4
Asheville Regional Office
Aquifer Protection
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 WAS CONSTRUCTED IN ACCORDA
A
WITH I5A NCAC 2C, WELL&/
BEEN PROVIDED TO THE WELL OWNER:
SIGN ' RE si PER3J*1 CONSTRUCTING THE WELL
DATE
the Division of Water Qua`(ity, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
19) 733-3221, within 30 days. GW-I REV. 07/2001

6. DOES WELL REPLACE EXISTING WELL.? .YES E3 NO li t-
7. STATIC WATER LEVEL Below Top ofCasing ,QC:, FT...
8. TOP OF CASING IS O Risc'v. ifAbome Top of Casing)
FT. Above Land Surface*
flop of casing tenataated attar below had notice requires a
variance is accordance with ISA NCAC 2C-I it •
9. YIELD (gpm): .2- METHOD OF TEST .g' I i1
10. WATER ZONES (depth):.7 70 it n:7 tog D
t I. DISINFECTION: Type Gibre=�Amount G otatt Z t>LOCATION SKETCH
1 CASING: T Show direction and distance in miles from at least
Wall Thickness iwo State Roads or County Roads. Include the mad
Dept` Una or We>gb4Ft_ IMa[uiai numbers and common mad names. m FroTo FL /r-
C �,er
From a To 12Z FL 10)4 ajp. --
4-14
From /2 , 2. To FL (oA atcrmal . f P ri Cjifi✓
13. GROUT:Ater.
MethodFrom To
FL
From 0 To_343FL e yps i
14. SCREEN: Depth Diameter Sim Size
Pefateral
From To Ft. in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Sire:..
From To Ft.
From. To FL
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prhR) D TUcERr1E'tcATIONad q l.� �
T gyp+)
wEL1. CONTS't
R,ACrOR COMPANY NAME J o �c E Ew P enxim
PHONE t` J
STATE WELL CONSTRUCTION PERMITS ,
ASSOCIATED WQ PERMIT,
(ifapplicahlei (ifappiicabk)
�ctcriu7
i i
1. WELL USE (Check Applicable Box): Residential OV Mtmiclpal/Public Cl Industrial O Agricultural C] Monitoring 0 Recovery 13 Heat Pump Water Injection ❑ Other El If Other List Use
2. WELLLOC4TION:
Nearest 74- wn: Coun
AVE(re tyIGC J-✓ .Ridgelat
aSlop Topographic/Land setting
realabt �$ ei f-c- L0� i't�115 Wm&apinquiateh �l u, (Sweet Name. Numb,az. cow.,mar. Subdivision. mm. Loa Na rola Coati '. 1"coa otitwkrIongiiude of well location
3s_ 3YmN Oil.° is- 233W
(degreedLatitude/longitude sotucef lOGPSOT opog[aphic map
nofitnrmbT q'Z. � Slx rip� ( DEPTH DRILLING LOG
o_From To Formation Description
Area code- Phone number
4. DATEDRILLED Z.-13 - o l lei
5. TOTAL DEPTH- So+''
j_fel roc
3. OWNER:
Address
0; ifs Acte-
rn
0
0
16. REMARKS:
I DO HEREBYCERTIF
CONSTRUCTION ST
RE OF PERSON
Submit the original to the Dhisio of Water Quality,
27699-1636 Phone No. (919) 733- 221, within 30 days.
.TTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
DS,AND Tii�. COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
ti&
undwater Section, 1636 Mail Sent= Center -Raleigh, NC
MAR 0 8 2006 GW-1 REV. 07/2001
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Neutral Resources- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (priat) apini 3 os4-;4 -
_ l F•CER77FICA170N? 2 In
WELL CONTRACTOR COMPANY NAME
5u4 cF W.G/.t„ Q ri ULI j.(C PHONE # ($2S 9ZYYsi/S
STATE WELL CONSTRUCTION PERMITS
tirapplicabte) ASSOCIATED bin) PERMITS
(ifap I�icable)
1. WELL USE (Check Applicable Box): Residential �l Municipal/Public El Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 II -Other, List Use
2. WELL LOCATION:
Nearest Town:il An O pl County
(e8 �c�Gt Sti
(Stott Name Rumbas. Commmmy. Sub&vismo, Lot No- Zip Code)
3. OWNER: 36).tcs P- An414-
Address to 5 t K;).1 wt Ltd 2 �
ar Rooter�
e o4. .Cy-
N
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C WELL
JSAND TF AT A C Y OF RECORD HASBEEN PROVIDED TO THE WELL OWNER
4441
• SIGNATURE OF
Depth
From To FL
From
Fro
13. GROUT_ Depth Material
From To FL
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVELPACK:
Depth ` Size Material
From To Ft.
From To FL
16. REMARKS:
�t [. -Cols Z o icrl
tU/T t-ty or Team Co- LF el a I zip Code
As cak. Phone number
4. DATE DRILLED /-V- Qco
5. TOTAL DEPTH: 2.2 5
6. DOES WELL REPLACE EXISTING WELL? YES O NO r
7. STATIC WATER LEVEL Below Top ofCasing gel FT.
8. TOP OF CASING IS ( (Use -+-ifAbove Top ofCaaog)
FT. Above Land Surface*
`Tap at easing tens anted at/or blow had surface requires a
variance is accordance with ISA NCACZCSJfa.
9. YIELD (gpm): /5 METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type cietewe Amount r� (02
12. CASING: Wall Thickness
Dimneta orWeightFL Material
Method
Ft.
Diameter Slot Sae Material
Ft is in.
Ft in. in.
Topo dLand setting
ORidge D)Slope OValley OF1at
intend appropriate boa,
Latittgde/longitude of well location
353s4((N 8z oy 2400 w
(demeethairadeshscoads1
Latitude/longitude sourccOGPSOTopogrdphic map
(weds boa)
DEPTH DRILLING LOG
From To Formation Description
ac-2Zr tiadx„tie
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads, btclude the mad
numbers and ., ...,. names.
i as nO ✓
�^M
f
1 DO HEREBY CERTIFY T
CONSTRUCTION STAN
THE WELL DATE
Submit the original to the Division of Water Quality, Group
27699-1636 Phone No. [phone], within 30 days.
enter -Raleigh, NC
GW-I REV. 07/2001
MAR 08 2006
Asheville Regional Office
An. fifer Protecting,

3- OWNER: �7 �V6. , ,
IStrcct R
Latitude/longitude source:OGPSOTopogr�aphic map
ar autc No.)
- Imct:boa) -
DRILLING LOG
Formation Description
2. WELL LOCATION:
Topograp 'dLand salon
Nearest Town- Q rt : K (
4 c ___ County YU S Gt . tG O$�,
Ridge e OValley fr7filat
(Street Name
. umbers. Community- Subdivision, Lot No., Zip Cade) (check appropriate heal t:i7
Latitude/longitude of well local n
Address
II. DISINFECTION: Type.�/LAI� Arnount
12. CASING: Wail Thickness
Depth Diameter or Weigh/FL
To FL
To Ft. — (Jo
To_2l Ft. 1 7y a A
13. GROUT: Depth Material d
- From To FtMethod
-�—�--
To 7� FL
Depth Diane��er SItR otSize
To FL
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Nf\Prna NG 2 67��
Cry or Town Stye Zip Code
(828 )- izv-gsgi
Area code- Phone number
4. DATE DRILLED_ 1- 4 — Oro
5. TOTAL DEPTH: 2 8 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EY
7. STATIC WATER LEVEL Below Top of Casing
/ (the "+" itAbove Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface'
`Top of easing terminated aUor below hand surface requires a
variance in accordance with ISA NCAC 2C Silt
9. YIELD (gpm): /0 METHOD OF TEST Mlle
10. WATER ZONES (depth): /Oran e.ref 2 dO
From
From CO
From %O
From tO
14. SCREEN:
From
f 0 J
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (4YDIVIDUAL) NAME (print)
/1 +Zs-/ Sit c f-i c.F cERnFtcnnoN a Z/ ,So 'AELI. CONTRACTOR COMPANY NAME ZUS-h,GF'
F( LA ti(iweVtt` PHONE a fR41 7241-95-"P
STATE WELL CONSTRUCTION PERMIT,'
(if applicable) ASSOCIATED WQ PERMIT',
(if applicable)
1. WELL USE (Check Applicable Box): Residential O-MunicipalPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
LAB
36e C fA ofiA
I6. REMARKS:
in. in.
FL in. in.
Size Material
DEPTH
From To
(degreesrminutesiseconds) f']
CCU- 7 Y /Zeck.
7Yl-_ z r Gptifx917-e
LOCATION SKETCH
O 2 Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Material
a
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WI0 are
TH ISA NCAC 2C, WELL
CONSTRUCTION DARDS, AND THAT - • Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1�62SIGN RE OF PERSONCONSTRU�THEWELL DATE
Submit the original to the Division of Water Quality, GrouRECEr u
Ea 27699-1636 Phone No. [phone], within 30 days. Mail Se ice Curter -Raleigh, NC
GW-1 REV. 07/2001
MAR 08 2006
Asheville Regional Office
Af)I lifAr Prnta..+;a..

4M_.
WELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and /Natural Resources- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Ur�I `9 St:5'L1 Lti-
CERTIFICATION it 2l
\ \-ELi. CONTRACTOR COMPANY NAME
SFATE WELL CONSTRUCTION PERNITB
ASSOCIATED WO pERAtITO
(if applicable) (if applicable)
PHONE it (t1¢') ?240
1, WELL USE (Check Applicable Box): Residential [D/i lunicipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: /%%A¢rr6 it../ County to e46 tie
(Street Name. Numhcrs, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Mftfa.L dg; 43 ;j9 %'SC,44e
Address E. ,416 i g, 5,k lr
(Street or Route No,)
poi7'L ASe/3.t A1;.'
Few? /ZtK NC a 6 73/
[a Ciiy or Town State Zip Code
V52Bi- r 3., 7/V7 S rvct4-`1.96Z
Arco code- Phone number
4. DATE DRILLED o2- 7.-
5. TOTAL DEPTH: 4407
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IW
7. STATIC WATER LEVEL Below Top of Casing: kO FT.
(Use "+" if Above Top of Casing)
3. TOP OF CASING IS f FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance is accordance with I5A NCAC IC .011g.
9. YIELD (gpm): la METHOD OF TEST 4 i
10. WATER ZONES (depth): Gag /041 0(11.1 130
I1. DISINFECTION: Type (CO2t'Vt' Amount it 2
12. CASINO:
From To
Front O To 2 S
14. SCREEN: Depth
From To _
From To Ft, in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Wall -Meknes
From 0Depth Dim - Kier or Weight/Ft.
To so FL Ca Y 46
From R t To J Z/ Ft ('/ g
From_ / To i a Ft. (�7 cj deg?
13. GROUT: Depth Material r Method
hod
Ft.
Ft. `--vDe
CC-
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appmpriatc box
Latitude/longitude of well location
X° 7 nI /09°Sb `i414►Y
(degeew/mtnut&seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
- 120
IZ� tteS
0112 41- 2 12 . tk
yrQ id P-Un c
0
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
Material numbers and common road names. ' 1.04- / Z
t� J e
e y
Diameter Slot Size Material
Ft. in. in.
in.
Material
Lt_ t')v'4LLi ytr
4
0-9\-'91
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STAND RDS, .AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r 1Lv SIG
URE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-i 636 Phone No. (919) 733-322,, within 30 days.
GW-I REV. 07/2001
a3A13O3a

RESIDENTIAL WELL CONSTRUCTION RECORD CV 3 2 9 613
North Carolina Department of Environment and Natural Resources -Division of Water Quality
A _ WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR
Wei Contz a IndMdS) Name
' K (aell QrdIdn1(
Well Contractor Company Name
STREET ADDRESS /3a n'gr r%r'nc f I)
.Y1 "5u; e yr. 'RV 17 i
City or Town State Zip Code
(.70u} $53-1/690
Area code- Phone number
*2. WELL INFORMATION:
SITE WELL ID Wet applicable)
STATE WELL PERMIT#(rfepplicable)
DWG) or OTHER PERMIT WIappficable)
WELL USE (Check 2bte�,Box): /ReesidentiS Water SupplyC]�
DATE DRILLED �Jll !- 10,, 0
TIME COMPLETED a (A J AM 0 PM
3. WELL LOCgTION:
CITY:
eLo
COUNTY P9
(Street Name, Numbers, Canmtnity, Sthth4san, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Sklpe ❑Valley ❑Flat ❑Ridge ❑Otha
(dads appropriate bad
LATITUDE 3
LONGITUDE
May be in degrees,
ramrod, seconds a
in a decimal format
Iatitude/longitugesotace: ❑GPS Topographic map
(bcaten of wet must be shown on a USGS topo map and _
attached to This form if not using GPS)
4. WELL OWNER " _
OWNER'S NAME k7 � _il5u1 1 fir y" /�
STREET ADDRESS 2�*'5 G . Math c /, SC.I)
incolhhbt, AC eRSG09—
City or Taws State Zip Code
Area code - Phone number
6. WELL DETAILS: f �
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO L4'
a WATER LEVEL Below Top of Casing: CO FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS f ' C FT. Above Land Surface'
'Top of casing terminated Wor below land surface may require
a mace it acwardance with 15A NCAC 2C .0118.
e. YIELD (gpm): /0 METHOD OF TEST 57G{.rrl,`jal
f. DISINFECTION: Type C61. /45 Amount
g. WATER ZONES (derp1 :
From 340 To .3)( From To
Fran To From To
Fran To From To
6. CASING: Thidmess/
Depth Diameter W[•
From 0 To Ft S4/
From To Ft
Fran To FL
7. GROUT: Depth /' - Material -!� Method
From () :To)c% Ft. Odn( real" PDC/-
From To Ft
Form To FL
Ib-
8. SCREEN: Depth Di Slot Size Material
Fran To Ft in. in.
Fran To FL In. in.
From To Ft in. in.
9. SAND/GRAVEL PACK
Depth '� Size Material From i To r Ft
Front To
From
10. DRILLING LOG
From To Formation Descripfj
6- ‹
1
11. REMARKS:
cc-217 7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCDCN STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG 14914.144CeillF1 SWELL CONTRACTOR
V
r•
er
PRINTE5NAME OF PE SON STRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-la
REv. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Eavironnent and Natural Resomees- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contract r (IndhMual) Name
Camp's Well & PumD Co. Inc
Well Contractor Company Name
STREET ADDRESS P
0 BOX
Ellenboro NC
City orTann State
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SRE WELL ID #(It apitM.le)
429
28040
Zip Code
STATE WELL FERMR#(YappNmble)
DWQ a OTHER PERMIT #Qf applicable)
WELL USE{Check Applicable Box): Residential Water Supply❑
DATE DRILLED to. aG D b
TIME COMPLETED I O. a 1)
3. WELL LOCATION:
CITY: `�1 &Iv try,
O b1 PLC,
AMC)' PM❑
COUNTYI\ LnI%Q Dot
(Street NameNumbers, Community. SabdiNsion.Lot No., PareenIP Code).
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley and Ridge ❑Other
Mhem eppropdatabw)
LATITUDE _LE 39 9a5 4
LONGITUDE i L �a
Latitudelongitude source: 4GPS °Topographic map
(bcatbn ofwelmustbe shown on a USGS topo map and
attached to this form Ifnot using GPS)
4, WELL R FAT NV h /J
OWNERS
NAME o � Q Ifri QGtIGC
May be in degree,
minutes, seconds or
in a decimal format
STREET o °frt
Clty or Tam
Area cede - Phone number
•
S. WELL DETAILS:
a. TOTAL DEPTH: /•S
b. DOES WELL REPLACE EXISTING WELL? YES p NO 0
c. WATER LEVEL Belo* Top d Casing: 14-0 FT,
(Use •d_IAbove Top d Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surfacer
. 'Tap d ash° terminated aVar below land surface me? requhe
a variance In aaadance with 15A NCAC 2C .0116.
e. YIELD(gpm): 0 METHOD OF TEST A.lr
r
f. DISINFECTION: Type chlorine Amount 2 Cap
g, WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASINO: Thickness/
•De D alneter Weight Material
Front 0 To�Ft Di SDR21 ' PVC
From To Ft _
From To Ft.
7. GROUT: Depth
Fran 0 To 20 Ft Sackrete Hand
Material Method
From To Ft.
From To Ft.
a. SCREEN: Depth Diameter . Slot Sim .Material
From To Ft In. in.
From To Ft In. In,
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Fria, To Ft.
Fran To Ft
From Qo Ft
10. r
DRILI:INGLOG
From7`l pia (le l
Fonnatbn Description
79 JI.S— ODi'tso/iciekted rock
11. REMARKS:
r
I DD FEREBYCERIa'YTHAT'IMS WELL WAS OONSIRUCIED NACWRDANCE WITH
ISA MAC 2C, WELL CONSIRUC 1ON STANDARDS, AND 1HATACOPY OF rla3
RECORD HAS BEEN PROJWEDTOIHE WELL OWNER.
eg������ U) %'c21-orb
SIONpTURE OF CERTIFIEDCWELLLCCONTRACTOR DATE
James W. Camp
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. (91917334015 ext 568. .
Form GW-1a
Rev. 7/05

AD
North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Se- ction
1636 Mall Service Center - Ralelgh,N.C. 27699-1636-Phone [phone]
329454
3 OWNER
Andress
WELL CONSTRUCTION RECORD WELL CONTRACTOR. 7 0/tW d fl A,'c 4 / Ns
WELL CONTRACTOR CERTIFICATION # : z5'G ?
STATE WELL CONSTRUCTION PERMIT # :
WELL USE (Check Applicable Box): Residentialkl Municipal ❑ Industrial ❑ Agricultural El Monitoring En
Recovery Heat Pump Water Injection ED Other n If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
Nearest town /11in' a'-1V County
9r /e/&s Woo el /Zd
112or.A.,G(L.
Road Name and Numbers Community, or Subdivision and Lot No )
Grp AY /V,gCVN9
96— /dcC wa o6 it d
NIP
(Street or Route No.)
"/Pbyte N ,yLr
City or Town State
4 DATE DRILLED '-3€' 'O j
5 TOTAL DEPTH in
6 CUTTINGS COLLECTED YES ❑ NO©
DOES WELL REPLACE EXISTING WELL? YES
B STATIC WATER LEVEL Below Top of Casing: FT
(Use "4" if above Top of Casing)
9 TOP OF CASING IS /7 q FT. Above Land Surface'
=asino terminated at/or below land surface requires a variance in accor-
dance with '5A NCAC 2C 0118
EILD (GPM1 /D METHOD OF TEST 13f3/1-67-
11 WATER ZONES (depth):
2t7r2
Zip Code
DRILLING LOG DEPTH
From To Formation Description
12 HLORINATION: Type 40:N Amount it b If additional space is needed use back of form
13 BASING Walt Thickness
Depth Diameter or We nt/Ft Material
-rem To r3 G Ft 4 27,4 g/ asrei, LOCATION SKETCH
(Showdirection and distance from at least two State
rrnm To
Roads, or other map reference points)
T,
om To t
14 GROUT r
Depth Material Method C
'ram To Ft 0
L -r1 1
Gmm To Ft r
15 SCREEN. D;t->
Depth Diameter Slot.Size Material CO z..<
"
-.nrr To Ft in in " _,
0
ca
"om _ To Ft in in rn
F"nm To Ftin in. t—�
1E SAND/GRAVEL PACK:
Depth Size Material
,gym
:.n n _
1' REMARKS.
To Ft
To Ft
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
SIGNATUREOF �RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99
r1.%1 6-3o-°u

age
North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mall Service Center - Ralelgh,N.C. 27699-1638-Phone [phone]
329453
WELL CONSTRUCTION RECORD WELL CONTRACTOR. IZ5h24/ic LOA/L i. ii✓S
WELL CONTRACTOR CERTIFICATION # : ad/fG
STATE WELL CONSTRUCTION PERMIT # :
WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 17
Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use:
2 WELL LOCATION: (2-low sketch of the location below) ✓�11
Nearest town qF ren Co ntv- /b1 f/O L.i e- 4
ns5/✓i`N' Ccwc¢ Cot bc& i3d
(Road Name and Numbers. Community. orSubdivis,on and Lot No.) DRILLING LOG DEPTH
3 OWNER JDwNy DvCh AHn.v From To Formation Description
Acdress. ,f '
33 /✓i C.44-!{ re—kg/Aar Lid
(Street or Route No
A,, %t [ /YG a875;1
City or Town State Zip Code
4 DATE DRILLED 4-14-e4
5 TOTAL DEPTH /6r
6 CUTTINGS COLLECTED YES ❑ NO[71
7 DOES WELL REPLACE EXISTING WELL? YES D NO{
9 STAT!C WATER LEVEL Below Top of Casing. 2.3 FT.
(Use "4" if above Top of Casing)
9 TOP OF CASING IS 20" FT. Above Land Surface'
'Top of Lasing terminated atfor below land surface requires a variance in accor-
dance with r5A NCAC 2C. 0118
10 VELD (GPM): At METHOD OF TEST RA%L.d.l.•
11 WATER ZONES (depthl
46
HL ORI NATION: Type % N Amount �' If additional space is needed use back of form
la CASING. Wall Thickness
Depth Diameter or Weight/Ft Material
From To Op Ft G 22• C PAsri>-ic_ LOCATION SKETCH
r rem To t (Show direction and distance from a' least two State
▪ m To rt
14 GROUT
Roads. or other map reference points)
O
Depth Material Method
rom To Ft -
Frnrn To Ft C 'r
15. SCREEN r— -"
Depth Diameter SIot.Size Material co - r-r+,i
..d <
='cm To Ft in In - _ •' tV
From _ To Ft in in. o cl--i
cr.
P-om _ To Ft in in.
16 SAND/GRAVEL PACK:
` Depth Size Material
To Ft
▪ -om 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.
��� l�iavLt G '.24 -c6
FOR OFFICE USE ONLY
Quad No.
Serial No
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Seci(oii'_v
1636 Mall Service Center - Ralelgh,N.C. 27699-1636-Phone [phone] 2
WELL CONSTRUCTION RECORD
WELL CONTRACTOR- J/OXik/ei %%s+' z-H i eVS
WELL CONTRACTOR CERTIFICATION # : a6-4
STATE WELL CONSTRUCTION PERMIT # :
"JELL USE (Check Applicable Box): Residential Municipal E Industrial ❑ Agricultural U Monitoring
Recovery in Heat Pump Water Injection ❑ Other❑ If Other, List Use:
2 WELL LOCATION: (Show sketch of the location below) ,vf
Nearest town ^1/1 h i 0 iv County / •, CROW CL L
999 C3/« Coo if DA
,Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3 OWNER /isaSs 4oe1$'J 4 /%03" From To Formation Description
Aodress 999 4v'At co 0 i D%-
reef or Route No.)
'WA4'aiv lyc. ,78�5'2
City or Town State Zip Code
4 ^ATF DRILLED - 4- G L
'I -.'AL DEPTH Sir
CUTTINGS COLLECTED YES ❑ NO[j
- DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
• STATIC WATER LEVEL Below Top of Casing: /2 FT
(Use "." if above Top of Casing)
2 Tr,c (DP CASING IS FT Above Land Surface'
n' rasing terminated atror below land surface requires a variance in accor-
dance with ' 5A NCAC 2C 0118
1C YEILD (GPM): O METHOD OF TEST
11 WATER ZONES (depth):
I
12 CHLORINATION: Type H77" Amount ' " If additional space is needed use back of form
CASING
t nm
Wall Thickness
Depth Diameter or Weight/Ft. Material
a Ac �yq snc LOCATION SKETCH
(Showdirection and distance from at least two State
Roads. or other map reference points)
- orr
Pfi IT
To a D Ft
To nt
To
O
Depth Material Method <
To Ft O
To Ft C Th
r-
1F SCREEN _ >0
Depth Diameter SIot.Size Material CO f-ri'.'
To T' in in .. rN ^-
=-om _ To Ft in in _. o Ch_:
°-om _ To Ft in in
6 SAND/GRAVEL PACK: -%
Depth Size Material
Fro To Ft
-n To Ft
17 =EMARKS:
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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12r99

North Carolina Department of Environment and Natural Resources -Division of Water Quality-Groundw&L4 ec'!ion
1636 Mall Service Center • Ralelgh,N.C. 27699-1636-Phone [phone]
322-450
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /al e141S 12h %s• �. J
WELL CONTRACTOR CERTIFICATION # : d o 4 4
-- STATE WELL CONSTRUCTION PERMIT # :
' WELL USE (Check Applicable Box): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitorinc ❑
Recovery in Heat Pump Water Injection n Other ❑ If Other. List Use:
,r✓ELL LOCATION- (Show sketch of the location below) �. C o cu 4 L
Ne e t toy /vi/Qh so ?V County i"'
/b1 Vfixr. LANE /Vsba.2Si6/
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3 OWNER Pow a-44 &At ot, From To Formation Description
Acdress ¥l 0A DAB. r ,=AAM Pd
/Vy6 a.s RA/St73� Hou/VA, th 55
City or Town State Zip Code
4 DATE DRILLED -- 0
5 TOTAL DEPTH / 0 3
6 CUTTINGS COLLECTED YES ❑ NO©
DOES WELL REPLACE EXISTING WELL? YES NO®
;TATIC WATER LEVEL Below Top of CasingS/,y FT .
(Use "f' if above Top of Casing)
TOG OF CASING IS /rt FT. Above Land Surface'
lop or rasing terminated atlor below land surface requires a vanance in accor-
dance with 15A NCAC 2 0116
'C YELD (GPM)_ Yr METHOD OF TEST a/1/47I2-1=
WATER ZONES /depth)
-=.HLORINATIONM Type /NrA`- Amount / h� If additional space is needed use back of form
13 CASING-
rorr
r •om _
rn
14 GROUT
Depth Diameter
o O Ft
To °t
To Gt
Wali Thickness
or Weight/Ft. Material
z7, t �wSPr2 LOCATION SKFTCH
(Showdirection and distance from at least two Sate
Roads. or other map reference points)
Depth Material Method
r-om To Ft
°-om To Ft
15 SCREEN
Depth Diameter SIot.Size Material
`.a^ To F' in in
=-om, _ To Ft in in.
•nrn _ To Ft in in.
'C. SAND/GRAVEL PACK
Depth Size Material
'-nrr To Ft
' rom To Ft
17 REMARKS:
N
0
o
rn
r-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH'ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No.
Serial No
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

TIME COMPLETED /„1i00 AMC PMV
3. WELL LOCATION: f r �j'�y
1�/,
CITY: 'AKOA. COUNTY / 1 N°, ll
. Lat No.. Parcel. Ze Cade)
TOPOGRAPHIC / LAND SETTING:
°Slope °Valley ❑Flat Wft'tdge ❑Deter
(check epprawiata box)
LATITUDE ,,,LS
1. WELL CONTRACTOR:
Ashley T. Moretz
Well Contractor (Individual) Name
Moretz WA11 frilling
Wcb Contractor Company Name
STREET ADDRESS 611 9 HWY 10 WeSt
Hickory NC 28602
City ay Town State
(704)- 462462-13 _
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(it appienblc)
STATE WELL PERMITS@ applicable
D WQ or OTHER PERMIT S(8 applicable
WELL USE (Check Applicable o - Residentitd Wator Supply
DATE DRILLED
RE DENTIA.L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Re
sources- of Wazcr Quality
WELL CONTRACTOR CERTIFICAT ON A Q
Zip C
Aire* kl� }� -202Z
(Street alarm Numbers. Comafund. `wIDdl+balal
L g /
sof3rw'�
LONGITUDE $ s9W
Latituddlongitudeurce; PS OTopographic Map
((catbn of asp must be shown on a USGS tope map and
attached to this Porn lnot uafng GPS)
4. WELL OWNER
OWNER'S NAME ��IGI 7Vp1 hiAte-5
�,a(
STREET ADDRESS 4 i& f-�40��� A..
D 4
� A, s
1.
City own State Zip Code
May be in degrees,
minute, seconds oe
ins decimal Emma
Area code- Phone number
5. WELL DETAILS: � a. TOTAL DEPTH: 1r7/
b. DOES WAC
WELL REPLACE EXISTING WELL? YES/ NO ❑
SO FT.
c. WATER LEVEL Sepw Top of Casing.
(Use 1+1 a Above Top of Casing)
d. TOP OF CASING IS FT. Abe Land Surface'
'Tap of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): T_i___ METHOD OF TEST Irr Li T
f. DISINFECTION: Type
g. WATER ZONES (depth).
From ia0 To /30
From © To O
Prom. 7o
6. CASING:
F
From p To ` Ft.
From�T To
Amount
To
To
To
Depth
/' ^ �a{r{yp� �Thhiic�okklIe7ss/
To,Aia—c+f1L�.r a,
FL
Frpn_
From_
Front
Ft.
A`
7_ GROUT; Depth Material
Fan, OZ✓ To Ft.�jq/
�/ To Ft 2
From To FL
S. SCREEN;
From
From
Pram
9.
rat
Memod
Diameter Slot Size Material
Ft. in,
n.
in. _____ _ n.... f•r
SAND/GRAVEL PACK:
Depth Size Malarial
From
Fr
From
10. DRILLING LOG
From T' Fojmat1r Description
J Q '« Jp0c'
11. REMARKS:
0
Cl
I CO HEREBY C6RT¢YT4AT THIS WELL WAS CCNSTRUCTE, X ACCORPAtce WITH
SSA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OP This
RECORD HAS Bf6N PROVIDED TO THE WELL OWNER.
// o2 1319.6
SIGNATURE CSC T(FIED WELL CONTRAC70 DATE
9.5
PRINTED NAMED P,R$ON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall service Center — Raieign, NC 27689-1617 Phone No. [phone] ext 568.
Farm GW-1a
Rev. 7/05
Ed WH£t':60 900E 80 '-zdti
2E2TE917170L : '0N XHd dWIld '8 103M Z1321014 : WOLId

' ?RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Reswums- Division of Water Quality
•
WELL CONTRACTOR CERTIFICATION g 21 3 8
t. DISINFECTION: Type chlorine Amount 1 M. Ci-t p
g. WATER ZONES ):
Fran To . From To
Fan To From To
From To From To
6. CASING: Thickness/
Depth y Diameter Weight
•Front 0 _To '7 FL• _ e�tR21 • P
From To Ft
From To .Ft,
7. GROUT: Depth Material Method
FrortS___To 20 Ft, Sackrete Hand
Fran To Ft
Fran.,„._To Ft
.3269 fir°
1. WELL CONTRACTOR:
James W. Como
Well Conhactar.(IndMdual) Name
Camp's Well & Pumo Co. Tnc.
Well Contractor Company Name
STREETADDRESS P O BOX 429
Ellenboro NC 28040
CRyorToan Stale Zip ode
(828} 453-7322
Area code• Phone number
2. WELL INFORMATION:
SITE WELL ID M it applicable)
STATE WELL PERMITM(y applicable)
DWQ or OTHER PERMIT M(H applicable)
WELL USE (Check Applicable Bat): Residential
rf
DATE DRILLED ` - / f��rr'J
TIME COMPLETED I ' y S
AMC) PMQY
3. CITY:
WELL LOC pile joD COUNTY /r CL Vie- II
TTNElerN)oCcL I)r, off Cemetary Rd.
(Sheet Nana. Number, Community, SubdMslen,.LotNo., Pa,ve421p Cone)
TD OGRAPHIC / LAND SETTING:
lope DValley OE N DRIdge ❑Other
Ow* RPprwm+tit, 1
LATITUDE SLe `t.3• t1D.
LONGITUDES if 54 .6 4.q &
Latitudellongitude source: OOPS OTopographic map
aeembn ofwe! must be o this lam / shown on a g GPS) GS topo map and
4.WELLOOWNER OWNER'S NAME ,� ,
A S+I K 4alA) I it S
I May bean
1
mlmnp, sewodsor
in a decimal !neat
STRE ADDRESS
Veto NG 2814l
City or To 'n State Zip Code
Area�code - Phone number
5. WELL DETAILS: 0
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES fa NOX
c. WATER LEVEL Below Top d Casing: b FT,
(Use W 11 Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface'
'Top d easing terminated aUor below lend surface may rogttlro
a valance In accordance With 15A NCAC 2C .0118.
e.YIELD (gpm): —METHODOFTEST acre
9. SCREEN: Depth
Fran To_
Flan_ To
From To
Diameter Slot Size .Material
Ft. M. In.
Ft In. In.
Ft In. In.
9. SAND/GRAVEL PACK: Depth Size Malarial
Fran ' Try Ft
Frahm ___To Ft.
Fran_,�_T•o :. Ft
19. DRILLING LQG
From To.
0 • qg
Formation Deseripdon
Clay , San
•
q$ 305' • flM'01idat&J ror.k
JUN 06 2006
11. REMARKS:
m
Try
a...1.1
n
'D.. rat n'
rV
m
r--`
WEILWAS
lir
CE WIN
WA MAC 2C. WELL CONSTRUCTION STANDARDS,A CONSTRUCTED A� 7 •
RECORD HAS BEEN tRovIDEDTOTHE WELL OWNER
0 Pea)Li CAMP
5 l oG.
Si RE OF CERTIFIED WELL 'CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit
7 Ma I Service Canter - Raleigh, NC 276991617 Qualityvision of Water honeryNo. 9 9) 733 9 6 ext 5Information Mgt.,
Form GW-la
Rev. 7/g5

RESIDENTIAL wELL CONSTRUCTION RECORD
North Carolina F+ a Department of Environment and Natural Resources- Division of Water Quality 6 9 3
WELL CONTRACTOR CERTIFICATION g 21 3 8
1. WELL CONTRACTOR:
James W. Canto
Well Contractor (Individual) Name
Camp's Well & Pumo Co Inc
Well Contractor Company Name
STREET ADDRESS
P 0 Box 429
Ellenboro NC 24040
City or Town State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Ot applicable)
STATE WELL PERMIT#(aapplicable)
DWQ or OTHER PERMIT #{If applicable) _ /
WELL USE (Check Applicable Box): Residential Water Supply IV
DATE DRILLED 5" I - I'
TIME COMPLETED 3 4'5 AM ❑ PM IY
Zip Code
J. WELL LOCAT
ION:
CITY:N
COUNTYI am —VI
n� a
l;Yana j%;e.W Peaks r )-Df 6
(Sheet Name. Numbers. Community. SubdMslon, I.ot No.. Pame1 Zip Code)
TOPOGRAPHIC / LAND SETTING:
&Paope OValey OFlat DRidge OOdmr
(check apWnOriamb?x)
LATITUDE . 5" 34. )SSIV
LONGITUDESl_3l± 6 to
Latitude/ongitude source: PS OTopographic map
(location of wel must he shorn on a USGS topo map and
attached to this form not ushg GPS)
4. WEU. OWNER I n
ei
STREET ADDRESSNt ! I C) , �" Cn
ofBPI &39
IttcVarr [�L 2 SS(no3
City or Tan State Zip Cede
IMay be. In derma,
minutes, seconds or
in a decimal bnnat
Area code Phone number
5. WELL DETAILS: A
e. TOTAL DEPTH: 0 Li-5
b. DOES WELL REPLACE EXISTING WELL? YES NOX
c. WATER LEVEL. Seim Top of Casing: - 40 FT.
(Use If Above Top d Casing)
d. TOP OF CASING IS 1 • FT. Above Land Surface'
;Top d casing terminated etor beim lend surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): ta.L.,_ METHOD OF TEST al r
f. DISINFECTION: Type chlorine Amount
g. WATER ZONES ):
Ram To t'10 From To
From To Frorn To
From To From To
6. CASING: /� } ate Thickmssl
From 0 ToDeDb� r SDWeRh21 PVt C
Ran To Ft
From To .Ft
7. GROUT: Depth
Material Method
From_9_ To 20 Ft Sackrete Hand
Ran To Ft.
Front__ To Ft
8. SCREEN: Depth
Fran To
From To
From To
Diameter Slot Size .Material
Ft in. In.
Ft. In. b.
Ft In. in.
9. SAPID/GRAVELPACK:
Depth Size Material
Fran To Ft.
Ran To Fl.
Fran To Ft
10. DRILLING LOG
Rom To
0 . 75
7s. 4s
Formation Descriptian
ala1, S&td
/ Ovzso l i dated
JUN C 2B05
11. REMARKS:
1<
rc
1aDOACORDANCE W111.1
NCAC 2C, WWELLLCCOTMNSTRUCTIOTHIS W STWANDARDS, ANDDTHATACII COOPYY WNW
RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER.
AT RE FCERTIFIED'WELti'CONTRACTOR DATE66
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit
I Servl original
Center- Rai igh, NC 27 99. 6117 Qualitye Division of Water h within 30
(9 9days.33 9Attn: ext 568.«on Mgt,
Form GW-la
Rev. 7/05

City or Tam State
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 80t applicable)
STATE WELL PERMFV#(aapplicable)
DWQ a OTHER PERMIT M(If applicable)
WELL USE (Check Applicable Bad: Residential Water Supply IV
DATE DRILLED 5 -0 6
TIME COMPLETED .Jr. 7 AM 0 PM[V
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION */ 2138
3269 72
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (individual) Name
Camp's Well & PITmD Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
Zip Code
3. WELL LOCAT Oµ�^ l
CITY: N.4 D COUNTY Mr-LZ L ki
i4ike✓ RA. off ,u
(Street Name, Numbers, Canmunity, SubdMsion, Lot No., ParceL.7Jp Code)
T?POGRAPHIC / LAND SETTING:
krSlope oValley 0FIat ORidge ❑Other
(check appropriate boe)
LATITUDE E.' 773• �`�"�
LONGITUDE,. Lc 52•E/ 3
Latitude/longitude source: 1�OPS ❑Topographic map
(bcatbn of we/must be shown on a USGS topo map and
attached to this form 1 rot ushg GPS)
May be in degrees,
minutes, woods or
in a decimal tonne
4. WELL OWNER 'I
OWNER'S NAME Q-
STREETADDRESS O-19"-
Ru tiet-e tb rt
City or Tam State
C(een-)ea I ecnst
Vet Tr✓0.ce.
Ni C >Z£e)39
Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: �'d�
b. DOES WELL REPLACE EXISTING WELL? YES/Ep NOA
c. WATER LEVEL Below Top of Casing: 7 ?5 FT,
(Use'+' 0 Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Top c( casing terminated age below land surface may require
a variance N accordance with 15A NCAC 2C .0118. "J e. YIELD (gpm): © METHOD OF TEST A 1 r
f. DISINFECTION: Type chlorine Amount 1 la cui
g. WATER ZONES depth):
From To �2a30_ From To
From To From To
From To From To
6. CASING: Thiiccleess/
Weight Material
PCFran ITolea Ft 6er
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From . To FL
8. SCREEN: Depth Diameter Slot Size .Material
From_ To Ft. In. In.
From To Ft In. in.
Fran To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
Fran To Ft.
From To Ft.
From ... To FL
10. DRILLING LOG
From T�3
0� `66
Formation Description
a gos Germ.,a,S 9
0
0
--t
.r. emrrl
?sir
JI IN 6 2006
11. REMARKS:
Orr
1 DO HEREBY CERTFYTHATTHIS WELL WAS OONSTRUCIED IN ACCORDANCE Wmr
1SA NCAC 20, WELLCONSIRUCDON STANDARDS. AND MAYACOPY OF TNIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I RE JF? RTI CAL CO
(9• E
SI T OF CERT FIED WELL O TRACTOR DATE
James W. Camp
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 566.
Form GW-la
Rev. 7/05

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM Page / or 1L
Q Ca fa
0408
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - CERTIFICATION Section ON n 25SS
WELL CONTRACTOR (INDIVIDUAL)NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. HONE WQ 4ERMITNE # (704) 77
STATE WELL CONSTRUCTION PERMIT it ASSOC(ifapplicable)PE
(if applicable) El
1. WELL USE (Check Applicable Box) : Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION.
Nearest town: NEBO
BIGGERSTAFF LOOP RD
County McDOWELL
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
(degees/minuteslseconds)
3. OWNER HORTON HOME OF RUTHERFORDTON
ADDRESS 342 HWY 74 BYPASS Latitude/longitude source: El GPS ❑ Topographic map
DEPTHDRILLING LOG
NC 28139 From To Formation Description
State Zip Code 0 65 Clay
(Street or Route No.)
RUTHERFORDTON
City or Town
828-287-3366
Area Code - Phone Number
4. DATE DRILLED 4/24/06
5. TOTAL DEPTH 220
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 35 FT.
(Use "*" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casting terminated at/or below land surface requires a variance an
accordance with 15A NCAC 2C.0118
9 YIELD (Wm): 16 METHOD OF TEST
10. WATER ZONES (depth): 50
ARDM
65
Topographic/Land setting
0 Ridge 0 Slope 0 Valley ® Flat
LatitudeiLongimde of well location
35.38.028 / 81.52.260
220 Consolidated Rock
it. DISINFECTION: TYPE HYPOCHLORITE
12. CASING:
Depth Diameter
From 0 To 37 Ft 61/4"
D. GROUT:
From 0
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
Depth
To
20 Ft.
16. REMARKS:
Amount 9
Wall Thickness
or Weight/FL Material
SDR21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
F in.
Ft,
Slot Size Material
in.
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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
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.
5/1/06
Date
O
O
:Erg
�1 -4rn
73 t
o CC
Qy
ITT
.+1
1,
GW-1 REV. 07/2001
JUN 06 2005
6

From To
13. GROUT: Depth Material
From3.__ To 20 Ft GEM'
From To Ft
14. SCREEN: Depth Diameter Slot Size
From To Ft io. in.
From To Ft pia in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft.
3. OWNER:
Address PO POC 33
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) W L PMUJE CERTIFICATION a 26C9
WELL CONTRACTOR COMPANY NAME HICKORY ' L OUILINC OD. PRONE It f I828-4-03.35
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) Crf applicable)
c :
i
ef4 R
i.- 4.h; Z
1. WELL USE (Check Applicable Box): Residential b Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: MARICN
MAA.LWE RD.
CountylL
(Street Name. Numbers, Community. Subdiwiao. Lot No., rip Code)
FIRM FEWS/GETCE R FIERT LIJQ O
(Street a Route No.)
RIITHFRF(R[7i(N, NC 78139
Cit(828 }y or Town
State Zip Code
Mn code- Phone number
4. DATE DRILLED 01-01-11S
5. TOTAL DEPTH: LOS a
6. DOES WELL REPLACE EXISTING WELL? YES 7 NO
7. STATIC WATER LEVEL Below Top of Casing: 11 FT.
(Use "t" if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of using terminated atler below Lad surface requires a
variance In aecordaneR with ISA NCAC 2C A113.
9. YIELD (gpm): L METHOD OF TEST BY AIR 1NJ1
10. WATER ZONES (depth):
11. DISINFECTION: Type EIIH TABS
12. CASING:
Diameter
From 0 To 78 Ft 6V't
From_ To Ft
Ft
Amount b1
Wall Thickness
or Weight/Ft Material
BC PLASTIC
Method
FOURFD
Material
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topograpbic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or Comity Roads. Include the road
numbers and common mad names.
n1 A7
MAk Ittio
0
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TJUS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.1 e, /24,07!-! 2 ki 03-C6-06
SIGNATURE OF PERSO NSTRUCTING 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], wlth(n 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRIQCFION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp_
Well Contractor. (Individual) Name
Camp's Well & Pump Co. _Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
City a Tam State
(828). 453-7322
Tip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/(d applicable)
DWQ or OTHER PERMIT #(a applicable)
WELL USE (Check Applicable
lBox): /Residential Water Supply V
DATE DRILLED C- 1�1`O4,
TIME COMPLETED 30 AMO PMO
3. WELL LOCATION:4 ,
CITY: D)rsar L i tie COUNTY Ilk �V u-)'
ellCICItnLA 45_�-r�,%'�
(Suess Name, Numbers. Community. SubdMsion, LotNo.. Parcel Zip Code)
TOPOGRAPHIC.! / LAND SETTING:
Vie
w aeey Peat ❑Rldge ❑Other
(cams 'peroPriata box)
LATITUDE S i 3 3 76 C IV
LONGITUDE I_ Ca.379 lei
Latitude/longitude source: OOPS OTopographic map
(location of wel must be shown on a USGS topo map and
attached to this forn I not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS 366_, I C)c'fk j pp
NUot antci, NC
City or Town J State Zip Code
Area code - Phone number
May be in degrees,
minus, reeondea
in a decimal fomat
Telttier
5. WELL DETAILS: 1
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NOW
c. WATER LEVEL Below Top of Casing: too FT,
(Use'.' If Abaco Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ,Q�) METHOD OF TEST d I /^
f. DISINFECTION: Type chlorine Amount /Cap
g. WATER ZONES (d th1):
From To \i/
From To
From To
6. CASING: Thickness/
Depth Dl er Weight Material
From 0 To 73 Ft 6 SDR21 PVC
From To
From To
From To
From To Ft.
From To Ft
7. GROUT: Depth
From 0 To 20
From To FL
From To FL
Ft
Material Method
Sackrete Hand
8. SCREEN: Depth Diameter Slot Size .Material
From To Ft In. In.
From To Ft In. in.
From To FL In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
0 t-5
Formation Description
•SeLttii c.
o f tsc ll ((d l e d )'Cc k..,
EGEIVED
MAR 2 7 200€
Asheville Regional Office
Aaoifor tectien —
11. REMARKS:
I DO HEREBY CERTIFY MATINS WELL WAS CONSTRUCTED N ACCORDANCE WTTH
'SA /CAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGWtUR OF CERTI ED WELL CONTRACTOR DATE
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within ;30.days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality YEI ,L CONTRACTOR (INDIVIDUAL) NAME (print) iv-7 A-i '>. /./CJ.' 77 CERTIFICATION it
CERTIFICATION46 3/
\Y ELL CONTRACTOR COMPANY NAME /ZL ; /vl Cam-)f L)H. (1 4%, PHONE #�.(/'�"%?6•-�'��r
S'IA ATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . \ /ELL USE (Check Applicable Box): Residential l' Municipal/Public ❑ Industrial 0 Agricultural ❑
I.•I minoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use
2. WELL LOCATION: ,n
Nearest Town: /74 , Z AT County 97 4l" 0 uLe,
SR / . 2 7 V Zia ) ,Q. /i 6 C Ariz .tt; 7Y
(Street Name_ Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: C ha /e s Da if s
Address E y %c-Y ? Gf . �. t. Zax sts-
(Sheet or Route No.)
/11zl�,y,l fc/ c 2Y?,r2
City or Town State Zip Code
5,/- C 5Ic 3
Area code- ('hone number
nr\TEDRILLED Li'_ l2— d 6
5. TOTAL DEPTH: / v &.
6. I i0ES WELL REPLACE EXISTING WELL? YES ErNO ❑
7. ::.IATIC WATER LEVEL Below Top of Casing: to FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING 1S / FT. Above Land Surface*
'ion of rasing terminated nt/or below land surface requires a
variance in aceordanc with 15A NCAC 2C .0118.
9. YIELD (gpm):,2 Z) METHOD OF TEST,°.-
10. WATER ZONES (depth): / 0 3 l=2
1I. DISINFECTION: Type& ) dj(
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
Frompt To_ F
From To Ft
From To
13. GROUT: Depth
From:Lot To 9. t
From To
14. SCREEN:
From
From To
15. SAND/GRAVEL PACK
Depth
From To
From To Ft.
Depth
To
F
Amount'���
C, • r f).e ,j) p %J' C.
Material Method
Ft. ce.aetc/t,
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size
Ft.
Material
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPS0Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
7J
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.
�h r J tit r+. I) i7) a e4 5-1?
/i/1/'l7
s' 71--A, / \ t eI c. cr
j rs A h .//
fl it .xY 7-4I2 Je)t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS FRUCTION STANNARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTR 1, - - - _ " DATE
Submit the original to the Division of Water Quality, Att : InforRg gightytifi 1617 Mai Service Center -
Raleigli, NC 27699-1617, Phone No. [phone], within 30 (ays.
MAR 2 7 2006
Asheville Regional Office
A•uifer Protection
GW-1 REV. 09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
CONTRACTOR (INDIVIDUAL) NAME (print) t) . (2... 4<.: l lc 21 CERTIFICATION an; 3
vV r:1.1. CONTRACTOR COMPANY NAME y C)t UJ mac+. 1) D4 , )/ z N 7 PHONE # fPil `I B P- 3 '7/ t.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifa plicable) (if applicable)
"'El USE (Check Applicable Box): Residential F3' Municipal/Public 0 Industrial ❑ Agricultural ❑
Cdonitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:A % 2 2=p County £II w 1/
3RIe 23 2 to v P&_
( Sheet Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. O\V'NER:C. S'Ci 7 t DtV d,h , ,v S
;,dchess /g 2 h' ifi 1 7-0 , Psi
(Street or Mute No.)
$` ?a lea 7 ,cJ c . 2
6
7
9
10
City or Town State Zip Code
6, e- - 2 6_
. ea code- Phone number
RATE DRILLED 2-1L_ a (z
TOTAL DEPTH: (G� A -
DOES WELL REPLACE EXISTING WELL? YES ❑ NO Et -
?TA TIC WATER LEVEL Below Top of Casing: -2h FT.
(Use "+" if Above Top of Casing)
TOP OF CASING IS / FT. Above Land Surface*
'mu of casing terminated at/or below land surface requires a
co riance in accordance with I5A NCAC 2C .0118.
I ELD (gpm): METHOD OF TEST,4JcZ> )� h
W A'I'ER ZONES (depth): / 3s , po
1 I. DISINFECTION: Type Gln}y to $ Amount,4bri //; ij
C'. INC: Wall Thickness
Depth Diameter or Weight/Ft. Material
Prom?Li To 9 PFt.& - y ,LJ,M5 /j 21c-,
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
1 rum7'1/ To Ft. c _i ,if-
i'roul To Ft.
Id.SCREEN: Depth Diameter Slot Size Material
Prom To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
I°rom - To Ft.
:rum To Ft.
I6. REMARKS:
Topographic/Land setting
Midge ❑Slope ❑Valley OFlat
(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
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.
gA'Ai BZf CQgc R& S�
01L2 /Cc
.-V / a t% 5l A2-eld
d%/2 tj cc i- 2c) b.,C
lbhf
3-tcd tt 5-1,eld 2t eel d cc
j/ptit did
1 Uf) I II,REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C'(1N ;TRl1CTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.C.C8-22 2_iz>_t�
SIGURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Attn: In
Raleigh, NC 27699-1617, Phone No. [phone], within 30 days
rmatitySllter yik 1617 Mail Service Center -
�j � (�� � V E17G1W-1 REV. 09/2004
MAR 2 7 2005
Asheville Regional Office
Aquifer Protection

Mte Z` 1',.bb
earievelarileat
Ian moseras IbiIM►n.sem Mall, 1111St
WELL CONSTRUCTION RECORD nu.costmaci01k PeZ) e .0 ,&N // -
waL CONThMiu A minimum 1t iJ / 3 v
a17ATiwal_oaia1 Ilat ONFwlritr
WE-
1. wat IIMI_Lesubsweentir1t1rliale d andapi Q Marietta U�LLOR
sr� 5
•a 0 o+•+Fwwirw��D Oarti ra
o1..cta.r » HMr+v.
z. watlot mt darrt+.lintrli.j
rgrullia as /V c b eh'ec -
ptdrY.ralliambes/mtrsar lislty
/.4: c- Arta a
orllltwlam_e 6-7 -
a TOTS rS
Maaagar
i. CUTT sYs
7. OolalwauilInall
a STAIIMINCORMIaltaakeTe• flier
garivion
O. TOPOFGAIIIIIatta.. PT. asislailluilat
everiptesessomoarldastmitatilagena
dussousbeti111. �*
11. wnia�lso
1L atmua1101t �TrG i i- onsion A-
1a�
C.
828
47-
DCD
moire t+mrhrrtlAMrrtt
onw ;t or ova pm ruu.l..` Ns* p..s-s_ ddburr.a..w.er.w.
--
Fr'RIIIIIresA_ __
Fral smalareamen.
Fes aw& Obleil -Md
_p er .Co-oh/el . , mod
Fs n
It aCS
onw Oboe Sao MINS
F.. . T. - w IL .__M.
Fes 7. K M. __� It
Pia Ti R_ IL —.IL
111. aA1 lIMILF/1016
anpr IIIIIAd
FM Ts...�I�
Te
17.
/0‘it_ Cccj
rONourtiirONNlrwtewlifLw.{O INA*ONI .awauNA am WILL
OO1 aICfloNRNlaMOa.NO'MaACW10#aswoo101wweNFaol111.111011i111 otrpl.
.emu... ,� �--��
aa1A1110 lO>tl.Nlr�wltwtws b'd
ateilitaalindlloweilearrares 1Mi171S t
S.+Ikri rtll

RECEIVED
MAR 2 7 2006
Asheville Regional Office
N
WELL CONSTRUCTION RECORD
vironmJeanttlaand Natural Resources - Division of Water Quality - Groundwater Section p
WELL CONTRACTOR (INDIVIDUAL) NAME1laiat) I(/ n C fi x o e p5 Z/S CERTIFICATION # 27 Q 9
WELL CONTRACTOR COMPANY NMI-G/�IA9 e e iii/ Lunt fee, Phu Th r/ niONE a i cn �o Y O fO
STATE WELL CONSTRUCTION PERMPF# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential t3 Mtmicipal/Public 0 Industrial 0 Agricultural ❑
Monitoring D Recovery 0 Heat Pump Water Injection CI Other C If Other, List Use
2. WELL LOCATION: / 1 /
N; Town: C/6 /99,T Cotmry�lC4och-e7/
/`C t/ Rno
No., Zip Cade)
Jet/
2 76r
(Street Name, Numbers, Community,
3. OWNER: Den) k/AW(
70
Address
f -C /191 e
At4 ;4tire' Q WG)
City cc Town Stale
(
Arta cede- Phase number
4. DATE DRILLED / - V _d
5. TOTAL DEPTH: 3os
6. DOES WELL REPLACE EXISTING WELL? YES ° NO Q--
7. STATIC WATER LEVEL Below Top of racing: (be) FT.
r/ (Use "+" if Abase Top of Casing)
8. TOP OF CASING IS 4 FT. Above Land Surfaces
'Top treeing ttroMated et/or below hoed name requires ■
vetiana bi accordant with ISA NCAC 2C Silt
9. YIELD (gpm): 30 METHOD OF TEST /i `ne -
10. WATER ZONES (depth):
6/9/et"a y mT
Zip Code
11. DISINFECTION; Type CC/7
12. CASING:
Amount 70 0 2
Wall Thidmess
Depth or Weight/Ft. Material
Front,_ To /CO FL De.17CDR 2/ PO
Frain To Ft.
Froth_ To Ft.
13. GROUT: Depth Material
Front 'tea
11 t fl.1=tN_ 1itztt sitmeter
From if To Ft in
Front To Ft. in.
15. SAND/GRAVEL PACK:
_Depth
Sir
Shot Size
in.
in.
Itiztelat
Material
TopografisiciLand setting
oRidge L3Slope °Valley GFlat
(check sppwopiate bur)
Latitude/longitude of well location
(degrxyminmeaecaay)
Latitude/longitude sornce:DGPSCYfopogrdpbic niap
(cheek bot)
DEPTH DRILLING LOG
From To Formation Description
J.00ATION SKETCIj
Show direction and distance in miles from at least
tate Roads or County Roads. Include the road
and common road names.
}'::s:llla,_6'4X4'rt „..tlwi r/te Gy 61r.- Bki wt//1/ CA4-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL 1tD IN ACCORDANCE WITH I5A NCAC 2C, WELL
CON ON STANDARDS, ANDTHAT/( COPY OF Tj8S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTING THE WELL DATE
Groundwater Section, 1636 Mail Service Center - Raleigh, NC
GW-1 REV. 07/2001

(Street Name, Number, Canonicity, Subdivision, tat No., Zip Code)
3. OWNER: yt j1Ct C/9/7/1
Address 46 /V Siena,/ cdieek led
(Street cc Route No.)
Mir/?-n/ wC ZE7/ak
City or Tower State Tip Code
Ana code- Phone amber
4. DATE DRILLED 2 - - b (e
5. TOTAL DEPTH 7 /5-
6. DOES WFJ 1 REPLACE EXISTING WELL? YES g NO
7. STATIC WATER LEVEL Below Top of Casing: VO FT.
.,(Uss "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of easing terminated atier bedew Ind surface require a
variance in accordion with ISA NCAC 2C .0118. ,
9. YIELD (gpm): 7 METHOD OF TEST / / Lh ea
10. WATER ZONES (depth):
Amount /? f? 7
Wall Thickness
Ft Material
From 0' Depth
Toh6O Ft 5p122or 1
From,_ To Ft
Front__ To Ft.
13. GROUT: Depth Material
From_a_To ZD Ft. Cd/7aP-Gn JA P iaa-//
From To Ft.
14. SCREEN: Depth Diameter Slot Sire Material
From_,Z To Ft in. in.
From To Ft. in is
15. SAND/GRAVEL PACK
Depth Size Material
To Ft.
To Ft.
11. DISINFECTION: Type Cl'&
12. CASING:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N
WELL CONTRACTOR (INDIVIDUAL)NA JM/9g,' (pant)
WELL CONTRACTOR COMPANY NAJta)r7tA) e'C
STATE WELL CONSTRICTION PERMED
(if applicable)
Resources - Division of 5
WaterlQuality - Groundwater Section
des U /�CERTIFICATIONa 272y
(.We// i R.np Otll rtONE a ftt‘tV cT 70
ASSOCIATED WQ PERMIT,
(if applicable)
I. WELL USE (Check Applicable Box): Residential 13 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
ILC Ctp el/ T c/Land setting
7(p� Midge tope °Valley °Flat
(check appropriate boor)
Latitude/longitude of well location
(degremlmioumiseeoods)
Latitude/longitude source:0GPSOTopographic map
(cheek box)
PEI DRILLING LOG
From To Formation Description
From al
From
16. REMARKS.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CON
CON ON STANDARDS, AND THATlA COPY
SIGNATURE OF PERSON CON
Show direction and distance in miles from at least �I
two State Roads or County Roads. Include the road
numbers and common road
UCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Ralei�h, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RECEIVED
Mfl,R `w"7 271n
WELL CONSTRUCTION RECORD
�� tt�� o al atle,
AsOltdl�kaM' t ern of . vironment and RResourc `Dives n of Water -Quality - Groundwater Section Q
• (INDIVIDUAL) NAME�s� (print) ti K/100 t5 ' 1 / CERTIFICATION # 27(1
WELL CONTRACTOR COMPANYNAMBa1J (Qt4-TeC Wei Dr: I 1tns PRONE # fitlemtlC]'WOO
STATE WELL CONSTRUCTION PERMITS/ ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential �Municipa1Public 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: el d tatr County
17SI0 rtt,// heck it' y/ r Ot f?vr rirn9Z
(Street Name, Numbers, Cammimity, 3 'vision, Lot No., Zip Code)
3. OWNER:62dy le4i)C
Address * O /y,%/ Cne4
(lid "O� /I (Street or No.)
City or Town State
Zip Code
C_--)-
Ares code- Phone number
4. DATE DRILLED 7 i3 ' O (o
5. TOTAL DEPTH: 6/00-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO a--
7. STATIC WATER LEVEL Below Top of Casing: 9' FT.
was "+" if Above Top of Casing)
8. TOP OF CASING IS 4 ' FT. Above Land Surfaces
'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 / /Hal/
10. WATER ZONES (depth):
11. DISINFECTION: Type (CA
12. CASING:
From,_ Two �6-0 Ft_�
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 70
From To
Amount /D at,
Wall Thidmess
or Weight/Ft Mficrial
Wei uc
Material//
Ft ollote61`C
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.
; ,' i
TopocJLand setting
❑Ridge 0Slope ❑Vallet❑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
LOCATION SICETCR
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
nu n11¢ rs and co..., .n road names.
16. REMARKS: U.711/ q bf fat/� �,4,�� G•4�P "i9Pfity 5 �'1
I DO HEREBY CERTIFY THAT/ THIS WELL WAS CON TAM- ea IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSCTION STANDARDS, AND A7A COP OF THIS RECOHAS BEEN PROVIDED TO THE WELL OWNER
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

v
RESIDENTIAL WELL coNSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138.
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & PumD Co. Tnc
Well Contractor Company Name STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID $(If applicable) '
STATE WELL PERMIT#(Bapplicable)
DWQ or OTHER PERMIT 8(5 applicable)
WELL USE {Check Applicable Box): Residential Water Supply
DATE DRILLED ,.- -ter, Y/
TIME COMPLETED 3o AMIDPM IN
3. WELL LOCAT ON:
CITY: Qr 1 o et COUNTY /' 1t 7P u)e
GICAW-ICJ —1✓L Icut L004
(Street None. Numbers, Community. SubdMslon,,LotNo.. Pak&, tp Code)
T POGRAPHIC /LAND SETTING:
iSbpe Malley °Fiat ❑Ridge ❑Other
(cheek eppropdatabes
LATITUDE `�`55" 711
LONGITUDE J ' L� ¶'. 3 o5 w,
Latitude/longitude source: ❑GPS ['Topographic map
(Iocatbn of coal must be shown on a USGS topo map and
attached to this term f not ushg GPS)
4.WELLOWNER I/ 1 (/)7I_
k OWNER'S NAME 120CSOI 1- flY(-SIat r.
May he In degrees,
minutes, seconds or
in a decimal 6rmat
STRESTADDRESS ' i I ✓L
ity or Town
Area code Phone number
5. WELL DETAILS: s� 5 .
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOA
c. WATER LEVEL BelowTop d Casing: if 1 FT,
(Use'? 6 Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface
. 'Tap of casing terminated etlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)• 1 METHOD OF TEST a) Y
t. DISINFECTION: Type chlorine Amount I /A el
g. WATER ZONES (depth):f�
Fran To al tot)
From_ To
Fran To
From To
From To
From To
6. CASING: a�n ThWefci�imesa/
From 0 Depth Diameter
Ft D]apke}er SDR21 PVC
From To Ft 62' _
From To FL
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft
From . To FL
8. SCREEN: Depth Diameter Slot Size
From To Ft. In. In.
From To Ft In In.
From To Ft in. b.
Material
9. SAND/GRAVEL PACK:
Depth Slze Material
From To Ft
Frorn To Ft_
From To Ft
10. DRILLING LOG
From .To.
0 .29
Formation Description
ecnh I i Jade
ariiz Tula
11. REMARKS:
z;nln
2I
100 HERBY CERTIFY MAXIMS WELL WAS OONSIRUCIED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCDON STANDARDS, AND MAT ACOPT OF TM
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
A R F ERTI EDWELLCO CTOR DATE
lames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: Information Mgt.,
1617 Mall Service Center -Raleigh, NC 27699.1617 ' Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & PUMA Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tovm State
( 828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#(irappllcsble)
STATE WELL PERMIT#(s applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply/
DATE DRILLED 2 04
TIME COMPLETED / iS AM O PMV
3. WELL LOCATION:
CITY: Dysart 'i Ile COUNTY Mc. loskI
ffidden L&ke —io± ,21 Tr
(Street Name, Numbers, Community, SubdMsion, LotNo.. Parcel;. Zip e)
TOPOGRAPHIC / LAIID SETTING:
❑Slope ['Valley Flat ❑Ridge ['Other
(chedr epgopdatab?x) ' J
LATITUDE �po Lv 3 4-. 02 LH
LONGITUDE1 I n Cal • °1sv
Iatitudellongitude source: r}6PS ['Topographic map
(location
l must be l shownot using GP j GS topo map and
a4.WELLOWNER II /7,
OWNER'S NAME K II (jre ei(lea- /n'J (.or(S . l0.
STREETI�ADDRE t L T e r (�-tract
ISty t ter4
77rd or Towntorta e / ti �. Z 3'
Zip Code
Area code Phone number
Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: 30 r
b. DOES WELL REPLACE EXISTINO WELL? YES p NOX
c. WATER LEVEL Below Top of Casing: 6D FT.
(Use '+'.0 Above Top d Casing)
d. TOP OF CASING IS 1 • FT. Above Land Surface'
'Top d easing terminated et/a belay land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ! D METHOD OF TEST fit Y
f. DISINFECTION: Type chlor ine Amount
g. WATER ZONES d/ep�th):
From To, 'ZO From To
From To From To
From To From - To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To %3 Ft. 6# SD21 PVC
From To Ft
From To Ft.
7. GROUT: Depth - Material Method
Fran 0 To 20 FL Sackrete Hand
From To Ft.
From_ To Ft.
S. SCREEN: Depth Diameter - Slot Size Material
From To Ft. In M.
From To Ft. in, In.
From To Ft in, In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
Fran To Ft.
10. DRILLING LOG
From .To
0 '3
73 ,305
CfFormation Description
a.y, divt
rc050llr tec: rccK
RE
�Aallevlile Peo on f
Arl, aiewe, Yr=)e...
11. REMARKS:
:ice
1
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wmr
15A ICAO 2C, WELL CONSTRUCTON STANDARDS, AND THAT ACOPY OF 1t*
RECORD HAS BEEN PROVIDED
(�(T��O((THE
ffWEE1I( OWNER
SAE OF RTIFIEDWELL'CONTRACTOR DATE
James James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1 1T Ma l 8 original
Center— Division of Water Raleigh, NC 2 699 1617 QualityPhone No. 919) 733 7Attn: xt 68.8on Mgt.,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contracta.(IndMdual) Name
Camp's Well & Pump Co. Inc
Well Contracts Company Name
STREET ADDRESS P 0 BoX
Ellenboro NC
429
28040
C
i
t
ysTovm State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Of applicable)
STATE WELL PERMIT#Or applicable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
g DATE DRILLED - ,T4J `O(0
TIME COMPLETED / 2 ..3 0 AM ❑ PM ®
O. WELL L TION: � I
CITY: SLtY ✓ COUNTY /' /�/Ic Deeik I1
Zip Code
(Tl die Yl LAKe — Lo f 7
(Street Name Numben. Community. Subdivision, LotNo„ Parcel Zip Code)
TOPOGRAPHIC / 4 D SETTING:
❑Slope °Nancy VFW ORidge ❑Other
(check approprlatebox)
LATITUDE 5° 34 22 f4
LONGITUDE 4 I o Sec 235 tAi
Latitude/Iongitude source: ftlirPS °Topographic map
(bcetbn of wel must be shown on a USGS topo map and
attached to fNe form not using GPS)
4. WELL OWNER
OWNER'S NAME AL )1- Gr'e Ceti/e&f
STREET ADDRESS e Y
RA. erfordtek C asI
City or own State
May be in degrees.
minutes, seconds or
in a decimal format
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NOO
c. WATER LEVEL Below Top of Casing: 75-
FT,
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING 1S 1 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): / 0 METHOD OF TEST A i f
Zip Code
05
T. DISINFECTION: Type chlorine Amount if, et
g. WATER ZONES ((depth): From
From To 41 0 - From To
From To From To
From To From To
6. CASING:
Thickness/
Depth a Dieter Weight Material
From 0 To dot Ft. 6# SDR21 PVC
From To Ft.
From To Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
Ran To Ft.
8. SCREEN: Depth Diameter Slot Sim Material
From To Ft. In. In.
From To Ft. in. in.
Ran To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Rom To Ft
10. DRILLING LOG
From .To Fonnationt Descriptbn
.0' is clot/ ,Mit
42 ) CovtsotaQ recK
RECLfV
AshetWt P4arlinP9
11. REMARKS:
J:
I DO HEREBY CERTFY THATTHS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANnaanc, AND THAT ACOPY OF MS
RECORD HAS BEEN PROVIDED TOTR HEEWELLOWNEL�
SIFVAAsTUt xR OFCE TIFIEDWELLCONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

"Jeri^'.armmna Department of Environment and Natural Resources -Division of Water Ouauty-Goundwator Sorter,
' F3F Vail Sorvire Center - Ralelgh.N C. 77699-1636-Phone [phone]
v\IF 1 CONSTRUCTION RECORD WELL CONTRACTOR: /Y6L,'vYd /ir, / .;ti ' n' S
WELL CONTRACTOR CERTIFICATION 11 : 25-6- ii
STATE WELL CONSTRUCTION PERMIT 0 :
I SF ;(Theck Apnlicahle Boy) Residentiatl "I Munlcipat fl Industrial El Aericut ural ❑ Momtrrr
'ery fl !-{eat Pump Water Injection rl Other If Other, List Use.
'CATION 'Show sketch of the location below) �1
WV)),i o Al County MC P6 C.
ajh✓/d Act,/ ✓J P ,d/G.i
Tnnimiln tv ,r c.ilhH,: cb•^ and Int Ian J
//S/4' ft'v7,e.'d cc ,,,a.- /7rt
iStreel er R ute No I
'2I;nc ,rdr
r ,7 1Y-cL
a6
r,.-), F,".TEf YES I NO
PE°LACE EXISTING WELL? YES I I NOrl
JJATER LEVEL Below Tor of Casino. ji FT
(Use "`" if above Top of Casing;
' CASING IS /o" FT. Above Land Surface'
is Tern' natec attO beesk ,and sur'ace reoulres a variance in accor-
C'I NCAG 7C n119
;PM- -S t' MEIHOD OE LEST 116"rLCI—
ZONES ideptbi
'N/A MON Type (r%f
1.
rb', F N
In
amete'
/e FI G
t.
Amount
4-n
DRILLING LOG
rrom To r.na'm. ^eK'
If additional space i5 needed IISP hack ^''Crm
Wail T4prknec,
n, Vc,q"1Ft Matergd
a, SS77c- LOCATION SKETCH
!Sho:odlrecbor And dbstac^r ` a"e?r' "Mr
Roadsor ether 'mac 'eferon-'.e nr
Depth , Material Method
n rt •
ir,
Depth
Fr
Diameter SIot.Size Material
In
Tr i i m in
4PPVEL PACK.
Depth Size Material
in
- CI
1 l\Shcvi„e Regional Office
Ao:]lfer Protedlon 0
"'C HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WEL L
nNSTR!ICTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED '^ `HE WC' i n
-nc TrrICE USE ONLY
Sena Nn
rr
,///1 'c ✓ZC-t9 3-422-ci
SIGNATURE F PERSON CONSTRUCTING THE WELL DATE
Submit original to Division o`Water 011ality Groundwater Section vete,. a oays
gy\,or.. ,.y

n,
tt ,r'•kna neoar'mant M Fnvirnnmont and Natural Rosourres-Division of Water Duality-Grnundwator Soctinr•
kks V,n Sa.vlre Center . Rale Igh.N.C. 27699-16.36-Phone [phone]
LF CONSTRUCTION RECORD WELL CONTRACTOR: ?G.4nNd OA 14 Z.,f^''L
WELL CONTRACTOR CERTIFICATION b : 3c '' er
STATE WELL CONSTRUCTION PERMIT d :
SF .Chock Arnhcahle Bost ResidentialMunicipal ❑ Industrial ❑ AoricuIurai ❑ Ma,— --
I+eat Pump Water Injection In Other ❑ If Other. List Use.
T)CATIDN ‘Show sketch of the location below)
own /k7 h CN County
G fDi .Cr .} 44-
and Numhent Community or Suhdivisinr. and Lot No '
Gmcc /iin'i S
.7144. %GnuG1 ai
(Street or Roue No
/A/th b it'
wr State
rrf=nIFrp.2 'C6
•_ -,a / io
? 9sf_
/to Code
DRILLING LOG DEPTH
=rom To rnrmatinr aesr'
w�pL'_ESTEE YES I 1 NO[5 1
=-Lr REPLACE EXISTING WELL? YES NO�('
nir TEP LEVEL Below Top of Casino c"" FT
i'Jse -+" i` ;hove Ton of Casino i
FT AboveLandSurface-
ro r -0'c, pt ('alnv ian(r ir'are rea'ii es a !Pna'Ae
, M,. 5 ME THOU OE ?EST
'ONES (depth)
/j2,3 ,/,6-in
-
PIN. riON Type /I TZr Amount % h "17 If addatonal space is needed use Care o' tear
c Pk( , Wall Thickness
rend-. Diameter or Weiontct Material
I ? Et G ;2 ` / .-.�7;iLa I ()CATION SKETCH
(Show direction and distan . tram it least 'ror f
Tr. t
Roads. or other mac reference points
it r
-...,
:J
Depth Material Method _
r . re —
Tr) Ft o
u-r N
Depth Diameter Slot. Size Material
Ir f^ in in
Tr r' in in
Tr r' in in
-At. N. -,RAVEL PACK_
Depth Size Material
To Ft
In Ft i An:life "r,TJfec
tG=K$
RECEIVED
.A hevjlie Regjonai Office
#�nrt
Cy'. HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
r)NSTRUCTION STANDARDS- AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL ^vvtIrr
-OP OFFICE USE ONLY
roar' vn
No
SIGNATURE OF P
Submit orioinal to Division of Water Oualiity Groundwater Serhnn v,ahin
-.12c v G
ERSON CONSTRUCTING THE WELL
DATE
r wave
._rW ' Qr

Norte Harnii na Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
•616 mail service Center - Ralelgh,N. C. 27699-1636-Phone [phone]
\NFL_! CONSTRUCTION RECORD WELL CONTRACTOR: vti" '� Tiff'A
WELL CONTRACTOR CERTIFICATION # :
STATE WELL CONSTRUCTION PERMIT #
USE (Check Applicable Box) Residential Er Municipal ❑ Industrial
ary E
treat Pump Water Injection n Othern If Other. List Use.
- P AT!fHv Sbr A• sketch of the location below',
OAS i tl T Cou tv Cod-, es -A. C
•
.Jsy ,' vnci. .:,d5
ore' Nnme and Numbers Community or Subdivision and Lot No
„eINFF? Cc,,,9 Ai=<:.-7Y
, /90 N /V)/ipilsc
abee! or koute tio.
-r town State Lie Cede
::-c HRH LFD s' /C. -cL
-)EPTH tiL
.0; LEGTFE YES I ; NO
runt' I REPLACE EXISTING WELL? YES
tr-E:_ Er 'Et aol w "roc of Casino 7?
NOf
('l lse .1- i• nhnve Top of Casing(
:AGING I; /)_w FT Above Land Surface•
. nrminatec at'or below land surface requires a variance in a000'
� ;C 0119
HrikA /Sy' t,,RF1Hrlll1/c TEST �iOra�r
--(NE', ;depth
Agnsueural n
DRILLING LOG
;roil, To Pnrnvaton Deserts r
vre / Amount �_
,Gt ION) T �` % it additional spare is "eerie( use ^.ar i
Wall Thickness
Depth Diameter or Weight/Ft Material
To 7= Ft L- "�•6 �tini�%`� LOCATION SKETCH
To rt Showdirection and distance from a' least 'WC
Roads. or other mac reference prints)
tr 1
Depth Material Method
To Ft
.n rt
Depth Diameter Sint Size Material
to Ft n _ in
To Ft in in
Tr r' in in
e AVEI PACK
!iati!b S'le Material
'FMURKS
tt
To Ft
RECEIVED
Region i!! Office
Anu'Ite: Protection
n0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
^.NC TRI ICTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEl L h%N,JF '
=OR OFFICE USE ONLY
-i,ar• Ne
Sena No
SIGNATURE OF PEON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Oualitv. Groundwater Section wdhin 30 lays
;W 1 RE!

WELL CONSTRUCTION RECORD $ 3 t
North Carolina - Department of Environment andAsTatural lippources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pint) Wad (7arf/l ess CERTIFICATION ir i 9/Y
WELL CONTRACTOR COMPANY NAME Al/C,kort.0Q .. //(VG g rj ll% n ()n, PHONE a 1/2d1.2 .j,5
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) Of applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial O Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIOV
Nearest Town: Nebo CotmtyeeZniNe//
he) e-o74'2659
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER). John's-i0PY/DyrAwe c dart eylesublik
Address Li/ 7j jrhnis a02irer 1?a
(Street or Route No.)
/14nf -avtldx A/C. .fl866-5-
City or Towe Some Zip Code
Topographic/Land setting
°Ridge ['Slope 0Valley OFIat
(duet appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude sounce:OGPSOTopographic map
(checkbmc)
DEPTH DRILLING LOG
From To Formation Description
Area code. Phone number
4. DATE DRILLED Ob .20 -ate
5. TOTAL DEPTH: 410 C
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO �I
7. STATIC WATER LEVEL Below Top of Casing:
(Use 'W' if Above Top of Cuing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of rasing terminated or land surface requires a
variance 1a accordance with ISA NCAC 2C Alta
9. YIELD(gpm)- /0 METHOD OF TEST75yAir Ts/
10. WATER ZONES (depth):
11. DISINFECTION: Type n 7"TSs
12. CASING:
w
From To Depth
Et D Its.
From To Ft
From To
13. GROUT: Depth
From t7 To 50
From To
14. SCREEN: Depth
From To
From To,
15. SAND/GRAVEL PACK
Depth
To
From_To
Ft.
Material
Ft. ()tett"-
Amount '7S
Wall Thtdmess
ar Weight/Ft Material
gar, Siee/
Ft
Diameter Slot Size
Ft in. in.
Ft in. in.
Size Material
Ft.
o 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.
HWY /26
5
6/7
e Waz-
46,
WT6'o F CEIVED
DIV OF \AtATe R QU
...ALITY
Hwy! %V 1 4 2006
16. REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PE
N CONSTRUCTING THE WELL
a,z/o<es
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & Pump Co. Inc
Well Contractor Qampany' Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State Zip ode
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #gf applicable)
STATE WELL FERMIT#Mepplleable)
DWQ or OTHER PERMIT #(6 applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3—I —/)G
TIME COMPLETED 41.1-45 AMID
3. WELL LOCATION: M Wen
CITY: M4Y/A1 COUNTY/ 4 Ic We
Y�f+ar .o —Arbor
(Street Hama N _ . , , Community. SubdMslon, Lot No., ParoeLZip Code)
PM p'
T9POGRAPHIC / LAND SETTING:
lope OValey DFlat DRldge ❑Other
(sac appropriate box)
LATITUDE 2 44.I17311'
LONGITUDE g c 575 41 Lli
Latitude/longitude source: 1116PS oTopographic map
(location of wet must be shown on a USGS topo map and
attached to this form ifnot using GPS)
May be in depres,
minutes, seconds or
in a decimal format
4. WELL OWNER OWNER'S NAME 6l l r' /
(� ,,t�yltttrchL
STR�E�EjT ADDRESS n
l Y 10 it a rc%rt c 2g6 S"5
City orTtti3+n State
Area code . Phone number
5. WELL DETAILS
b. DOES WELL REPLACE EXISTING WELL? YES NO
O
c. WATER LEVEL BelowTop of Casing: 7 O FL
(Use r.' H Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 0 METHOD OF TEST a.. / r
a TOTAL DEPTH: •C>)
Zip Cede
f. DISINFECTION: Type chlorine Amount Ili Can
g. WATER ZONES (99 ):
From To t7� u From To
From To From To
From To From To
6. CASING: �a�neter Thlc$ness/
Depth .-7 Frain 0 To /30 Ft Diameter
SDR21 PVC
From To Ft
From To .FL
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
Froth To Ft
8. SCREEN: Depth
From To
From To
From To
Diameter . Slot Size
FL In. In.
Ft In. In.
Ft. in. In.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From__„To Ft
From To FL
From To FL
10. DRILLING LOG
From To
o' )30
Formation Description
c/a f San A
130 . ?,oS (1005rUna tea roaX
s ev - -eaio
11. REMARKS:
1 CO HEREBY CERTFYTNATTHIS WELL WAS OCNSIRUCIED N ACCORDANCE WITH
ISA 'CAC 2C, WELLCONSTRUCTION STANDARDS. AND THAT ACOPY OF MS .
RECORD HAS SEEN PROVIDED TO THE WELL OWNER
Amw
�
3 �i'ob
URE OF CERTIFIED WELL ONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submit all the
ge Center- Raleigh, NC 27 99.16117 Quality Phone INo. (9 9) 733 6 eat 68.�on Mgt.,
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section %%ELL CONTRACTOR (INDIVIDUAL) NAME (print)Gria)21 3u s +ic(' CERTIFICATION/I Z/S--
?
��"ELL CONTRACTOR COMPANY NAME J u Sin l c E Wed, ir:LGA, PHONE if729 7 2 £i-14y4 9
STATE WELL CONSTRUCTION PERMIT(/
tifapplicable)
ASSOCIATED WQ PERMIT*
(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 C If Other, List Use
2. WELL LOCATION:
Nearest Town: `em-rl o^J County 74Cit/,yJe
(Stwet Na,,... Numbers. Common)._ Subdivision, Lot No- Zip Code)
3. OWNER: (3; LL 1404,4r41 er
Address q9 AscE/d?loN or
AShu;14..e W e
44by or- irnt7'_ Sine Zip Code
Area code- NSW number
16 35
4. DATE DRILLED, ZO —0(p
ti‘C_19 Log j
5. TOTAL DEPTH:
(Street or Route No.)
tics
Aft A-17,7`
z 8Re6
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL Below Top of Casing /00 FT,
I ( "+- if Above Top of Casing)
S. TOP OF CASING IS
FT. Above Land Surface*
*Tap of easing terminated at/or below land surface regains a
variance in accordance with ISA NCAC 2C.61 It
9. YIELD(gpm): Z METHOD OF TEST IQ'l2.
10. WATER ZONES (depth): WPM 6-ti7 3m
11. DISINFECTION: Type CLo1Gi ME
12. CASING:
From 0 Depthcr
aaua
To /2SFL
From / ZS To / VS FL
Front / To / d/ 7 FL to
13. GROUT:
From
From 0
14. SCREEN:
From
From To FL in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT
CONSTRUCTION STAND
Depth Material
To FL
Amount a oz.
Wall Thickness
'/o �I/ MatpdC.
Method
To 25 Ft. 4- pa 'coped
Depth Diameter Slot Size Material
To Ft. in in.
in.
Material
GC Topographie/Land setting
dge °Slope °Valley °FIaI
(ehxk appropriate box)
g�Latitudeilon iittude of well location
�iN ° �7 �
e1%i
N o 82 oG .72o �t1
(degees/minuos/seconds)
Latitude/longitude source:°GP$°Topographic map
(check boa)
DEPTH DRILL/NG LOG
From To Formation Description
90 of 24- settocic.
/90 905- 4ea,v;44.
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.
44
'
7o6
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
N
J
0
SIG RUtFPERSON CONSTRi INGIIIE.WELL_.._._.___._..._._gATE
Submit the original to the Division of Water Quality, Groundwater Selltiow, t636#nil Service Center Raleigh, NC
27699-1636 Phone Nn. [phone], within 30 days.
GW-1 ' RE V. 07/2001

N crr , a ronna Department of Environment and Natural Resources -Division of Wator Quality -Groundwater Sectinr
4636 Man Service Center - Ralelgh.N. C. 27699-1636-Phone [phone]
WEl L CONSTRUCTION RECORD
WELL CONTRACTOR: /f. AA.vz! fir• ;e-AiN
WELL CONTRACTOR CERTIFICATION p : .23-G y
STATE WELL CONSTRUCTION PERMIT # :
:SE rCheck Applicable Bot` ResidentialMunicipal n Industrial n AgricuL'ura! E Monrxrin_
+ea' rump Water Injection 7 Other Ll If Other List Use.
AT!:N Show sketch of the location below!
AMA:o.tr County
/G/ Rd
-' ,nn.r and Nun -there ';ommunpN or Suhrtrvisin^ and Lot No - DRILLING LOG DEPTr-'
^tNE /3(LL /)'C.rtilti =row To nrrna'inr Devrirt�m
qbk j/fiNSEY S'_
I SFeei or Reute No
inwr State Zin Code
1LGTL /C4
tip;, T,OL_ESTEE YES n NOpC.
L rvEnt ACE EXISTING WELL^ YES n NO7
rdA.TER LEVEL Below top of Casing. ?-;— FT
(Use'4' if above Too of Casing)
i 4SING IS /G FT. Above Land Surface'
inns eater; atror below land s rr'ace reowres a variance in actor
;r nr•p
'IA At; ME IN(11)(11- TEST- %39r=i-
.. ,',SOW 1derth)
'r.. AT(1N Tyne /X/f� Amount /; Cal
Wall Thu-keret
hamere' nr 'wetcint!FI `Matera!
tr„ L
Depth Material Method
To Ft
Ft
N
Depth Diameter Slot. Size Material
l-t n
iC 1 in
Tr Ft in
AVnl PACK
Depth Size
to Ft
Tn Ft
in
in
Material
n addrtiona, snare is needen .sn hard term
LOCATION SKETCH
Fhrm direction and d'stan::e cm^' a''6 .
Roadsor other man -efererce nor-'c'
Levniona:owre
/ Oiii"er P rotecti,
RECEIVED
- 'IF REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
-,NS`RIICTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO WEI1 ^fuNre
FOR OFFICE USE ONLY
]uad No
e-���'•/4(•
/-.22-nC
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division et Water Quality, Groundwater Section within 1C ^.ays
SW RFV

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment an
WELL CONTRACTOR (INDIVIDUAL) NAM (print)
WELL CONTRACTOR COMPANY NAME NNpp ►la�ia�l'We
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
Natural R
324404
oes - Division of Water Quality - Groundwater Section
CERTIFICATION # p__
PHONE # Ssti)? 3-/Rti
a 1) /u,ui•
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential Li Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT *N:
Nearest Town:
County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: �i fir, f'�
Address,f�'f `(Q �f�iftai
(Street or Route No.)
2iioN nre aS 752
ry or own State Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: AO //
6. DOES WELL REPLACE EXISTING WELL? YES NO Iti
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use `+" if Above Top of Casing)
8. TOP OF CASING IS If FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordant` �ga.,g ISA NCAC IC .011&
9. YIELD (gpm): n_. _— METHOD QF TESTGtY(. Cott,2�%ne✓
10. WATER ZONES (depth): too,IYO
/Topographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/lo i deofwelllocation
N5,5*M.7ttT keg;` 0a.*a
(degrees/minutes/seconds) C 4iager✓
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
glpo
11. DISINFECTION: TypeStref Amount 02
12. CASING: Wall Thickness
Depth
From—e3P' To I64 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From
From "lbF
14. SCREEN: Depth Diameter Slot Size Mat rial
From To Ft. in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Diameter
or Weight/Ft. Material
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.
flECEIVED
Ashevilie Regional Office
AC'itvr Prr:!Cc:ti
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL 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
v

,L\ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
1. WELL CONTRACTOR:
James W. Camp
WeE Contractor (Individual) Name
Camp's Well & Pumn Co. Inc_
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC
City or Ta.vn State
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID hoer applicable)
28040
Zip Code
STATE WELL PERMR#(rapplcable)
DWI or OTHER PERMR NW applicable)
WELL USE {Check Applicable Box): Residential Water Supply
DATE DRILLED 2 -lS-6fo
TIME COMPLETED 4: /S AMP PMIB'
3. WELL LOCATION:
CITY: �fAY1Pn COUNTYMrIV? II
/vtLikd- fawe �'d C
(SaeN roam aN D. Canmwllly. Sub No. jarc$ilp Code)
TOPOGRAPHIC / LAND S G:
❑Slope Malley°.Flat E Wge ❑other
(check appropriate burg ,/
LATITUDE _a_ r;i q i . it8D N
LONGITUDE I_ A_ 00 . 791 tJ
May be' in demo,
minutes, seconds or
in a dedmal format
Iatitude/longitudesource: DGPS oTopographicmap
(bcatbn of wel must be Shown on a USGS topo map and
attached to thb form /not ushg GPS)
4. WELL OWNER a \ ) . 1'1 --
OWNER'S NAME S. "=-' ' ✓O4I 011-0l5
STREET ADDRESS /1' 5 L� .�° 1'd.:fV f'r tL 4Ly
C : e be- C Pl `7/. r
City or Tan State Zip Code
Area code - Phone number
5. WELL DETAILS: I ��
a. TOTAL DEPTH: L�-
b. DOES WELL REPLACE EXISTING WELL? YES (3 NOX
c. WATER LEVEL Below Top or Casing: SAD FT,
(Use se B Above Top d Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top d casing temdrteted at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118. ,
e. YIELD (gpm): .2. METHOD OF TE$T (L) V
t. DISlNFECTION:Type chlorine Amount //2 0-(is
g. WATER ZONES (depth):
From To ?2'17
From To
Fran To Fran To
From To - From To
6. CASING: - Thid ess/
DeFran 0 To 6S Ft. 6r Diameter SDR21 Pt VC
From To Ft.
Fran To .Ft
7. GROUT: Depth Materiel Method
From 0 To 20 Ft Sackrete Hand
From To Ft
Front To FL
8. SCREEN: Depth Diameter Slot She .Material
From To Ft. In. h.
From To Ft In. In.
From To Ft M. In
9. SAND/GRAVEL PACK:
Depth Slur Materiel
From To Ft
From To Ft.
From To Ft.
10. DRILLING LOG
From To.
0 5—
Form n•Description
rt/e/14 irf
!0 5 .405- /'vYlso/'d ate re,c_K
11.
100
15A
REC
O
ASOONS1RUCTED14 ACCORDANCE WDH
DARDS, AND TWA COPY OF THIS
EEN PROVIDEDTO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within.30. days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699,4617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

From To
13. GROUT: Depth
From_ To -?o
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
324303
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME /t(prfat)� k1txeS C=iVS. ^ CERTIFICATION# e.1 (eV'
WELL CONTRACTOR COMPANY NAME &LC a. r 'N e\I Oc: �\ (t.5 PRONE # &Xi GS9- 3411
STATE WELL CONSTRUCTION PERMED ASSOCIATED WQ PERMIT./
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ErMunicipaWPublic 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION{., �n
Nearest Town: C+Cton County 1 ` `C�we tI
S�ot,e ceeK
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Co
ode) 3. OWNER:It�G�p�t.lek� � �re�4Yle Noos:e5
Address Oee.c 9oc i,>X ..
AJ e.lz� ( 'cN.e c Na, a ri
(Thry
or LS9— I144 Zip Code
Area code- Phone number
4. DATE DRILLED %I it) 0 (P
5. TOTAL DEPTH: 1 11
6. DOES WELL REPLACE EXISTING WFI.i 7 YES ❑ NO air
7. STATIC WATER. LEVEL Below Top of Casing: &S FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 S FT. Above Land Surfaces
*Top of using terminated at/or below land surface requires a
variance fa accordance with ISA NCAC 2C .011&
9. YIELD (gpm): N METHOD OF TEST (.,:e f
10. WATER ZONES (depth): (' I / d
11. DISINFECTION: Type 5L� cS \nal i 'Amount 14 0 C-
12. CASING: Diameter Wall Thickness
From C To th' I Ft. 6' a -or Crr/Ft dal
Front_ To Ft NY
Ft
Material
Ft. don en
Topographic/Land setting
❑Ridge ❑Slope Malley ❑Flat
(check appropriate box)
Latitudenor ^_•de of well location
(degreea/miaureslgxmds)
Latitude/longitude source:❑GPS❑Topographic map
(died( box)
DEPTH DRILLING LOG
From To Fonnation Description
ECEIVED
ills{ 4�sp�ie•�a� Office
au! Ci r lt`JtecEoft
LOCATION SKETCIJ
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
7_ C
Method "--n)
Ft
Diameter Slot Size Material
Ft in. in.
Ft in
Size
Ft.
Material
Ft
1/454C /-'r7it .ISk.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/
„urban tt"-- I /1 ss/o (n
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original t 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

CO 324302
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Dx'visiig1n of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i3-6 tY% fl� �+`^cl. S't CERTIFICATION #<D L �7.I�/
WELL CONTRACTOR COMPANY NAME C-XACcI % 1 W e kI DC\1\ . AQ PRONE # i��) G�1 I '� �7 T
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PPEERM T#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residentiale Municipa1/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO. /�(�
Nearest own: \ACC[M\ Calmly (Nl \cOcw<1l
o n \t..* -{�r.0 e`� Lx`, ` F 1
(Street Name, Numbers, Community, Subdivision, Lot No., Tip Code)
3. OWNER: Tu/11 KA- Nev. e V
Address Occ,C c n 0 c',4,2-
(Street or Route No.)
Mafia N
Q%?SD
/
City orT State tip Code
(?, a'G) Zit ` cR`kka
Area ado- Phone number
4. DATE DRILLED of 14/ O Le
5. TOTAL DEPTH: 1-1'\
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C
7. STATIC WATER LEVEL Below Top of Casing:
if Above Top of Casing)
8. TOP OF CASING IS \ _ 5 FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a
variance In accordaaee with 1SA NCAC 2C .a118.
9. YIELD (gpm): METHOD OF TEST ,12 C
10. WATER ZONES (depth): IIo— P
/ 5— 1)�
ype4 Neer. ;j- Amount It, OZ
Wall Thickness
Diazgt ter or Weight/Ft Material
(� /4
11. DISINFECTION: T
12. CASING:
p Depth
From 1 To b 7 Ft.
From .S1 To (eO Ft
From To Ft.
13. GROUT: Depth
From'1 op To.(Z Ft
elamen
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.
Mothod
Material
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
From To Formation Description
vD
Asheville Regional Office
tion
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.
ex
FceS-
La+ 4F%
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRULI>:D IN ACCORDANCE WITH 1SA NCAC 2C WELL
CONSTRU ON STANDARDS, THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a2/L1/6
SI ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submiithe 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/rl Resources A Division of-Watteranalty-.�munclasterSection
WELL CONTRACTOR (INDIVIDUAL) NAME (print)f[//Cn C K ca.' s 7/C ... CEKRFICATroN# 27l Y
WELL CONTRACTOR COMPANY NAME4 t.k e e ( W e/ LUY- I/ % Ur7�[/_ .� PHONE a (? 2) e 419— y3c
STATE WELL CONSTRUCTION PERM/Ill ASSOCIATED WQ PERrII17►
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential L`7 NfunicipallPublic ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: /
Nearest Tows Ci
County %? i U, B
(-ILL cis - ale 1c/'t'S kr)" 16762
(Sheet Name. Numbers, Community. Subdivision, LotNo., Tap Code)
Topographic/Land setting
❑Ridge ilslo alley ❑Flat
(cheek appropnate box)
Latitudellongitude of well Location
3. OWNER: (/'t'S k•, /) e ue% r'i5 (dim' 60 )
Address Sig/e S n She e Cies /t r, li ie Latitude/longitude source:❑GPS❑Topogrnphic map
J ( or Route No.) (aback bunk)
Ol (D kJ, r N G 7 7/ - DEPTH DRILLING LOG
city or Teem Slane Zip code From To Formation Description
�}
Area code- Phone number
4. DATE DRILLED 3 -/ i -0 In
5. TOTAL DEPTH' 5 ri 5`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0--
7. STATIC WATER LEVEL Below Top of Casing: WC" FT.
(Use'+" if Above Top of Casing)
8. TOP OF CASING IS / Fr. Above Land Surface*
flop of cadog terminated at/er below land soarase requires a `
variance g accordance 15AM TOD OF TEST i et'7Ye[
9. YIELD (gpm):
10. WATER ZONES (depth):
11. DISINFECTION: Type r C /i! Amount /C? c2 Z
12. CASING: Wall Thidmess
Dept�,� D , or Weight/Ft
From To ((r; Ft. (f, h 40R-?!
From To Ft
From To Ft
13. GROUT: Depth Material
Fromm 9 To %() acenci"Pi"t'
From
To Ft.
14. SCREENS,( Depth Diameter Slot Size
FroToTo Ft in• in.
From / To Ft_in. in.
15. SAND/GRAVEL PACK
of Depth Size Material
From ' To Ft.
From // To Ft.
0
J,OCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
nu:, • ers and common road names.
V,
.......-.r C'fire
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH44ANCACK /WELL,?
CONSTRUCTION FTANDARDS, AND T A CO} OF THI ORD HAS BEEN PROVu1i•.UTO THE"WELL OWNER—
DATE
SIGNATURE OF PERSO CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 163f Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-f REV. 07/2001

WELL CONSTRUCTION RECORD
th Ca(i.„1,4ituaent of Environment and Natural Resources- Division of Water Quality - Groundwater Section
cerTzks...c, (iNDA-ran)Au NANct5)-„,,,,„; / err) _Li_ is A A__ ITC t tp,ThricAnoN# Z 7
,1 71s
r
MIE1,14' 7.1'211:i. rICY`472:,XV N i:1042,-2:27',2472 e i1/4/0 /4 Ay- ilvert: afil:s.,:fr?Vlf 014i: 0
STATE. VILLL Mir WQ MIMI*
Of applicable) Of applicable)
I. WELL USE (Check Applicable Box): Residential la---g-tmicipai/Public 0 Industrial 0 Agriculturallgi m
MknvgEJRew-vesyLi ireet Puthp Water Injection 0 Other 0 If Other, List Use V711 CD -fl
43
tryi
Topopaphi.c1Laud settiliii
EIRidge °Slope I:Walley 'DAM I
(check appropriate box)
Latitude/lougitude of well loggia()
3 OWNER: /MS fr (degreceirnivedesMomada)
i0
Address g (I/lel P 2 i? Latitude/longitude source:OGPSEITo
iie
or Route Na) (check toe)
d seuec 2..Z 7 DEPTH PRBLING LG
City or Town State Zip Code From To Formation Description
Area code- Phone number
4. DATE DRILLED 3 V 7 - 06
5. TOTAL DEPTH: ?O 4
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0"
7. STATIC WATER LEVEL Below Top of Casing: 3 Vr FL
(use *4-'1 IfAbcwe Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing termbutted War below bead surface requires
"wince ht tm741wa wet ISA NCAC 2C .011S.
YlFtil W-11): 4,0 METHOD OF TEST tfl re7
WAtERZONFS 1-
WELL LOCATION:
Nearest '1own: pi nv County Int rkt4-' et/
c-q Cis Aiti vie - ars Ion E
(Settee Name, Numbers, Commute% Subdivision, Lot Nt, Zip Code)
1 i DI-TINFECTION: Type C, r.17/
12 (7. Astmo:
• Depth
Front_g_ ToS.C2_ Ft
From_ To Ft.
From To
13. GROUT: „it, Depth
Front„(eTo ?CJ
Ft
,-Matetial
Ft ( enc fro
Amount /es) 7
Wall Thickness
or Weight/Ft Material
soR -e ( P tit
From To Ft
tb
14. SCREEN:j Depth Diameter Siot Sim Metals!
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
From 0 Depth
To Size
Ft. Material
nor, si, FL
?„ 6 R.21,,,IA)XKS: cO/Ci, - co-ed
11
IL)
0
LOCATION SRETCU
Show direction and digital)" in miles from at least
two State Roads or County Roads. Include the road
and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS C0NT1WC ttD IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUil STANDARDS, AND
F THIS RE HAS BEEN PROVIDED TO THE WELL OWNER.
C r, tie
SIGNATURE OF PERSON C9RSTRUCTING THE WELL DATE
. -
STA brit lt origiael to tits Mwu ot Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
y:699.4 633% phort Nek, (979). 733-3121, 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 (ry-t) //en C K Ao elf s .7"R CERTIFICATION if 2 7 e V
WELL CONTRACTOR COMPANY NAME SC',. P e)t (:'v/4 feet I.v f/l 7 Aces,/ / PRONE M (FZi) Yt/YJS/F0
STATE WELL CONSTRUCTION PERMIT* _ASCOCIATED WQ PERMIT'S
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IiMu nicipal/Publie 0 Industrial 0 Agricultural\O, °*
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Odra, List Use 1` i
2. WELL LOCATION:
Nearest Town U / ) ' r' CountyMt DI u e / dge Slope
suKtu4g'_ c
?�c� T � !! ❑Ridge 2fSiope ❑Valley
e'-%(1 C/'e's r lei) t!'rie_5kn 't n'76 2- (check appropriate box)
(Sheet Name, Numbers.//Community, Subdivision, LotNa, Zip Code) Latitude/longitude of well loc n,
3.OWNER: <it5)`C'n l)eu.e/0 et,
Address C-%O r/'e5Ion 0
/J ( or Route NO
©h/ 4, ivc 73T67
City a Town Stare Zip Code
Area code- Phone comber
4. DATE DRILLED / 5 ci
5. TOTAL DEPTH. S-() S`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: Z 70 FT.
(Us "+" if Above Top of Casing)
8. TOP OF CASING IS 7 6 r/ FT. Above Land Surface*
"Top of codas terminated at/or below laud surface requires a
variant h aeeerdaae war 1SA NCAC 2C A1I8. /
9. YIELD (gpm): METHOD OF TEST //!� r/
10. WATER ZONES (depth):
11. DISINFECTION: Type C
12. CASING:
Depth
From ToO Ft
From To Ft
Amount /O ' ?—
Wall Thickness
or Weight/Ft Material
,50K-z( DUG
From To Ft.
13. GROUT: Depth Material
From F To 20 Ft Cmr"SC
From To Ft.
14. SCREEN: Depth Diameter
From To Ft in.
From To Ft in.
15. SAND/GRAVEL PACK
From ) Depth
To Ft Size Material
From To Ft
Method
cue% /11//
a - +
I
(degreedmimaes/secends) .,. ``
Latitude/longitude source:❑GPS❑Topdlgrap*c map tf
(check box) DEPTH DRILLII�(CLOG---
_
From To Formation Description
Slot Size Material
in.
in.
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.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCfi0STANDARDS, T/ICOPY OF S RECORD HAS BEEN PROVIDED TO THE WELL
Q
SIGNATURE OF P,
N CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone Na [phone], within 30 days. GW-1 REV. 07/2001

WELL CO?4STItUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divicinnof W*ei4 Iality—GieooadaoterSoctioa 1�
WELL CONTRACTOR (INDIVIDUAL) NAM�E ut) AdenC Rhe d(/`PS SIeCERTIFICATION # 27&%
WELL CONTRACTOR COMPANY NAME it Pe tome!" wle) I or Ppin-2 PRONE,/ arts vie -owe
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PF.R IIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 2 Municipal/Public ❑ Industrial CI Agriwltula c
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:, / ff �/
Nearest Town. �/a ?'Ut' / County lved)toe//
94// 5/9 r/lvn/t Rd 7i763
(Street Naaw.Numbers, Community, Subdivision, tat No., Zip Code)
3. OWNER ?onnit 0400
Address 9'// 5s lPI31 rALL, rii fJ
(Street or Route No.)
01 d fbr r 1U(
?alto 3
Zip Code
NCAC 2C All&
9. YIELD (gpm): 3 C) METHOD OF TEST if /
10. WATER. ZONES (depth):
City orTown Sate
(
.)-
Mn code -Phone mnba
4. DATE DRILLED 5 ' VV..0 G
5. TOTAL DEPTH: 3'6
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
3 D FT
7. STATIC WATER LEVEL Below Top of Casing: .
t (User if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface* casing of slag tenanted der below land surface requiresa
verbs.* in accordance wills ISA
Topographic/Land sr tin
DRidge lerope OValley, _Flat
( ) '
Latitude/longitude of well looauon
7.31
(deowhninut&swondtl tii '.. rll
Latitude/longitude source:OGPS[topa raphicmap a
(check brie), -:
DEPTH DR>1 LOG
From To Formmtion scription
11. DISINFECTION: Type C cg
12. CASING:
,,( Depth
From X0 To /Al
From_____ To Ft.
From To Ft.
13. GROUT: Depth
From To 70
From To Ft.
14. SCREEN. Depth Diameter
Front To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
y� Depth Size Material
From_V�To Ft.
From / To Ft.
Amount in a7
Wall Thickness
sw l
Mateial Method
Ft Cvl�Cre7 Lo e 1 rti' $
LOCATION SK.ETCII
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.
16. REMARKS:
St{
. ,..,,ed
I DO HEREBY CER
CONSTRUCT' '/ '1 ANDARDS, AND THAT
THAT THIS WELL WAS
NSTRU - r IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF r; S RECO '; HAS BEEN PROVIDED TO THE WELL OWNER
3-C c
_ — — SIGNATURE OF PERSON CON UCTING 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 CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Grotmdwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME .lot) fit, C %S' li rJ t%RT s CEIFICATtoN s Z 7 $ Y
WELL CONTRACTOR COMPANY N Wee W fit )4V' /deg 4' t,a f,PUONE x no
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0--Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI N:
Nearest Town: 42&- l(Art Cotmty Ade ccfi'%/
/6/2 Pecs ks f)/L 'iTAr Pet/4 " ! E7 ,
(Street Name, Numbeer, Carmmaity. Subdivision, Lot No, Zip Code)
3. OWNER: CA67e (_ (r////V Pk
Address /6 ft Piet As PR
(Street Street or Rome No.)
lWC tU 2T 7 5 e
City or Town Sty Zip Code
(
Arca coda Phone number
4. DATE DRILLED Z'/?-0
5. TOTAL DEPTH: '? (c 5'
6. DOES WELL REPLACE EXISTING WELL', YES 0 NO 0'
7. STATIC WATER LEVEL Below Top of Casing: (o 0 FT.
(Use"+" if AbTop of Casing)
8. TOP OF CASING IS /e /r Mom FT. Above Land Surfaces
*Tor of casing termlaated atfor below land surfnee regains a
variative In accord**. ISA NCAC 2C .Ol It
9. YIELD (gpm): c b METHOD OF TEST / men r
cir
10. WATER ZONES (depth):
11. DISINFECTION: Type C. G N.
12. CASING:
,�( Depth Dian
From W To 4/0 FL
Fron__ To Ft.
From To FL
13. GROUT: Depth �,Mat�/
From 0 To ZD FL _a( /der ,e
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From fir To FL in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From.- To Ft.
From To FL
Topogra ahic/Land setting
Midge Higlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreWmimaethizadr)
Latitudellongitude source:❑GPS❑Topographic map
(check hoc)
PRU.LING LOG
To Formation D.a..iytion
DEPTH
From
J.00ATION SKETCI€
Attmtmt /0 o z. Show direction and distance in miles from at (east
Wall Thickness two State Roads or County Roads. Include the road
or Weight/FL numbers and eominon mad names.
50R 2/ _AEl
(614
16. REMARKS:
f„
M J[
W> /A K
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL I EU IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST S, AND THAT A ♦ OF RECORD BEENPROVIDED TO THE WELL OWNER
a�,l c C � �1 — 2-I2 -06
SIGNATURE a F PERSON CONSTRU G THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No(919) 733-3221, 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 p �/
WELL CONTRACTOR (INDIVIDUAL) NAMEJprtat) "I/ n 0 f AO Q t"S CERTIFICATION 0 z 7 0
WELL CONTRACTOR COMPANY N /W e e "Pt
W /¢ /xr Weil q i st,PBONE M id to Vg-o o
SCATF. WLLI FONSTP(It'Tlrl*t PERMIT/ IT/ • ran /
_.�. ' _,._...,..!.'Z4'r,'E7� 4t t23+'N.S.:.II1P
cp:i ail 3..•): Ps s iar .ice ,
MIgimpaittat,Le i :I ial 0 Agricultural 0
Monitoring ° Recovery D Heat Pump Water Injection 0 Other D If Other, List Use
2. WELL LOCATION: �
Nearest Towp: ein tot `f Cosy i? deCIL'
1d/ m.- / creel i ri Mi'(/ rfee/G /rlsi ,n
(Sweet Name, Numbers, Community, Subdividon, lot No., Zip Cade) Z$ 7/0
3. OWNER: B&yJ/5 /21/ 9E, ,'/t;XPus
Address /Ci kr.`[/ I.'fr', /ZC/
( or Route No.)
Gila ,cy' o`''1/oC�
City or Torn Sint Zip Code
}
Area Cade- Phone number
// -O G
40
EXIS INCQ WELL? YES 0 NO ®�
, r ., afCasing: /3 FT.
'$ Above Top of Casing)
si r a . Above Land Surface`
a:ziur b in taa.$ aSlS`Y*s requires ■
i 15A NCAC 2i:.GiliL
METHOD OF TEST / i /neat
10. WATER. ZONES (depth):
Topographic/Land setting
°Ridge O Iope °Valley °Flat
(check appropriate box)
Latitude/longitude of well location
(degeeu7mimaesre )
Latitude/longitude source:DGPS°Topographic map
(cheek tor)
DRILLING LOG
Formation Description
DEPTH
From To
4. DATE DRILLED Z
5 TOTAL DEPTH:
6 SXESWErL-RIIi
•
vy n.P rssisg tc-atinav:d
'+'iirtajnz iai ae[ittlaaee, rt�'
4. YIELD (gpm): _1L
11. DISINFECTION: Type
12. CASING:
Depth
From Y To CMG)
From To
From To Ft.
13. GROUT: Depth
From i To '2C
From To
14. SCREEN: Depth
C/.il4 Amount //5 uz
Wall Thickness
Ft
orSp/Z Z/ WeighUFt. Material
PUL /fi cr/
Ft.
{<iNS TR
Ft(C /e
Ft.
Diameter Slot Size
in.
in. in,
Material
Material
JOCATION SKETC$
Show direction and distance in miles from at least
two State Roads or County Roads, Include the road
numbers and common road names.
`Il Craft
S'TR�.Ur�(r.� /t) IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF $is RECORD I198BEEN PROVIDED TO THE WELL OWNER
OF PERSON CONSTRU
G THE WELL DATE
ice Center - Raleigh, NC
GW-1 REV. 07/2001
t

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME i en .C{ /ehCC/es `Sr? CERTIFICATION #273O'V
WELL CONTRACTOR COMPANY NAME <i.l: C P l.v r-!'V f" (AN I I 7 P0,4-1, PRONE # f Z) /t, 5/% "C fe d
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I WELL USE (Check Applicable Box): Residential LL-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: illAit' jn) County 7i COLL'e7/
/710 Hy& /? 6 Z/.576 3
(SueetNaae, Nambus, Community, Subdivision, Lot No, Tap Code)
3. OWNER: (i' se//I (07./1/fcYgj`C5
Address /7 0 IIy ui I 6 5,Q/rs oA4re
(Steetbs Roue No.)
114iltILw A''L 2t7& 7
City or Town State Tip Code
�)
Ma cods Phone number
4. DATE DRILLED Z
5. TOTAL DEPTH: So 9
6. DOES WELL REPLACE EXISTING WELL? YES O NO B
7. STATIC WATER LEVEL Below Top of Casing: f 0 FT.
n (User if Above Top of Casing)
8. TOP OF CASING IS /o FT. Above Land Surface'
`Top of easing ter dented ape below land surface requires a
variance to accordance with ISA NCAC 2C .0110. }—
9. YIELD (gpm): (In;
METHOD OF TEST / da'+c
10. WATER ZONES (depth):
11. DISINFECTION: Type CC H
12. CASING:
Depth
From To /60 Ft. o e(/
From_ To Ft
From To Ft
13. GROUT: Depth
From 0 To ZC'
Amount /., (' L
Wall Thiclmess
or We&ght/Ft klaterial
we Z/ pi)
Topogt9phic/Land setting
ORidge Ot. lope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrw/mimumhemnds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH, DRILLING LOG
From To Formation Description
(,v tit i X
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From / To Ft ______in. in.
From To Ft in. in.
Material
Ft�it/eetie
15. SAND/GRAVEL PACK
�( Depth Sire Material
From Y' To Ft
From To Ft.
I6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL
CONSTRUCTION STANDARDS, AND
0
LOCATION SICETCI{
Show direction and distance in miles from at least
two State Roads or County Roads. Include theroad
numbers and common road names.
e
Ake Pline,
AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY OF THIS<4EQORD i}elS BEEFPROVIDED TO THE WELL OWNER
bk. r
SIATURE OF PERSON CONSTRUCTING
z- i5`-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-1 REV. 07/2001

WELL-1ONSTRUCTION RECORD
North Carolina - Deparhnent of Environment and Natural Resources - Division of Water Quality- GrooadanterSection
WELL CONTRACTOR(INDIVIDUAL) NAME (ptlat�/'8/1 ,o, tic e5- SlZ,7 CERTIPICATlON i Z7 o[�
(
WELL CONTRACTOR COMPANY NAME Sik?r � Lt:.04161' Lk; P/f i' M< rrlr PHONES, & a LY99-twee
STATE WELL CONSTRUCTION PERMTTI ASSOCIATED WQ PERMITS,
(dlu) (if applicable)
1. WELL USE (Check Applicable Box): Residential QiMtmicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: , ��
Nearest Town://'!i L County
tot /h L&i f'g, er �..C// I ,l, - / (Vowe
i y
(Brest Ns Numbers, Cemmmity. Subdivision, Lot No, hp Code)
3. OWNER: t!'PS(!// CDfrinu/t/re;S
Address Spec !%sit,*Is
(Street or Rome No.)
///1/�)q w/✓ //l)L -z 7(o 3
City or Town State tip Code
(^1
Ares code- Phone number
4. DATE DRILLED "2 7 -0 (v
5. TOTAL DEPTH: 2 (0 5�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er--
7. STATIC WATER LEVEL Below Top of Casing: 3 0 FT.
it (Use *"4"' if Above Top of Casing)
8. TOP OF CASING IS / 6 FT. Above Land Surfaces
"Top of casing terminated at/or below land surface regulra ■
tartans la aeeordaue with 1SA NCAC ZC A11a. /
9. YIELD (gm): / 7-METHOD OF TEST / !!.^/ ter
10. WATER ZONES (depth):
11. DISINFECTION: Type (: / It Amount /£7 :5'Z-
12. CASING:
Depth
From_ _ To 70
From__ To
From To
13. GROUT: Depth
From f To Z e,
From To
14. SCREEN: Depth
To Ft in.
From_ To Ft in.
15. SAND/GRAVEL PACK:
Depth
From_T
FroTo
m
Wall Thiclmess
Ftrn"Cr lC
Ft.
Ft.
Ft.
Diameter
From_
16. REMARKS:
o
Ft.
Ft
Topographic/Land setting
Midge ['Slope Malley Orkt
(check appropriate box)
Latitude/longitude of well location
(depths/mimeos/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
0
Method
We/ mix
Slot Size
in.
in.
Size Material
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
ec\
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARD AND THAT A CO >'}(QF TIE tECORD ijAS BEEN PROVIDED TO THE WELL OWNER
Z 7-0e
SIGNATURE OF PERSON CONSTRU'Cr1NG THE WELL DATE
1414 G
n,
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone Na [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) 4HR ' )D• Su St IGc CERTIFICAATIION*Z/S°
WELI. CONTRACTOR COMPANY NAME 3 4IC F WeL`d f (4Gr MC) PHONEY 13211 7Zt USIe
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERM
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Puuu Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: ,,,��tl
Nearest Town: meats County /1/Cbpf.+GL,(❑ - Flat
f SUNNY etrode (CI /9 bika.LWm! D✓
( Name. Nmnbas. Community. SuMivtvm/. Lot No. Zip Code)
3. OWNER: taunt �� Peck
Address / O S S A.✓cit asked � e
(Street or Route No.)
tbo
C
City or Town � rap
> 4S9.2446
Area code- Mom numbest
4. DATE DRILLED S/ Z 3 O(0
5. TOTAL DEPTH: 465
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 6✓
7. STATIC WATER LEVEL Below Top o?Casing y 0 FT.
(Use"+ if Above Tap of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top of casing tenanted odor below bad sorbet requires a
variant L x..,d with ISA NCAC 2C J11*.
I0. WATERZON9. YIELD EG��oa 9pOF aSo
1I. DISINFECTION: Typea6R1NE. Amount % 6Z
12. CASING: Wall Thickness
Depth Diemctcr or WcigbUPL Material
From To Ft.
Flom V To Ft.
Fro& 't To Ft ,/
13. GROUT: Depth Material
From To FL
From p To zo FL pv�►t/►ed
14. SCREEN: Depth p Sfot Size Material
From To FL in.
From To FL in.
15. SAND/GRAVELPACK:
Depth Size Materit
From To Ft.
From To Ft.
16. REMARKS:
Method
sutour 6t1o44
T°po�Phic/Land setting
Rrdge ®Slope OValley ❑
(theca appropriate box)
oai' uutk oi On(so3S L.�z 34 ivf ©well 92 0n7 , 8sa l
nhowshninutes
Latitude/longitude sotacc❑GPSOTopographic Dap
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
yS
Died
ors v* s-,.
8 - f65- tit c tfrife
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads er County Roads. Include the road
num�b1e,trs t6lRA�DIPV yu9%,j onnon road names.
224 s
ll — p1SMrdis 6 44.,
G hoditeG Cam$
r.
Cux
1 DO HEREBY CERTIFY THAT
CONSTRUCTION STAND
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
THATA COPY OFTfCORD HAS BEEN PROVIDED TO THE WEIL OWNER
ATU0
NSTRUCTINC, THE WELL
DATE
Submit the original to the Division of Water Quality, grounchiata
tea, `I43tE S., — ...1,__
27699-1636 Phone Na (9I9) 7T;-Tl+T, withal 30 days- (t�a,. 1 R s GW 1 REV . err
07/2001

WELL CONSTRUCTION RECORD 3 2 9 7 5 2
North Carolina - Department of Environment and Natural Resources- Division of Water Qua)iiy - Groundwater Section
(('ELL CONTRACTOR (INDIVIDUAL) NAME (print)�rT l-n7i P l.t -s �15n '1 CC CERTIFICATIONf%fi N 2150
(v ELL CONTRACTOR COMPANY NAME 3e S#icG. WT./♦ r r I L17-3 PHONE R y[;.12cf-4Stjy
$"MATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT/.
ttf hc+ble) (if applicable)
1. WELL USE (Check Applicable Box): Residential II MunicipaVPublic 0 Industrial 0 Agrteultural D
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
WELL LOCATION: a Topogphic/Land setting
Nearest Town: et» cbr#r County %Yl�L,Olr-'L�t, °Ridge HRSlope ❑Valley 0Flat
(45 V O c- ft 4 -C 1-a-L. c 4 t...-- ,— ,
(Strew Haim:- Numdnz Community, Subdivision. tot No. Zip Code) Latitude/longitude of well location
Car-e�'u- Fo-Q-Q-o PALge.(-0-C 35°35. ioto 0 092° 15.t%i W
3. OWNER: ; (degreeshnin�u�mtgyrmoods)
Address /Si V OS E Yt. it'{ FALLS 174 Latitude/longitude sourcc:SGPSDTopographic map
(Strew or Route Pto.% (chock boxl
C3() fors- %V e- 21.9 2— DEPTH DRILLING LOG
Cry or Town Sue. ZrpCade From To Formation Description
Any. code- Plume number
4. DATE DRILLED -V to I 0to
5. TOTAL DEPTH: (C v
6 DOES WELL REPLACE EXISTING WELL? YES 0 NO I3'
7. STATIC WATER LEVEL Below Top of Casing: *(ob FT.
(Is ifAbwe Tap of Casing)
8. TOP OF CASING IS t FT. Above Land Surface'
'Top of casing terminated ator Deism (and satiate minims a
nriance is accordavec with ISA NCAC 2C .O11t
9. YIELD (gpm): %L METHOD OF TEST )4 I R.1Si¢INII
10. WATER ZONES (depth): Wyv/n by, 00'
1
it/
CoS (yn-144v/
505-.5'r0
•sya - coos-
.�cy�y G�iG►.�c ,
frig- ig r C3ttt A-e
LOCATION S ETCH
11. DISINFECTION: Type C Loic NC Amami 9 UZ Show direction and distance in miles from at least
12 CASING: Wall Thickness two State Roads or County Roads Include pthrer, road
Depth Diamctaz or Weida/Ft. Material numbers and common road names. Iy!A9
From To FLl�t-� COW -Cis From 0 To (04 Ft t, p Uc /t 4L1 y' C ,(J""'
From 10 Z To /04 FL (0Yrl . / 99 y ¢/t/ �
13. GROUT: Depth Material Method
From To Et.
From 0 To 7-0 Ft az re,t
14. SCREEN: Depth Di er Slot Size Material
From To Ft. in. in.
From To FL in. in.
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Fe_
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STAND AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S
TUOF 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
no to

329767
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater SMOOT::
CERTIFICATION it 2]f
PHONE # f )
\Y ELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL. CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if a y.Iicable)
ff
1. WELL USE (Check Applicable Box): Residential EI/MunicipaUPublic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: �I C/A�
Nearest Toown: ar : tp Count{1q /rt �"-—
108 J4WdrgtDoNejnr N¢(rc S I Zy IluMMISAMt
(Street Nauru. Numbers. Community. Subdivision. Lot No., Zip Code)
3. OWNER: 0' ({ WO f(e`l
Address 1 /O8 $9tAtot.Se,.a,c
Ajtho(streatvReeNo.) zgni
Cny or Town State Zip Code
(929)- Sot — 62go
Area cote- Plttwc number
4. DATE DRILLED
5. TOTAL DEPTH: 4 b5 /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IIY ltt' 7. STATIC WATER LEVEL Below Top of Casing: 1 V0 FT.
(Uses"' if Above TopofCasing)
3. TOP OF CASING IS FT. Above Land Surface'
Topogr ic/Land setting
❑Ridge 19SIope ❑Valley ❑Flat
(check appropriate box)
3,7?ud3 ngiludgofc'etioc' •�3,7
(degrees/minutes/seconds)
Latitude/longitude source:DGPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
'Top of casing termiaated atlor below land surface requires a
variance in accordance with ISA NCAC ZC
9. YIELD (gpm): 4 METHOD OF TEST A / N"
10. WATERZONES(depth): 3 Iprt tp .300�
4'qp.,. @ 140(1t
1 I. DISINFECTION: Type Amount
I? CASING:
Depth
From To FL
From O To 25 Ft.
From_ . To an FL
13. GROUT: Depth
Wall Thickness
Diameter or Weight/FL Material
Material
From To FL
From 0 To___` _ Ft p
14. SCREEN- Depth Diane�� er— Slot Size
From To FL in. in.
From To FL in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
WC
Method • 0 /840 n'C <4
�— t S D't tut-
tor- (7 dem) fc
LOCATION SKETCH
tion and distance in miles from at least
or County Roads. Include the road /
tubers . . moron road names. r 7616W0 /4
,7g
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Marl Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

Diameter
Ft.
FL
2 ?88
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisito_n of Water Quality - Groundwater Section
Zirti
tY ELL CONTRACTOR (INDIVIDUAL) NAME (print) V H 1L 3U U.
,T(Cjf- I p CERTIFICATION�x �/ fie
,t'ELL CONTRACTOR COMPANY NAME .10 S.�t Cn.. U. D Y, U.I Nq PHONE r 829 7a 'i- 45 f CJ
l t
STATE WELL CONSTRUCTION PERMIT,/ •svv'IATED WQ PERDIITR
rstzgazarega(i(applitabk)
(if applicable)
1. WELL USE (Check Applicable Box): Residential jf Mtmicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Material
P ✓G
4A1, ✓
Pu topel
14. SCREEN: Depth Dilleter 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.
2. WELL LOCATION: •
Nearest Town: OA Q{ I a
Eask Pikyysit A.
(Street Name_ Numbers. Community. Subdivision, Lot No.. Zip Code)
3. UWNER: 6:hL A/ ,NC
Address 3 9 R rev Ps oc
Mellott (Street or Rome No.) "Bin.
v a
City or To wn sun: -p Code
Area Cede- 'iln h
4. DATE DRRILLED I•- zfrr- 1P
5. TOTAL DEPTH: Lion
6. DOES WELL REPLACE EXISTING WELL? YI 0 NO Glee
7. STATIC WATER LEVEL Below Top of Casing: E60 FT.
(Use "a" if Above Top of Cooing)
3. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of cosine terminated at/or below Iaad surface requires a
variance is accordance with ISA NCAC 2C.9lit
9. YIELD (gpm): 15 METHOD OF TEST AI R
10. WATER ZONES (depth): 1 Clem & I r701
14AyrC340
ll- DISINFECTION: Typefeta kJwee Amount S 02&laa
12. CASING: Wall Thickness
Depth or Weight/FL
From To
From-1—T
From qo
13. GROU :
From
From Q
To
Depth
To
To 2a
16. REMARKS:
MaleTial Method
Ft.
Ft. 1
County N\ b oWeL-
opographic/Land setting
dge OSlope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude itude of well location
37 35°. 367 1J oBZa as. (L3 Id
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(diets: box)
DRILLING LOG
Formation Description
Diltit
DEPTH
From To
0- cc
So-
85- IDS
12oc(t f o: zr
Cs/LAWtrtC
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and commgn road names.
4p4r'
k
&.rk �e
21 o0 1,hi4
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
SIG
.l�
F PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Dhision of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days ,,G1Y-i REV. 07/2001
r-

4:), 329772
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natinal Resources - Di of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prim) 95¢% c iijje(, CERTIFICATI rO� (f''l !/
<
'\'ELL CONTRACTOR COMPANY NAME PHONE * Z �T L • 5 V
STATE WELL CONSTRUCTION PERMIT*
(if applicable)
ASSOCIATED WQ PERMITS
(ifappliable)
WELL USE (Check Applicable Box): Residential tMtmicipal/Public 0 Industrial 0 Agricultural 0
:Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 if Other, List Use
C: ELL LOCATION:.
Lod-(5 Toot:
iSucei (tau. Numbtrs. Comm
i. OWNER
Address
O(-r1 ford
a:, ez a -*b, e
{v C 9 876 2 DR., Link -,LOG
Typo ific Land selling
�-_.%c !epe Ura'. Uk!
I)vF
/44 - I/. toed: appropriate box)
S»&iivi,-i&n.iutNo..Zip Coile) Laiitudvn.ongiludeofwcll1o(nion b id
__sea Sic 35, o,SSN °R /57 y"
lciaerersm mur6isewmaj
1 i yoSE�d
;�e fa-lt5Id Lalif.flo.- itadcs�w.lGPs0Top�
paiic map
. -o.) -
6 Zi ran
Ai.:a cede- rii;me raanbet
4. DATE DRILLED (V/c/Q 6
5. TOTAL DEPTH: .QSIS"
at m S'
DEPTH
Frt,,m Tn Format en Deerription
o- ec Dih'l'ACciC
6. DOES WELL REPLACE EXISTING WELL? YE$ 91 NO 0 9 2 -.
7. STATIC WATER LEVEL Below Top ofCasing (;10 FT.
(Use'+- if Above Top of Casme)
8. TOP OF CASING IS / FT. Above Land Surface'
'Tap of casing terwiated athr beta had swiace requires a
nonce ia with ISA NCAC 2C MIL
9. YIELD(gpm): METHODOFTEST
10. WATER ZONES (depth): 6 ye, Al cc Z''
gas
11. DISINFECTION: Type re Wit, fie Amount g 02.
12. CASING: Wall Thidmess
Depth Diameter or Weight/FL Material
From To FL
From 0 To—y Ft `r'
From 61/4/ To9 Eta_ e (tier Q4/1/
13. GROUT: Depth Material Method
From To Ft.
From 0 To 20 FL +ye / r err„
14. SCREEN: Dcpeh Diameter Slot Size Material
From To FL in. in.
From To FL in. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft-
16. REMARKS:
1 DO HEREBY CERTIFY
CONSTRUCTION STAND
v/)
Submit the •rigi.a1 to the Divmnn tad Wad' Quality, Groundwater Setlloa,106 Marl Service Center -Ratio, NC
27699-1636 Phase N. (9I9) 733-32Z1, within 3! days. GW-I REV. 07/2001
LOCATION SKETCH
Show diection and distance in miles from at last
two Senate Roads or County Roads Include the road
numbers and common road names.
retas
PJ°#'C
yo5r,"P6
Frya5
0
N
1Ole 749
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
AND THAT A COPY OF THLS .HAS BEEN PROVIDED TO THE WEU.OWNER
PERSON CONSTRUCTING THE WELL DATE

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division�iof Water Quality - Groundwater Section
w ELL CONTRACTOR (INDIVIDUAL) NAME (print) 6/� TO S4'I CERTIFICATIION# Z1J`r
\\"ELL CONTRACTOR COMPANY NAME sus.4i et= ui,,LC Dri LIA bet PHONE 1 (WM % 2Y.YSy F
STATE WELL CONSTRUCTION PERMIT# A WWt&TED WQ PERMIT
(if a ip t) (if applicable)
WELL USE (Check Applicable Box): Residential fa/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 if Other, List Use
2. WELL LOCATIQN: �`
Nearest Town: PVC, t•
N
7_36 aft Co —eft
County r CUCktR�IL
(Street Nang. NNum/bers, Community, Subdivid�.LLot No_ Zip Code)
3. OWNER: "(Jr,(,xpe SM9 kS
Address �'/O 13 o r 704
(Street or Rome No.)
5G'ONa fdr.41 ve& 2277 S
DEPTH
(4ty or Town State 2q Code From To
)- 7 t' - 7L�Xo2
Area code- Plume number
4. DATE DRILLED numbers,
5. TOTAL DEPTH: tio5 4 - i c
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13— -
7. STATIC WATER LEVEL Below Top of Casing: a 0 FT.
(use "+' if Above Tee ofr_S et
3. TOP OF CASING IS ( FT. Above Land Surface*
'Top of casing terminated actor below land surface requires a
variance is accords with 15A NCAC 2C.0I It
9. YIELD (gpm): ETHOD OF TEST
10. WATER ZONES (depth): trims 0 360
1 1_ DISINFECTION: Type 11-0iez/t Amount S D 2
12. CASING: WallThiaiuoa
DepthFrom 0 To From To (e 7
From To (tp 7
13. GROUT: Depth
From To FL
From C To to Ft. —i-evy/ soon ai
14. SCREEN: Depth Diameter Slot Size Material
From To FL in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
or WcigbVFt. Material
pC
tcsJ T.RIa
Material Method
16. REMARKS
1 DO HEREBY C
CONSTRUCT}
Topographic/Lanl-setting
❑Ridge ❑Slope BC/alley ❑Flat
Knees appropriate box)
Latitude/Iongitude of well loccion
35-° 54.473 N otz e5434W
(degrees/mimstcs ecoot)
nde source: PS❑To
Latitude/longitude pographic map
(cb xt box)
DRILLING LOG
Fommtion Description
O- lZ 5/ CL•+cj xCetic.
See &A; e f g,lew
Kack-
9/1e47Vr 4-e
LOCATION SKETCH
Show direction and distance in miles from at least
two Stale Roads or County Roads. Include the rood
nutuL... s and common road names.
226,
22/
WY 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
'-C
RE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the I ision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone Na [phone], within 30 days. GW-1 REV. 072001
Lug.

Posted
WELL CONSTRUCTION RECORD
c9 329769
North Carolina - Department of Environment and Natural
Resources
(-�Division lof�Water Quality - Groundwater Section /�..
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 4� A. 9rt4 #lCc CERTIFICATION ti 21 Sit
WELL CONTRACTOR COMPANY NAME SOS ftr tG fJSSt( Drtetfi PHONE a Bit emu- CPC
STATE WELL CONSTRUCTION PERMITS/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential i3-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: 114 aer:6/J County 1N SAeea.le[G
/SN (j/aijeme ForesVOr
(Start Name. Numbers, Community. Subdivision. Lot No.. Zip Code)
3. OWNER: «,-C DAQis'
Address 2 HV 7-atvy gel
(Street or Route No.)
MaC0/11 LUC 2g7S2
City or Town State Zip Code
(tier)- L54.26er
Area code- Phone number
4. DATE DRILLED q. 5 t4
5. TOTAL DEPTH: 2 4 C
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO fir
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+^ if Above Top of Cuing)
8. TOP OF CASING IS / FT. Above Land Surface'
'Top of cosine terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TESTS/AN
10. WATER ZONES (depth): / 'fir/ £ 2 SO
11. DISINFECTION: Type CLDftriu a Amount 8 O'L
12. CASING:
Wall Thickness
Depth Diameter or Weight/Pt. Material
From To Ft.
Fromm To 79 FLy y�
From i To %/ a (n IU 782
13. GROUT: Depth atonal thod
From To Ft.
From(_ To-ZO Ft. ,fry �/e
14. SCREEN: Depth Dian ter Slot Size Material 61i1
From To Ft. in. in.
From To Ft. in. _ in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS
I DO HEREBY CERTIFY THAT T
CONSTRUCTION STANDARDS,
Size
Material
Iy" LL WA
THAT A
otAto
Topographic/Land setting
❑Ridge OSfope ❑Valley ❑FIai
(check appropriate box)
htude/ longitude of well location
2s°21.37o.W 08/ ° 5-5.zzI W
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
6o-Cy
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. c7
1,Z4, ynal.odU
fV — .i
n-
(/59) �.
�j yn 4C60A)
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS ' i ORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUR '° F PE &N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Senicc Center -Raleigh, NC
27699-1636 Phonc Na [phone], within 30 days. G W-1 REV. 07/2001

(Stitt Name, Numbers, Cammtmiit/2/.:Subdivisioa lot Na.
3. OWNER: I U L/Lz
Address
"(sostorxomer1- C,
Area code- Phone aomber / �G
s. DATE DRILLED 6
5. TOTAL DEPTH: / /;
5- DOES WELL REPLACE EXISTING WELL? YES O ❑
�j.
North Carolina • Dapamtant ofEavil ____ aid
WILL CONTRACTOR piernoQAL) PIADaI , L>�! //.'-.// f-T ✓ : •::
wrr s CotcrR*cio& COMPANY NA)a' c r �? �t ��'l / �) i-r y]1
STAR WELL CONSTRUCTION PERMITI ASSOCIATED WQ Pnt3
(rfapplicabk) ' cifapplioble)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agriculaaal ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION
N To •
County / ' % �Q btl44 CJRid dyiopnl�L�� setting ge ❑Vallry ❑Flat
/ � % -o- OA 1*t 2 /2S �-- (checkapaw appropriate )
Code) Latitude/loagimde of well location
��/ Latitude/longitude solace:❑GPSQTopogtaphic map
(cheat box)
�j-j-/ 1)� 2tj S� — DEPTH DRILLING LOG
From To Formation Description
7. STATIC WATER LEVEL Below Top of Casing: 8- FT.
(Use "+" ifAbe Top of Caning)
3. TOP OF CASING IS � aFT. Above Land Surface'
`Top wrote terminated odor below lad =dam requires ■
variance in accordance with ISA NCAC 2C .0113.
9. YIELD (gpm): /r METHOD OF TEST C^F}
10. WATER ZONES (depth): 9
LOCATION SRElC
11. DISINFECTION: Type a _ Amount _/ . Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter a Weight/Ft Material n»mrs beand conames
road namo
Fro t'- To 2 /c Ft A —
From_ To Ft
_ FromTo Ft _
13. GROUT: Depth Mate ial
FroC To »t' Ft. (7`.�
From To Ft.
14. SCREEN: Depth
From To_ Ft_in. in.
m FroTo Ft in. in.
15. SAND/GRAVEL PACK •
Depth Material
From To Ft.
From To Ft.
Method
Diameter Slot Size Material
Size
. ct
r
l�t`ijD1
pr
6 n 1 N
• o
m
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDAI ICE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD Hr,S BE:N PROVIDED TO THE WELL OWNER
SIGNATUREOF PERSON CONSTRUCTING THE WELL DATE
l
Submit the original to the Division of Water Quality, Groundwater Section. 1636 Mail Service Center - Raleigh, NC
194°a-1.416 1.A09e V^. '9t9\ "13 7221-ritrlin 30 days. G W -1 1` v 3 1:001

`WELL CONSTRUCTION RECORD
North Caroline - Delisted ofEnv and Resources -
WELL CONTRACTOR (2eDIVIDlIAL) NAME... fE . I ?fa_ -/ &-S COCA.
WELL COPfinACIOY COMPANY NAI R .. ( CA) 10 r/ / .01^,'1/1 !Horn.:;
STATE WELL CONSTRUCTION lSEafill ASSOCIATED WQ PERMITS B
ctapplicable)
(if applieable)
1. WELL USE (Check Applicable Box): Residential 2i7 MtmieipaUPublic 0 Industrial. ❑ Agtiwtbnal 0
Monitoring 0 Recovery 0 Heat Pmnp Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION• K Topographic/Land setting
Town: l In/ ,en— I— it County /1 1 Midge OSlope Malley Gnat
rrri . .s 4 D {^. / 2S A"- (check , O k., *nominate box)
(Street Name, Numbers. Cammunity,fsubdivicae, tat No, Code) Latitude/longitude of well location
3. C
OWNER: r/. it-kir (daWsaaa ees_mimaevo<)
Address ler m el S t - ! )�k • Latitude/longitude source:OGPSOTopographic map
//f���
/':YT/// ar -) .di7_5 � DZFmi
(cheek box)
DRILLING LOG
Cay of Town Siam Tap Code From To Formation Description
3
Are mdo- Phone tuber
4. DATE DRILLED -? J
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 19'
7. STATIC WATER. LEVEL Below Top of Casing: . CA FT.
(Use -+" if Above Top of Caamv
8. TOP OF CASING IS / FT. Above Land Statues
'Top of odor terminated attar blew lead surface requires a
variance la a® with ISA NCAC 2C .0113.
9. YIELD (gpm): METHOD OF TEST , !
10. WATER ZONES ( tit): / 2 O
LOCATION SKETCH;
11. DISINFECTION: Type 2. / . / Amount - / LA. 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 � numbers and common mad names.
FromTo_J22Ft tthvFt J L.. r�
From_ To Ft
From To Ft — o
13. GROUT: Depth Material Method c
From % To fYC Ft C P r.• P "\�NSA r��:t
yr)
From / To Ft Ca rn T1
14. SCREEN: Depth Diameter Slot Size Material ,Zi<
From To Ft in. in. o o fl
From To Ft in. in > f ` c- >`�
15. SAND/GRAVEL PACK /
Depth Size Masaial
From To Ft.
From To Ft.
16. REMARKS -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2C, WELL
CONSTRU ON STANDARDS, AND THAT A COPY OF THIS RECORD Hr,S BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOFPERSON CONSTRUCTING THE WELL DATE
- Submit the orginal to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
7.749O_t 6:4 pk., _e vy 1119)713.321L within 30 days. G•• - 71200-

WELL CONSTRUCTION RECORD
.._...`��_ .::.. :... .. __... - ......... b ...... :. 1.
North Carolina - Department ofEnvROt®ent and -Division of Water Quality -
WELL CONTRACTOR (IISDIYIDIIAL) NAME Clt7AC13ICA11015
WELL CONTRACTOR COMPANY NAME C' �. ys'- PHONE a
STATE WELL CONSTRUCTION PERMIT, ASSOCIATED WQ PERMIT,
/darn, Heidi.) (itarclimble)
1. WELL USE (Check Applicable Box): Residential MimicipaYPublic 0 Induattial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, Liat Use
2. WELL Locknogafr,j�f r
Nearest Town Oom etyt• Connsy/ ' ykil,r//
n 0NDSSi
(Street Name, Numbea, Community, Subdiv Lot No, Tip Cote) Latitude/longitude of well location
3. OWNER: sus.- e0 6�
(saaet tl r)• 7 fDEPT6
Cay or Tem See Tip Code
( —)
Area code- now ember
4. DATE DRILLED , - t, _
Address o?r j j-c 5c > t
J
Topoe iopeJLand setting
ORidge 5ope OValley OFlat
(deck Npeop^"" boa)
(devea misson records)
Latitude/longitude wiace:OGPSOTopograpbic map
(cheek box)
DRILLING LOG
From To Formation Description
5. TOTAL DEPTH: //2
6. DOES WELL REPLACE EXISTING WELL? YES L NO ,
7. STATIC WATER LEVEL Below Top of Casing: /7 FT.
(Use "+" if Above Top of Cauoa)
8. TOP OF CASING IS l FT. Above Land Surface*
"fop Mcasiag tardusad attar below led surface regahv •
varteo be aemrdaan 15A NCAC 2C .011a
9. YIELD (gpm): METHOD OFIEST A
10. WATER ZONES (depth): 3,5
11. DISINFECTION: Type 'SJNc% Amoimt .
12. CASING: Wail Thickness
Depth Direr
or Weight/Ft
From To 25 a
Fromm To Ft
From To Ft
13. GROUT: Depth Material L Method
From4iaz To 95 Ft (2/ehn* s el
From To Ft
14. SCREEN: Depth Diameter Slot Sim Material
Froth To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
Frost_ To Ft.
From To Ft
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Inc! • ' the road
ntmtbas and common road names.
?2 -era/ A)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2C, WELL
CONSTP.UCTION STANDARDS, AND THAT A COPY OF THIS RECORD Hr,S BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Seetion, 1636 Mail Service Canter - Raleigh, NC
374904p •1t6',hone No.-'ai9) +3L:221within 30 days. - _
uw-, REV. . J,_
iGVVl

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION !{ a s-)
1. nr—
Ca)�V actor (tik/id Name
� 1 anV_1)t,S h(
Well Contractor Company Name
STREET ADDRESS Cl 4)) i aS T r—cc1 SE
1-\,c\\t;c' !<
.'3 �R�ba
City or T State • Zip Code
(y a* )-3)-7 o )-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif app calve)
STATE WELL PERMIT#(t applicable)
DWQ or OTHER PERMIT #(t Napa -whip)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED &
TIME COMPLETED ` ' AM ❑ PM Ly"
3. WELL LOCATI ��JJ /� d /
CITY: 0 COUNTY 4 C�l/.(,J[ie (. L(
(Street Numbers, Community, � �ion, 01- 1 f /6"a
ode)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑Otter
(check appropriate bop)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oGPS ❑Topographic map
(bcabbn of wet must be shown our a USGS fopo map and
attached to this form T not using GPS)
4. WELL OWNER
OWNERS445
NAME c(nn� (o; jC 05 ..“1,4 Ez
STREET ADDRESS N� 0, go Y 6j / ,L
6.A� Il< A-( .2V429
City or Town State Zip Cade
( rdr)- 3(2 376 C
Area code - Phone number
5. WELL DETAILS: //''
a. TOTAL DEPTH: �j/ OQ
b. DOES WELL REPLACE EXISTING WELL? YES ❑
e. WATER LEVEL Below Top of Casing: 4)0 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top d casing terminated ator below lend surface may require
a variance in accordance with 15.4 NCAC 2C .0118.
e. YIELD (gpm): C METHOD OF TEST, ( -1
f. DISINFECTION: type&"-' "46'nmount 7 CV
g. WATyE�R ZONES (depth):
3 From To 3026From To
From 560 To_ 3'O From To
From To From To
6. CASING:
- Thickness/
Depth Diameter Weight Material
From O Tot /C Ft. (-, ‘Q5 /7VC
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To ;.-0 Ft
From To FL
From To Ft.
8. SCREEN: Depth
From To
From To
From To
Material Method
Diameter Slot Size
Ft. in. In.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To - Ft.
Size Material
10. DRILLING LOG
From To
b )10
))n )-Op
t tOG
1 M CS
Form n De dption"
f, l (KCi C
kw- 4) tp c. 5 ✓-Q r�
100 HEREBY CERTWY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CO WSTRue1ON STANDARDS, AND THAT A COPY OF THIS
RE�CORDttAS BEEF PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED DATE V�LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submft the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. 0419) 733-7015 ext 568.
' f'$Jwlrioal COA1 f/,
Fenn GW-Ia
Rev. 7/05
aN.
.

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1.WELL CONTRACTOR:
STEEE PRICE
Well Contractor (Individual Name)
DEWEY WRIGHT WELL & PUMP CO., INC.
Well Contractor Company Name
STREET ADDRESS P. O. BOX 308
BOONE NC 28607
City or Town State Zip Code
( 828)- 284-2851
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID #(n applicable)
STATE WELL PERMIT #fn applicable)
DWQ or OTHER PERMIT #fn applicable)
WELL USE (Check Applicable Box): Residential Water Supply O X
DATE DRILLED 7f10/2008
TIME COMPLETED 8:00 AM ❑ PM OX
3. WELL LOCATION:
CITY. SPRUCE PINE COUNTY MCDOWELL
HWY 22SAOFF 19.E
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope O Valley O Flat 0 Ridge O Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: 0 C.'S 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this forrn'1 not using GPS)
4.WELL OWNER
OWNER'S NAME LLOYD JOHNSTON
STREET ADDRESS % MOUNTAINEER BLDRS. , P.O. BOX 57
BAKFRSVII LE28705
City or Town State NC Zip Code -
( (828j1- 888-3370
Area code - Phone number
5.WELL DETAILS:
a. TOTAL DEPTH: 905
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO OX
c. WATER LEVEL Below Top of Casing: 150 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118
e. YIELD (gpm): 0.5 METHOD OF TEST Air
May be in degrees,
minutes, seconds or
in a decimal format
2878
q all 11 Q
32
J J tl
060350
f. DISINFECTION: Type MTH Amount 143
g. WATER ZONES (depth):
From R55o R56 From To
From To From To
From To From To
6.CASING: Thickness/
Depth Diameter Weight Material
From___9io_____Vt. 6 1/4 GAL'V'
.188
From___)-ro 0=t.
From To Ft.
7.GROU7 Depth Material Method
From_0'o_.26Ft. Cement Gravity Flow
From To Ft.
From , To Ft.
8.SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
. From To Ft. in. - in.
9.SAND/GRAVEL PACK: e
C
Depth Size Materials
From To Ft.
'From To Ft.
From To Ft. ri
c-›
c:a
10. DRILLING LOG
From To Formation Description
0 42 DIRT
42 855 GRANITE
855 B56 • - QUARTZ -..
Et GRANITE
C7
• Ifx,
11. REMARKS:
05GPM 855-858 0GPM - 'z
0 GPM - 0 GPM - `
0 GPM - 0 GPM - ...
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THEWELLOWNER.
— /
�SIGNA
//
Or CERTIFI WtLL CONTRACT /L,"'DATE
STEVF PRICE
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

WELL CONSTRUCTION RECORD
Nat* C Mlin - DEputitift bf Eh*ltiiiith t Mid Nat
WILL t llttttAt ttil (ifill2IVIbUAL)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION P
PERMITS
(if applicable)
Reaoirrces - Di i n Of Water Quality - Groundwater Section
C--�/yJ d �E+ 5 `rX CERT1nCATION s 27? Y
t9 Sl1�F L.tfrr um-7/ 7 r�tn PRONE 1 &d 1yf a G
ASSOCIATED WQ PERMRY
(if applicable)
1. WELL USE CheckApplicable Box): Residential / pAgricultural9
( ) � Monici aVPublic 0 Industrial 0 ❑ I � � ,'„�
Monitoring 0 Recovery ❑ Heat Pwnp Water Injection 0 Other 0 If Other, List Use W
r_ Y rn
2. WELL LOCATION: Topogaphic/Land setting m m G) 0
Nearest own: /0 t/(' County11lf�O�GtJB / $ dge ❑SI Malley t D
/i//� Mkt* ///0fity Pf 13/l9CX r9/'K' 5/ z?76 9 (,reek aP wopriam box) ! 9 t6 c a e
(Street Name, Numbers,
Ccaur,mey, subdiv�i�o., tat Na., rhp code) Latitude/longitude of well to t Ls c m
3. OWNER 1 ueij 13tt e?r or, %4,-, L) ( , y, ,) -' 0 u L
Address L/ /t�ff gc/Pr� P Latitude/longitude source:❑GPS❑Topo P mg'(Street or RouteNo.) (cbaY box)
117/p/" / ate, /V r -Z? 7 ‘ 9 'DEPTH PRILLIN LOG
Ghy at Town Star Zip Code
Area cods Phan amber
4. DATE DRU LED 4/'/0 O 4
5. TOTAL DEPTH: 7i O S'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ci'
7. STATIC WATER. LEVEL Below Top of Casing. S 0 FT.
// (Use"`e" if Above Top of Cana)
8. TOP OF CASING IS / 6- FT. Above Land Surface*
*Top of raslag tenanted attar blow Lad amine requlrn a
variant la ascordsoce with 15A NCAC 2C A118.
9. YIELD (gpm): 2. • 5— METHOD OF TEST // n-rn- /
10. WATER ZONES (depth):
11. DISINFECTION: Type r C ,V
12. CASING:
Depth
From_e_ To /00 Ft
ir
From_ To Ft
From To Ft.
Amount /r7 OZ
Wall Thickness
°rya:shrift Maorial
Z/ UG
w /7//rX
13. GROUT: Depth /.,Material
From To 7-0 Ft `elltd eice
From To Ft.
14. SCREEN: Depth Diameter
From 91. To Ft _in.
From To Ft
15. SAND/GRAVEL PACK
Depth Size Meads!
From_To FL
From�To Ft.
Slot Size Material
in.
in.
16. REMARKS:
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
and common road names.
Jai
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUnON STANDARDS, AND TFI/1T A Cf Y 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 Caner - Raleigh, NC

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 0.3/
1. WELL CONTRACTOR:
WellClxta (Individual)
ividual Name (�
p ( )
Rw.ssa I Welt Dr, C
Well Contractor Company Name
STREET ADDRESS oI
City ar Town State Zip Code
(g'.S)- l03LZ-3/o FE
Area code- Phone number
LI'befr±nyCd
nnh R
A c 3-g6 1
2. WELL INFORMATION: SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #[d applicable)
WELL USE (Check Applicable Box): Residential Water Supply IW
DATE DRILLED 7)' O!o
TIME COMPLETED w( 00 AM ❑ PM la-
3. WELL LOCATION: CITY: NJ tip COUNTY-ThrNIIL.)'EA I
(Street Name, umbers, Community, Subdivision. Lot No., Parcel, lip Code)
TOPOGRAPHIC / LAND SETTING:
CI Slope &valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE S k) 43. Li7/)
LONGITUDE 4.U. °$ic_7A• tAD
Latitude/longitude source: EitPS ❑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 6-/H-Q4iL7f QZAiTIQ,Piyl.i;(.-
STREET ADDRESS J.5tl caty l
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State
c7D�l) 4109- oolDnt
Area code - Phone number
5. WELL DETAILS: �i,'
a. TOTAL DEPTH: dY'-5-
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ®-
c. WATER LEVEL Below Top of Casing: %D FT.
(Use -+• if Above Tap of Casing)
d. TOP OF CASING IS / �a FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /S METHOD OF TEST act,
22 r 2'?8
f. DISINFECTION: Type /4 77-1 Amount
g. WATER ZONES (depth):
From 7D To at%S From To
Fran To From To
From To From To
6. CASING: Thickness/
Depth /. Diameter Weight Material
From C To / l Ft. Q V C
From To Ft
From To Ft.
7. GROAT: Depth
From C To Qio
From To
From To
8. SCREEN: Depth
From To FL in. in.
From To FL in. in.
From To Ft. in. in.
Material
Ft_[
FL l�
FL
Method
pern e if_
9. SAND/GRAVEL PACK:
Depth
Fran To
From To
Frorn To
10. DRILLING LOG
Diameter Slot Size Material
Ft.
FL
Ft.
Size Material
From To Formation Description! -
n - '76 eLQvl-
7b' n?4Sf /Lc-t:K
11. REMARKS:
1
I DO HEREBY CERTFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WFIH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS AM) THAT A COPY OF THIS
RECORD HAS BEEN PROVCED TO THE WELL OWNER
SIGNATUgE OF CERTIFIED WELL CONTRACTOR DATE
IVAe_ usse(j
PRINTEdJNAME 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 Cite llh* - Dipitttttilt Of EtiVttti>lilibilt (did
WILL Cbb*tliketta (1145ivISNAL)1QAMt L
WELL CONTRACTOR COMPANY NAME SV.)
327785
Resbutc Di ion of Wainer Quality - Grocmdwater Section
/td4_/5 Ltkti)tCATION #Z72/./
et well 1 PHONE a en 69-ovEc
STATE WELL CONSTRUCTION PERMTT4 ASSOCIATED WQ iR
(if applawae)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 4twiicipal/Publiic ❑ industrial O
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other O If Other, List Use
2. WELL LOCATION: d
Nearest Town: 0
_MOO 5/
(Street Name, Numbsa. Cammmiry,.,Subdi�e.. Lot No, Tip Code)
3. OWNER: k&,id )--n sr
Rcrulg
Address / 0 S/Arer5 LUE A K!+
a Rama No.)
)Slut /vl- 2F7‘7
City o: Teat Stale Tap Cods
Ares code- Ptwx mamba
4. DATE DRILLED S —/— 0
5. TOTAL DEPTH: b O
6. DOES WELL REPLACE EXISTING WELL? YES O NO 5 '
7. STATIC WATER LEVEL Below Top of Caning 72 FT.
(Thuif Above Top of asset
8. TOP OF CASING IS /0 FT. Above Land Surface"
'Top of raring terminated attar below hod verbs: requires ■
cerium ha smofauce wtb ISA NCAC 2C A111. /
9 YIELD (gpm): /G METHOD OF T EST // rrl {fit
10. WATER ZONES (depth):
11. DISINFECTION: Type r C hi Amount /0 dZ
12. CASING: Wall Tekrii m
DePthtlFetu
From - To -4 G Ft Spi( Z/ Min('
From To Ft.
From_ To Ft
13. GROUT Depth
Agricultural
TopogaphicdLaad scig)
ORidge DVallcy off*
(check appropriate box) %a
Latitude/longitude of well loco oral
(daymrhaimoslawWa)
Latitudellongitude source:OGPSOT _
(cluck box)
AEPTH
From To
pic map
Formation Description
LOCATION SKFICH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road names,
1/4524
matenai
From CO To 7Q Ft rL per_ e tuf //74-4-
From To Ft
14. SCREEN�:q' Depth Diameter Slot Size Material
Frottl_� To Ft. in. in.
From To Ft,_in. in.
15. SAND/GRAVELPACK:
Depth Size Material
Fro To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS
STANDARDS, AND,7jijtf' A
SIGNATURE OF PERSO
5/ Ur&5
ACCORDANCE WITH 15A NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTING THE WELL DATE
Sabudt the original to tie Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC

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 ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): al Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MARION County: MCDWL
LES 1 hR HOLLIFIELD RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER MARTY SMITH
Address LESTER HOLLIFIELD RD.
(Street or Route No.)
MARION NC 28752
City or Town State Zip Code
4. DATE DRILLED 05/22/06
5. TOTAL DEPTH 57
6. CUTTING COLLECIED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 27 FT.
Ilse "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with I5A NCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: S 1 rhLL TAPE
11. WA1'ERZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 13.8
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 57 Ft. 24 CEMENT
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND7GRAVEL PACK:
Depth Size Material
From 27 To 57 Ft. 78M GRAVEL
From To Ft.
17. REMARKS:
If additional space is needed use bacit.oflbmt..__.,
327701
LOCATION SKETCH
(Show direction and di tanae from at least two State
Roads, or other reference points)
HWY. 3226 N. FROM MARION. LEFT ON LESIT,R
HOLLIFIELD RD. IN WOODLAWN. (BESIDE PEPSI PLANT)
1/10 MILE ON LEFT.
0
c 1
.73
t;.7
>n
rrt
N O 71
o c-
m
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.t
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG F 0 C0 TR� THE ELT /rl7 7 D DATE 2-
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division o ' ater Quality
-�
\\-P,1,1. CONTRACTOR (INDIVIDUAL) NAME (print) +ll -L' • At( /(e. H� CERTIFICATION n3
t
\\-ELL CONTRACTOR COMPANY NAME � e //�Lac- II ,t .k . I %. et; PHONE # (yd4 e73 . 31 t
5"!".\TE \FELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
327710
LL USE (Check Applicable Box): Residentialtie Municipal/Public 0 Industrial 0 Agricultural 0
onitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
`A ELL LOCATION:
rarest Town: /j , U Jf
SR i/ee/
County 5 w,t
Street Name. Numbers. Community, Subdivision, Lot No.,(.,Zip Code)
:. OWNER:' /t(ye..� J.� .4. ; » a AZ [ems-. , .t1 S,
Address --j3` -C ksQ» RQ1-
(Street or Route No.)
AcaA;t a ,v c ay2cc 2—
IV or Town State Zip Code
rl+1i'i-
N
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Tat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box) i.H.."
DEPTH DRILT [NG;6OG
From To Formation{ Description
ra code- ('hone number
-I. DATE DRILLED (o - `l - 6 Ca
5. TOTAL DEPTH: Pi E !—T
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cr'
STATIC WATER LEVEL Below Top of Casing: 02 D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Tnp of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD ELD (gpm): / METHOD OF TEST 4.2 i/e.1f
10- WATER ZONES (depth): ( a ,y7
IS INFECTION: Tvpoeik,4 Zs y
I -.,\SING:
Depth
Don tty ® To �� Ft.
Ft.
Ft.
i um To
i Tom To
GROU�T: Dept.
Prom l y To
From To
I-. SCREEN: Depth
From To
To
ID/GRAVEL PACK
Depth
:cm To
Diameter
t�. s
LOCATION SKETCH
4-1� Show direction and distance in miles from at least
W a I Thickness' /1" two State Roads or County Roads. Include the road
or Weight/Ft. �Mateiaterial
Lk -day/ T /
Material
Ft, C.2 _.t71—
Ft.
Diameter
Ft. in.
Ft. in.
From To
I6. REAIARKS:
Size
Ft.
Ft.
Slot Size
in.
in.
Material
Method
numbers and common road names.
O
/i��
2 Yt/c /tat R, i4/
Material 74/;N LR
"
carc. d err creciAa
D%.cfi�t
I ID I I IJKEBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
<S TRIICT ION STANDAIW$. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c' elf ;z - 7-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
I?::hriii the original to the Division of Water Quality, Attn: Information Management, 1617 Mail Service Center-
r;^ii ..5C 27699-1617, Phone No. [phone], within 30 days.
GW-I REV. 09/2004
'7`

331250
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envbaunem andNetted Resources- DWbion of Water Quality
WELL CONTRACTOR CERTIFICATIONS 213 8 '
1. WELL CONTRACTOR:
James W. Camp
Was Cmtractor.(I dMduan Name
Camp's Well & P11mD CO. Inc..
Well Contractor 4wpany Name
STREET ADDRESS P 0 Bog 429
Ellenboro NC 2Q040
City ccTavn State 1
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL roSGePpla ble)
.p
STATE WEU. PERMIT#(Bappkable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE {Cheek Applicable Bald: Residential Water Supply D
DATE DRILLED /-14-06
TIME COMPLETED / D Mao PM IH
7. WELL LOCATION: CITY: l'Air o Yl couNMe- 1 ' l e- Do
i�den_ ii%es • 1Dt3( Pita5e Li
(EMS Nam Nmnbsaa. Community. Subdldsion, Lot No.. Perak27p Code)
TOPOGRAPHIC / LANDS NG:
oSlope oValey DFlat Midge OOther
(ahedcappopdatahm0
IATT UDE , ,TLD 'r D
LONGITUDE, ,1%� /•• / 31
Latitude/longitude source:. SOPS ['Topographic map
(hcs0an of twf Turbos show on a USGS tope map and
dtadredto thb font 'not us.h-s1g GPS)
WELL OWNER
1
A. OWNER'S HMG �YC/i I/Le/d Li) rtG WPS
STREET ADDRESS oDh /J
or Tow
C RIG J
C orTown State Zip Cede
Mq1;ta.1
Snubs, somber
In • dedmal knout
L_}
Area code• Phone number
6. WELL DETAILS:
a. TOTAL DEPTW
57)5
b. DOES WELL REPLACE EXISTING WELL? YES p ND%
e. WATER LEVEL BaavTop of Casing: • (at' FT.
(Uare f Above Top ol casing)
d. TOP OF CASING IS 1 FT. AboatLand Sudan*
. lop dcasing tanlhiated otterbelow Ind sulfamyregke
madam In amordrroe w1th 16A NCAC 2C.0118.
e. YIELD (ppm): 3 METNGD.OPTEST bt.I
t DISINFECTION: Type chlorine Amount —2 c1-741
Ix WATER ZONES (depth):
From_______To Fom____To
flan To Fran To -.
From To Fran • To
s. CASING:
Fro Depth Ft taameter SDR21 •PMate'vc.
From To Ft
Rom__ To
T. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
Fran To Ft
From To Ft
A SCREEN: Depth Diameter . Slot Size -Material
In.
Fmk__ To
From To _ FL h, In.
6. SANDVGRAVEL PACK:
F Depth
S Material
'T �
o_ Ft.
From To Ft
Frart _To Ft.,^_
10. DRILLING LOG
From .To. Fo nDesaip6on
o ss d;rT. 4/
. 57>5 Lonstli7%ate CJ ror k�
11. REMARKS:
n
ID) KEEP CERIFYTNATTIBI WELL WAS OONSIRUCIED NACCOMI C!WM4
SAMAC 20. WELL CONSTRUCT= SIAWIARDS.AROTHATACOPYOETh$ •
RECORDBEEN PROVIDED To1HEWELL OWNER
SIGNM9RE OFCERTIFIED ERTIFIED ELLCON7 CTOR MTE
James W. Camp •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the DivIslonof Water Quality Within E0. days. Ater: lnfonnatipn Mgt., .
1617 Mell Sorv(ce Center— Raleigh, NC 27699.1617 ' Phone No. (9191733-7015 ext 568.
Fore GW-la
Rev.7105

c}xit tiCp
•
,cfarsSID NTJAL WELL CONSTRUCTION RECORD
Nord' Carolina&penman of Envtrontncm end Natal Resources. DIvislon of Water Quality
WELL CONTRACTORCERTIPICATlONA 2138'
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & Pumn CO. Inc.
Well Contractor company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC
CityaToan ' state
(828.). 453-7322
Area code. Pharr number
2. WELL INFORMATION:
SITE WELL ID SW applicable) '
STATE WELL PERMIT1gvappfabTe)
DWQaOTHER PERMIT OWapplkabie) ' J
WELL USE (Check Applicable Boon: RMidemiai Water Supply[3"
DATE DRILLED/ lED - 13 - D �.
TIME COMPLETED )r: „CO AM CI FMai
3. WELL LOCATION:
a>'DK COUNTY
(}NcDoPie
tl
(Sap! Hu*HYonbep„L`annu�idlyclkS dl'vlakn. Lot No., Parmen Coda)
TOPOGRAPHIC / LAND SETTING:
❑Step. DValey OFIal �dge OCther
(aadi appropd b?=)
LATFnJDE . 5° 35. g99
LONGITUDE 9 ,L' ri l7-. 40
Latitudelongibtde source:. fpoPS °Topographic map
(began
attached to this form tnot using GPS)
CITY:
4. WELL OWNER
OWNERS NAME
STREET ADDRESS
City ati•am
MAY 6em&Pea,
woodierDana n
in a decimal fau
klYch'lle1d Le.
l7Dh'Ies
flox 10
R7G I
Area code- Phan number
Zip Cede
6. WELL DETAILS:
a. TOTAL DEPTIt .1G)
b. DOES WELL REPLACE EXISTING WELL? YES p NO,1
tv e WATER LEVEL StloTop dCaeinp. • / 72 FATT.�\
(Useelf Above Top of Casing)
d. TOPOFCASWGIS ' 1 . FT. Above Land Surface
'Top dcasing m itdad'Forbabw land maf6c.MW tequha
■vat nce In exordewe Wah15ANCAC2C.0116.
e. YIELD(gpn) aD METNOD.OFTEST Q/ r
t. DISINFEcrloN:ryp.chlorine *mourn //A ct
g. WATER ZONES (depth):
Fran_._ To From To
Ram To Fran To
Fran To From • To
6. CASINO: ,TWae�prstl
Weight
_PVC.
.Fran 0 To 702 Ft
Fran To R
From To R_
7. GROUT: Depth Matelot Method
Fran 0 To 20 Ft, Sackrete Hand
R
FronT To
From ,To
6. SCREEN: Depth Dimteter . slot Sir Motorail
From To Ft__ta. b,
From______ ro FL..__m. b.
Run__ To Ft. in. In.
& SAND/GRAVEL PACK:
Depth Sim Material
Frarq,_,,,,-Te FL
Fran To R
Fran ^_To_ FL
10. DRILLING LQG
From .o.
.0'
11. REMARKS:
FoRnation 4eudptbn _.11 _
rT rlay �.
IDDIEMEBYCERTPYTHATTi06 WELL WAS CONSTRUCTED NACCORDANCE WRH
IMICM = WELLCONSIRUI:TION STANDARDS NOTNATACOPTPERM
.emenu�a SEENpPROJIOEDTOTHE WELL OWNER. �y
Arne`.
SIG RE OF CERTIFIEDWELLOO RACTOR BATE
James W. Camp •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the odglhaltothe Divlsion.otWater Quality wlthln.30.days. Attn: lntonnatlonMgt,, .
1617 Mall Sant Center— Raleigh, NC 2769941617 ' Phone No. (9191733 7015 ext 568. .
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD
Nonh Carolina - Department of Environment and s ral Resources - Divisi
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME J t,)311(O/II IS J 1 ti it/. (.(IV) pI LLCM PHONE itua5 2- 249
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 12 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: C
Nearest Town: i�4rk %2fd0Q)2county inDBWt//
CI cri/jW CA,- 6
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ehM �.nk-iIJS
Address 19 (,'Q t) m(1G n ,
(Street or Route No.
a;rU;ew g C fl73o
City or Town - State
[) &e2M8- 3'!By
Area code- Phont number
4. DATE DRILLED
Zip Code
/7/ 344
5. TOTAL DEPTH: / yys-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO C3'
7. STATIC WATER LEVEL Below Top of Casing: go 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 ISA NCAC 2C .0118.
9. YIELD (gpm): 2 METHOD OF TEST2I0 , lNq-�S t'q
10. WATER ZONES (depth): 240 J JJ
�Opographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
Nis i5S,S/7" 1fJan'iVdb$
(degrees/minuteslse onds)
Latitude/longitude source: PS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fortnation Description
0- S9
C/a/
v11 bl sa.tislo,''c
by >Y ,Oor-f-
7y- Yr/S
13. GROUT: Method
From i3 —(fit, pjdq
From 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.
LOCATION SKETCH
11. DISINFECTION: Type ('h/i,j we Amount gel 2- Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From . 0 To 7V FL L s?-5 2/G,41s AAft.5O01/
From To Ft.
From To Ft.
Depth 4 Material
To a i7 Ft. (.nitZEi45
To
16. REMARKS:
90 004
of Water Quality - Groundwater Section
CERTIFICATION #2
Cr eStoi1
SEE
Led-'` 4
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRULIED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS_ AND THAT A COPY OF fdjllS REC9RD HAS BEEN PROVIDED TO THE WELL OWNER
Gh4ATURE OF PE
ON CONSTRUCTING THE WELL
66
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

From
From
From To Ft.
13. GROUT: Depth n Material Method
From nTo a n Ft. ( ..onC2E%E "ilr�t t ei t{q
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
To Ft.
WELL CONSTRUCTION RECORD
Nonh Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME r
STATE WELL CONSTRUCTION PERMIT[#
(if applicable)
ral Resources - Divisi
08
of Water Quality - Groundwater Section('�
CERTIFICATION NQ (1 JA (7
(1SOAI Lay D, 1 LC PHONE e€aaaia52-8'444,.
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 0 If Other, List Use
2. WELL LOCATION:
Nearest Townr'dfk #,3 di, e County fr rDt &6l/
tspinay Lot 7
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
Kf
89
• (Street or Route
No.)
City or Town State
Zip Code
l )- /oAR- 3 Li-81
Area code- Phone number
4. DATE DRILLED ///)7(
5. TOTAL DEPTH: t/t/T
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO i3
7. STATIC WATER LEVEL Below Top of Casing: SU FT.
/ (Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface`
*Top of casing terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): a METHOD OF TEST 2IOi, hdq—Rt'q
10. WATER ZONES (depth): J J
�ep6graphic/Land setting
tdge ❑Slope ❑Valley ❑FIat
(check appropriate box)
Latitude/longitude of w,e1 location
W A 1.3 S/G lee 5'2, I/b>
(degreesiminutes/c�onds)
Latitude/longitude source: L�1GPS❑Topographic trap
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
(�Q - 7
7r ' yc(S
LOCATION SKETCH
11. DISINFECTION: Type (4(dA rs✓C Amount /G 0 9 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
0 To 74, Ft. /#rots .Z/G./aLS PicstV1/
To Ft.
From
From
To Ft.
&ts/or. b-t4f1
1ti
ROE;
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUUIED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI NATU OF PERSON CONSTRUCTING THE WELL
DATE 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

Zip Code
%at- Oen- 31f24/
Area code- Phone number
DATE DRILLED l�.Z,7�OG,
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and al Resources - Divisi
W ELL CONTRACTOR (INDIVIDUAL) NAME (print)
v J 81
of Water Quality - Groundwater Section (�
CERTIFICATION #___,_I�__
(Npt... PHONE .]SI.�.5S?-ST)L
WELL CONTRACTOR COMPANY NAME Filly (at8
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
2
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
WELL LOCATION:
Nearest Town: L1/4c4 /1.4oR/qia! County /flit_PDefJlai
etc Sxdw LDJ`
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
ru
(Sueet or Route No.)
(c A /tTC- ai /736
City or Town State
ALHOS
Topogra and setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
DU3S"? S.SzO/a3022'id/,367
((legman/minutes/scent's)
Latitude/longitude source: QfPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
clay
DEPTH
From To
0 —85-
GS - Ff Sgqn1010446.•
4' 8f — 9Y At r 6s"
5. TOTAL DEPTH: fSOS �RM� y`
6. DOES WELL REPLACE EXISTING STING WELL? YES 0 NO t� FY —
7. STATIC WATER LEVEL Below Top of Casing: -- 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): e METHOD OF TEST1IDl.hrlq-Ri'q
10. WATER ZONES (depth): — J JJ
LOCATION SKETCH
11 DISINFECTION: Type Ch,'Odaie Amount .— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 'Q To QV Ft.4.AS U6.-/M AYCfOghl
From To Ft.
From To Ft.
13. GROUT: Depth n Marerial Method
From D To ; 0 Ft. ( 'OfCeE}E 1 ill
From To Ft. 1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SANDiGRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
16. REMARKS:
erc4w (f"//
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
"Ca ai
SIGNATIJXB OF PERSON CONSTRUCTING THE WELL DA
to
O i
Cri
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Maul 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 #
1. W CONTRACTOR:
�Ihr U WI
Wa.1 tract (ttd/vid al)�Narn ® S
E oJJJN� Is W E I1 f�a'cl�uln pr Q.L.C.
Well nlraclor Company Name
STREET ADDRESS31 Xeki C
Lflee.sig /I* C a8749
Zip Code
City or Town I State
( gag >- a5g—WO
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(inapplicable)
D WQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply I3'
DATE DRILLED _/%y/6
TIME COMPLETED 1 , "yob
3. WELL LOCATION:
CITY:
AM PMp
COUNTY Mr Dow/1�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND ING:
❑Slope ❑Valley at ❑Ridge ❑Other
(check appropriate box)
LATITUDEN 3 S,,itr /6/
LONGITUDQQf)V C li/�Vt
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME 1r OU e
t 1(
May be in degrees,
minutes, seconds or
in a decimal format
,STREET ADDRESS - 6 )C2% 5
11.N4nntvnock. 1I C ani9
City or Town State Zip Code
(`6253 3o— 356o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / OO
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: /0 FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS i FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /d METHOD OF TESTTBbJJlV
b1C L+ a
L DISINFECTION: Type Ch/QA,U e Amount /GD7
g. WATER ZONES (depth):
From To 63 From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weiy9,h�tt Material
From D To V FL Ii •%7r'S�Ce 7
From To Ft.
From To Ft.
7. GROUT: Depth
,An-1 concede
Material
D
From To 20 Ft.
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
4 ^ f'6
�p ^59'
c9 _4y
64? — 0f
11. REMARKS:
Size
Material
Formation Description
cru
OH-e-.
CPI
Grnw, 'f
11
SEP 19 1006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
T5A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN fROJIDED TO THE WELL OWNER.
SIGNATURE
PRINTED
CONTRACTOR ATE
PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
Nut Carat. • Deparimwu otEwrimumW rd
PAUL CONTRACTOR MONYII aAy
WILL O NTRACYON COMPANY
STAIR MILL CONI RuCTIRN Pfalt7rs
OfafBwNd
331484
Ramourms-eWnprQuaky -crouoth eeraeotino
ze
o/% -7 Air e'ow s z rat sir
,-
AMWAY= WQPERNEW
Ofsolleibie)
1. WELL USE (Check Appliot6b Haz): Hddoatial @i aledalpYtubtic O ebteltial C Agricultural O
Moeitatiog O Recovery O feet Pump Water *Woo O Other C If Oilier, Litt Use
2. WELL LOCATION:
Nana Torn: /)//9f1/ &/ Cowry
y 5 '/ Ceti/ `N t ,ei1 2 75 Z
(/rrM Nor. Nabas. Casa. f 4/Mdw. La N. 74,Csi)
3. OWNER: rat' Ci7Uiv6'
Address 53-35' (: e/n Glt f Rd
(frwawastoti.)
l21/i/'(ort-i we Zra 75`0
a4ctaa
AaraMrlfasrarrYr
4. DATE DRILLED (r
S. TOTAL DEPTH; 2 - C
6, DOES WELL REPLACE IDOSTINO WELL? YES O NO t
7. STATIC WATER LEVEL Below Top dCSns _.. . 7.
nnie
S. TOP OP CASINO IS /R `i Ohre If
Imd alehouse
-Tip etam.r,i.r..rkrSaw hod Armoire
9. YIELD (p): 5— )IWrBOD OF TEST //1.11
10. WATER ZONES (depth):
11. DISINFECTION: Type l'CY Amount 70 t z
12. CASING: WeM Mks
Prom•,_'_ Tom C Pt-= CWITD aACt
n
Praat_+_ To Pt _
Froc,__ To Ft _
13. GROUT: Depth
Prom 16. To Z2 Pt, C c34-tetC
Prom_ To Pt,
14. SCREEN Dept Dirasrr She fist led
Prom ¢' To Ftti� b.
Prom__ To Pt ;s, in.
15. SANDKIRAVEL PACK:
Depth Sire MSISI
From To
PromTo Pt
Topo i ,d setting
Midge f pe�mDVaby OPlsi
OW* "prodder
Lelilodalenghode dwell bodice
(watensse nYrrar)
Latiradadrogitede asurO(IPSOTapographic imp
OW& mu
Prom To FamodooDaeripda
Lareaniiacii
Show *sodst ad tau b aieu from at lout
two Stan Roads or County Roods include the road
abets sod oat rood rims.
16. REMARKS:
1 DO CERTIFY THAT THIS WELL WAS Pf ACCORDANCE WRH ISA NCAC 2C, WI L
STANDARDS, AND COPY HAS BEEN PROVIDED TOTES OWNER
--fof
4
Submit the original to the Divides ',Water Quaky, Gratmdwwr Beettsa,1f36 Ian Straw Cartw-Rrltigh. NC
3700406PhD=Ns. Alf) 7334231, wtitUa 3t dais. OW -I REV. 07/2O01

tJi' (.
tl � 1
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nainal Resources - Di yion of Water 9 ality - Groundwater Section J�
WELL CONTRACTOR (INDIVIDUAL) NAME (pried )9//LI/) 6 1k i� te€ S ) cnnncknote a278
WELL CONTRACTOR COMPANY NAME 5i.JPf A o9 st,� e// o/ tti at non s 0,27) ,-47-05/6
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT/
(if applicable) (ifypl)able)
1. WELL USE (Check Applicable Box): Residential B1 MScipIUPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery O Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATION: ,,/
Newest Town: /79/i/`/C�E� Countyd'tcr/Ocur'l/
179 M onlie.d cove 2 87tz
(Street Name, Ni mba, Cmmity, Subdivide., xet Nt, Zip Code)
3. OWNER: chivG'fP /li9//yrc
Address /751 Man r o v e
(Sum et Ram No.)
I1'I tW b/l 7ft
City oTwo Stye Zip Code
Area aide- Paine samba
4. DATE DRILLED .'-7— 0 6
5. TOTAL DEPTH: 2 /o S`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO B-
7. STATIC WATER LEVEL Below Top of Gnaw /D/> FT.
0 (Use 'WI aW) if Above TopnW
S. TOP OF CASING IS / 0 FT Above Land Surfaces
`Top er eodq termYaad solve bets tad mdsea requiem a
Tartan he aenrdauee s4M 1SA NCAC 2C A114
9. YIELD (pm): 7_ METHOD OF TEST // 01 eel(
10. WATER ZONES (depth):
11. DISINFECTION: Type (r /i/ Amount /0 cry
12. CASING:WallThilmm
From (O D�SW eir
/J (
From__ To Ft
From.. To Ft.
13. GROUT: Depth Mue®at mod
From_0_To 2 % Ft(,)c/"t/C 11�� iwi
From To Ft
14. SCREEN: Depth Dinner Slot Size Material
Fmta 7' To Ft in. in.
From__To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Sin Mall
Fromm To Ft
Fmm To Ft.
T d setting
ORidge� alley OFlat
(drsckappropdate box)
Latitude/longitude of well location
Oloomstodos shocoods)
Latfmdeilangitade wtace:OGPSOTopographic Dap
(dent box)
DEEM T.W4(•rrnr
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CDNSTR
IN ACCORDANCE WITH ISA NCAC 2C, WELL
COMM ON
STANDARDS, AND THAT /J OgPY OF T)BS RECORD BEEN PROVIDED TO THE WELL OWNER.
1,1
�.-
`770�
SIGNATURE OF PERSON • e i G THE WELL DATE
Submit the original to the Divialoa of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
21699-1636 Pine Ne. [phone], within 30 days. GW-I REV. 07/2001

From_d_To Ft
From_ To Pt
Froo-- To Ft_ _
13. GROUT:Depth Mattis!
Fro To 20 FCCant/ bte
From__ To Pt.
14. SCREEN: Depth Dander Slot Sias MaidFrom To Pt_in, in.
From_ To Ft_in. in.
15. SAND/GRAVEL PACK
Depth Sire Malaria)
From V To Ft
From_To Pt.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment anti Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (n(DrvmUAI) SAME i �� r- /Zifd% S awrin amorr s27b'F'
nueconAci'ORCOMPANY HAMS cox, e (,0(4- eel LPe// 4 lb flora a ( i 67rt) g'o
STATE WELL CONSTEDClow TLRMITS ASSOCIATED WQ PERMITS
Cif ttuliablpt (IfatpIiable)
1. WELL USE (Check Applicable Box): Residential l Maicipel/Public q 1Rdantrlal 0 Agricultural C7
Monitoring Q Recovery O Heat Pump Water Injection 0 Other CI If Other, List Use
2. WELL LOCATION:
Nearest Town: : /'/
�(o County //ti�lr DP Nuke/ e5 2F7p7
(Snastroe.Nsmea.Cab.fubo4--.LatNa.TapCods)
3. OWNER: // n s �A
Address se /4k/ Ve /7/Z
($Dun at Rs No.)
flnbit) 6NC 7�7s2
CigraTown Scare T; Cade
Ara clods Pbonaber
4. DAM DRILLED "7-6'06
DEPTH. '?e
6. DOES WELL REPLACE EXISTING WM. L7 it; NO ;IV"
7. STATIC WATER LEVEL Below Top of Cat. 30
A 8. TOP OF CASING IS / 0 PT. Above Land Surfaces
trodasied ett below lad SSa regale•
claims h aerdnce ISA NCAC 2C Ala
9. YIELD (pm): 00 METHOD OF TEST T, /n e
10. WATER ZONES (depth):
11. DISJANFECIION: Type C Armor /O d'z.
12. CASING: Waf Thic r.
aW.
nit 41
Topogragbieltand setting
Midge ale
(cheekspptupriele box)
Iatimddlongihide of well location
(dwaretta iaaaheeoads)
Latitude/longitude stir r.D'(_•T_, _ t ••JJc map
(Cbeta bat)
QF.ETB DRILLING LOG
From To Formation Description
'LOCATION smETCIi
Show t•••-^tio -x &stance in tiles from at least
two State Rods or Coo'.! y *r.nric Ti:-J -.4 the road
nit
2u_ .
16. REMARKS'
I DO HP1.P.BY CERTIFY THAT THIS WELL WAS
���p�.
Q )CrED IN A rORDANCE wrm ISA NCAC 2C, WELL
ON STANDARDS, aaQ/yi/TH: T CO rf Tt P 'rd.. PROVIDED HAS SEEN PRO 13 THE OWNER
SIONAIURE OP PERSON er e t errriii ThE WELL DATE
•-•eL "t "''''''_ -era''"' Sys Seetlaa, Ifi3f Mai gerrlee Caura-IRalalgly NC
names
Ne.00)13i332i, was_
30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and 9NatturaallpR`esou rrfc�ess - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM (�priiantt)/N'P Liza -Rey ywo?�/d / CERTIFICATION r#AR663j
WELL CONTRACTOR COMPANY NAME 1pJAiAQLI;ALL-1 tv7QJ1 D�I L (I �LG� PHONE # (JI'%s)ab 3 eV a
STATE WELL CONSTRUCTION PERMIT# t 1 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. W ELL USE (Check Applicable Box): Residential unicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring LJ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Usc
2. WELL LOCATION:Nearest n�
62Voi ON NeS3 county
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: illI4'Getc/7 Thorn rs �,/t�
k
Address073' I/eilu M)<N 2t_..
(Sues or Route No.)
i\-kNC AS
City or Town State Zip Code C.Q
( )-
Area code- Phone number �
4. DATE DRILLED $(� 36)
5. TOTAL DEPTH:: f 2f
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /CCM FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
graphic/Land setting
edge OSlope OValley ❑Flat
(check appropnate box)
Latitude/longitude of well lo-ation_
N 35' 35. 0S0 � g1 ' 9-6
(degrees/minutes/seconds)&EV /(fr
•
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accord epsjith ISA NCAC 2C .0118.
9. YIELD (gpm): • METHOD OF TEST GIA (' Calk,,/Q`l/T fie
10. WATER ZONES (depth): (5-, 3 Z h
��f/
11. DISINFECTION: Type—TAt1CC Amount oZ
12. CASING:
Depth
Fronr rT To 1 Ft.
From To Ft.
From To Ft.
Wall Thickness
Diameter or Weight/Ft. Material
13. GROUT: Depth Material
From To 3 Ft/j ONO-f Q t
From To ' Ft.L LN+d11/4-(rCt
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Diameter Slot Size
Ft. in. in.
Ft. in. in.
Material
Depth Size Material
From To Ft.
From To Ft.
16.REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at le
two State Roads or County Roads. Include the r
numbers and common road names. •
3L"":r
{
1 '
CA
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCT ON STANDARDS, A$D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WE1l. 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

r '✓ Borth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
.636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Bo:): ® Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MARION County: MCDWL
DYSARTSVILLE RD, DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER PAUL ROBINSON
Address DYSARTSVILLE RD.
(Street or Route No.)
MARION NC 28752
City or Town State Zip Code
4. DATE DRILLED 08/03/06
5. TOTAL DEPTH 305
6. CUTTING COLLEC.ihD ❑ YES NO
7. DOES WELL REPLACE EXISTING WFT.1 ? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 5 METHOD OF TEST: ARD
11. WAIERZONES (depth):
If additional space is needed use back of form
12. CHLORINATION: Type: CHLORYTE Amount: 7.5
13. CASING: LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #226 N. FROM POLKVR i F RT ON TRINITY CHURCH
LOOP RT. ON DYSARTSVIT.T F RD. 1/2 MILE ON RT. OR 31°D
DRIVE ON RT.
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 160 Ft 6-1/4s SDR21 PVC
From To Ft. _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUILKRETE POURED
From _ To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft _ in._ in._
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
CA
rT-t
CD•
rn.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
r SIGNA OF PERSO O STRUCTING THEeArt
`i!?D DATE
glut to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mai Service Center ;Raleigh, N.C. 27699.163E-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• L_A.fInn A f'CI(
WELL CONTRACTOR CERTIFICATION a:&1
STATE WELL CONSTRUCTION PERMIT#:
R rl 9 0 c ej i)1
1. WELL USE (CheckAppilcebe Box): Residentiale.r Municipal ❑ Industrial ❑ Agricultural 0 Monitoring 0
Recovery Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOQTA 6Shh ske h o the location below) t�/� I
Nearest Town:lc-I I County e n C ` \ t'
(Road Nit n_NumDnx. Conn>uniry, or Subdivision and lot Nod DRILLING LOG DEPTH
3. OWNER ' 7 x '� jr� FromTo FomationHesertp on
Address 11 _ I2_O Sara( dk r A-
.____
Pa��%1 Nt« c d. a� (4 (>o— z q /'�'),t rar tc
City or Town State Zip Cads 3 —4cxn l "both f12
4. DATE DRILLED el )n-a Q goo - (DO(- V 112
5. TOTAL DEPTH to i
6. CUTTINGS COLLECTED YES El NO9-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOB'
8. STATIC WATER LEVEL Below Top of Casing: FT. -
9. TOP OF CASING IS ' (um •: a AbeveTopof Casing) r_.,
FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with l5ANCAC 2C.a a
10. YIELD (gprn): S METHOD OF TEST
11. WATER ZONES (depth)* CA
12. CHLORINATION: Type
13. CASING:
Amount
If additional space is needed use back of form
Depth Diameter oru Thickness LOCATION SKETCH
Fromp elenvFL ,.,Materiall (Show direction and distance tram at least two State
Toep 1, W Ft ( s etc ! ei.. b�\ 1 C. Roads, or other map reference points)
From To Ft. ` l V
From To Ft CO)
14. GROUT:
Depth Material Method
From i...._ To c-)Q Ft %frO,Vd
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:
ttk
U
G
e ack Mtn. &ti-
I-140C
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY f jF THIS RECORD HAS EEN PROVIDED TO THE WE OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
MGM TDRE OF PERSON CONSTRUCTING THE WELL DATE
Submit oriphW to Division of Water quality, Groundwater Section within 30 days
GWI REV. 12A9

North Carolina • Department of Environment and Nature -Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-phone (91g) 733-3221 n n .�� q� ,.
WELL CONSTRUCTION RECORD WELL CONTRACTOR' ( 1 u A.1 wY 7JC�t
WELL CONTRACTOR CERTIFICATION #:~7I j
STATE WELL CONSTRUCTION PERMIT#:
90
1. WELL USE (track Applicable Sox): Residential pa Municipal ❑ Industrial ❑
Recovery Ei Heat Pump Water Injection Other © if Other, List Use:
2. WELL LOCATIS][I; (S�ow.�hof the location below)
Nearest Town: ��,,JJ (t County: r 1('ci'ue.I'
' (Road Name and Hunters. ConrmWty. or Sub rtn an Lot No.)
3. OWNAddER
Crfu t AP, Lu-I•i`f) t
t JIC , S 1 or Route No.�c�4'Yi R0. ]
City or Town Stas Zip Code
4. DATE DRILLED -. -f 712
5. TOTAL DEPTH t Oa.S
6. CUTTINGS COLLECTED YES El NOgJ'
7. DOES WELL REPLACE EXISTING WELL? YES NO` 1
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use 1' 9 Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated atlor below land surface NQulna a varlance In accor-
dance with 15A NCAC 2C .0116 n
10. YIELD (gprn): tfk7 METHOD OF TEST t 11 q
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth r «WefgnVFl ^Material
___
From k To Qn Ft. S�� 1 �l—
From To Ft
From To Ft
14. GROUT:
Depth Material Method
From 1 To JO Ft ( eCrnetr)t
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in ___ in.
From __ To ._ Ft in. ._ In
From __ To __ Ft. __ In. _ in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
(Show direction and distance from at least two State
Agricultural 0 Monitoring ❑
DRILLING LOG
- 5
4�- (0(-f
To
co02 - cOl(7
DEPTH
Formation Description
[ +C1dr-I-
(1r t \-e
(rev c e
Iran
H additional space is needed use back of form
LOCATION SKETCH
Roads, or other map reference points) 3
..n-Y,.MQ-Y Kpr / c/1
n0 :
/20
crtH:�tfc
9
rct
drip` j i tnnEY
2SS
o c, 'or+ .i-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF THIS RECORD jBEEN PROVIDED TO THE WELL OWNER.W
/
FOR OFFICE USE ONLY�� 7-2 3 6»
Quad No:
SesW No.
SIGMTURE OF PERSON CONSTRUCTING THE WELL DATE
Subnil odphW to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12199

Nett Cahn -Dorms a llodo smtsd
fl&c e*.cio.=-40
afw:«tr
Rat WILL CO
--- A[asWra�n !!e
333526
flaw lestion
Mow 12320
1.11(askAMIS.lhoec sYY 314isitlpi.ebtoC Med D Myo noway a ParpTier *odes U Now 0IlCrsr.tag the jD
2. MI. Lo A
Wait T
it
Ctd rar t�r.li
v c 2On few as *OS
As air Pia set
.B
4 DA1tDRW.1 b -2 z6
3. TOTAL WPM. 1125
t XIS NRl.sanaatammoo MILL Yls D No 9'
7 STATE NAM IBM Saw Top ma -J'SD !T.
etari statire
Tor rCANNi11 l"i" !?wAbortL� Sans
`rr♦M•rYfswr•rsasrbatisi wfrwaa•sa•
wrfarYrsrewwerYAMAC ICAS
O. MILD(fttk o, hatoon oe,M1 7:.,7
to. NATU.21QA111
atitiaTopattraid Slay
tomoC7Ys1N Oust
wrettiiwtl�loots
Il � .rr,r, ep•a
moo
MTe O LAagual
'"DI
redpika
11. DI R10Win „idsd2:., Anse s` v Z.
12. Can
at WSW 4+dd
P sol-v
IS. 4110bob /�frrar�
ngerr it cue
1s 8211Eis D4r drttr Swan MS!
ta.
la
t!. sAWIDtlllAVII.PACL:
„( DIP. Nor f,1srL1
Phis �(J
1haliamS....TR.1111111.•••• p►••••••••IIMIS
16. MAUS:
Unithanno
Sew Abase aefrbLs ad drum bulks betlenatloss
asstYand Skit Se
mid we
1 DQ lri CiprY 7'AT3MI aL N*s
Cowntucnalorlf/l1 MAT ACDrt'
110166111111101'111.011
AccasM1NSM11fKf!A ocrec2c,MILL
uAaarff 1110411ammf weu.avaml
T1sMit DAM
SINS Oas71/s71Mtat SIPS a .11fe atio R11ofWs,IliboltOslo.Color-Ilia NC
2711101011 Raft pin issat,.INIr7Args. ow-tav Omaoi

Nam n i ' 4" d 11
# /0 a ' ores p g/rnc lvtis
010.411 lemi ►Ctaarlt.SdiiabletNa.syoarl
3. Mak Te Ft Owe
Mks IO Mace Enres7 AR
ea.reboriso
4?" f "-S % 5 G`
tarell t tar *CS
Mae flisiat
4. DAMMA -2 /-O/c
S. TOTAL tor I: 505'
6. DOS WILL RRPLACSIIRwz*IO WAIT YSS 0 NO 0
7 STATIC WATS Mt Ms. atOrimp 200 py.
S. TOP OFCASINO Ii /6 PT. Above Land Same
nae aeaatra s.rraua■ rite tit Mass nobsmiss Is MO lit NW IC AUL —
•
It TIMID (tea /A M111110D OFTIST l , i.-n ref
Ilk WATER ZOIIIS( N
11.INIMPICTIO/tTpe
U. CASIMICi
`BO
3n5
WILL C C nON g� 5
Use Caalea-Dapa.aatatatMaiaaaanteadMott ltn..a..- =ale_aallty-Oaaaadeaa.Sorban
ving.Ctegt.a.7aamasi.U>r imerre)
ern well 4 nos . OnflY-c *p
RAITWILL COMbio II..JI--- aaOnAfleatle
AfaslfatMd
ellasualo
1. WILL USE StAM;aibIse SSW @V-iisYMWAiio13 ISM SAWS 0
Mallaki Merry 0 Rut Pep %erNadia 0 OSar0 flea
2 WSLLLOCAT1I:
Tit
eMataeFgd�arw OPIat
es b dean bee
Smartainsa
L'ishOssads pgt.ptie
Pros To Fanosio• Dawelpdos
ir// Asps Ili 0"7
eMal liltiaar
l0eq_ [ R 2a j:'j. A
Tat__
IS. GROUT D�{ps met 1dr_/
Pta. u _Te ItPt,! onetter tuef m, X
Sas
14. SCRI®t., Dqs Caw SiaAaa
TA ---
IS. SAPIDASAVELP CR:
!Is MAW
MSS
Slwar/ssinaid 0ew*
tie1 load tam*Made.
smileaadaa swadaa , 9.
JAI
IDOSSSSStfp._il71UTIIIIII LLVMS StAOOOSDANiiwAllISAwow 2c, vets
COlwIfl7L71ONRTMOApILAIO OF MOM MICAMIDTOTINvats.oww
-2/-c2
1KMA11SOFIPORSdITlltI= EWE
*SS ramidtortltlSeateat pnilp,dae nu Sae" MN NO SA*. Des-- y pc
flMp.sssiMaart. alM vats Sign. OW-1 RSV. e'l/IOOi

S �qq�/ ��� '`�y�� Lae*
214 5 F 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ) �.)a taint La 1r d C
WELL CONTRACTOR CERTIFICATION #: t>Z 9 KS
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]
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑
Recovery D Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below) 2VC Id
f(ijcl
(Road me and yumber;, Co unity, or Subdivision and Lot No.)
3. OWNER is%. f7( C'rt�.e
Address
St for oueAo.)
met✓ ti.tt. c2YiSL
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH .a a
6. CUTTINGS COLLECTED YES NOM,
7. DOES WELL REPLACE EXISTING WELL? YES n NOS,
8. STATIC WATER LEVEL Below Top of Casing: ;,S' FT.
(Use II Above Top of Casing)
9. TOP OF CASING IS 14 FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01113
10. YIELD (gpm): 7 METF�OD OF TEST t%Lssyi
11. WATER ZONES (depth): Oat.2ar
12. CHLORINATION: Type 7 dYS Amount 3
13. CASING:
DRILLING LOG
From To
Monitoring -
DEPTH
Format ion Descdptiipn: `?
O
g
-sm
a
s 23
m
up "--
r+1
If additional space is needed use back of form
H
Wall Thickness LOCATION SKETCH
Depth Di a er or WeighVFt. Material (Show direction and distance from at least two State
From O To / Ft. a/ ®vd Roads, or other map reference points)
From To Ft. pur
L
From To Ft
14. GROUT:
Depth Mated
Ft
From To �0
�_
From To Ft
15. SCREEN:
Mat d•
am•
Depth Diameter Slot Size Material
From To — Ft in
From To in
From To Ft In
16. SAND/GR • L PACK:
Depth Size Material
From To Ft
From To
17. REMARKS:
in
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP RECORD EEN OVIDED TO THEWEE OWNER.
ANC
SIGNATURE OFF /�o O?) PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
GW-1 REV. 12/99
Serial No.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalpResources - Division of Water Quality - Groundwater Section
w'ELL CONTRACTOR (INDIVIDUAL) NAME (prtht)I(' -T � tu- 9-( CifCERTIFIC�AT.I,ON a 24S° rrrs w ELL CONTItACI'OR COMPANY NAME 50S .I CO4iCLC- C I. i. Ci � PHONE a (♦. G 7zv-ei v s
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
7
WELL LOCATION: 1s Topographic/Land setting
Nearest Town: tt i (1(=or'l' County /v'.�ybt„IAu. ❑Ridge ❑Slope ❑Valley ❑FIaI
O1L iI3 J4fl RsJ t • e Atv t s7`R4r L (check appropriate box)
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code) Latitude/longitude of well location
3. OWNER: eat /t e� .N
s tire
Address 4Zt 6 t4 F+t,Uty &uldL
(Street or Route No.)
(DLO fe,.,r- ry C. 2A9
City or Town State Zip Code
(L ass- ig7/3
Area code- Phone number
4. DATE DRILLED S'ZQ'O(i
5. TOTAL DEPTH: (pcc
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 1IIS FT.
(Use "+' it Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance is accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): YL METHOD OF TESTy' 41 ✓C
'`i
10. WATER ZONES (depth): i2 4)OM v500'
l 1. DISINFECTION: TypeCitvt. s Amount :f OL
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From To 5 Ft
From 4 To_i____ Ft.
13. GROUT: Depth
From To Et.
From O To7D Ft. /!f P'Ittpel
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:
Material
p p C
Ct)i4tV
Method
3 5.o'j4 0 On. t al.t`! 17 L_I
(degrees/minutes/seconds)
Latitude/longitude source:BCriPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fomiation Description
0-- Z%ef 0 ACtc1 attic
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. EC 11 VEL'
DIV. OF WATER QUALITY
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRU ' ' STANDARDS, AN. THA COPY OF THIS RECORD HAS B
SIGNATURE OF PERSON
Submit the original to the Division of Water Quality,
27699-1636 Phone No. [phone], within 30 days.
OALP
OCT 0 6 2006
0.0a14 fa ay
H I5A NCAC 2C. WELL
TO THE WELL OWNER
sO-gvkrot.,Kj
DATE
REEIVED
roundwater Section, 1636 Mail Seni a Center -Raleigh, NC
OCT 1 7 2O'bS
GW-I REV. 07/2001
Asheville Regional Office
A.uifer Protection

N
Fj ,
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcees - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) he rU S/+CT; )14� ) CERTIFICATION #C) / 5�
tv ELl. CONTRACTOR COMPANY NAME —T0 S4 . C e W r 0/.� a• c h c3 PHONEY
STATE WELL CONSTRUCTION PERM ITU ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential BI 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: #lcr:on
IV/or/et/ Rel. 456
(Street Na4w. Numbers, Community,
3. OWNER:a N W4'ses
County ni C/90 W4 )'
tuorL
bdivision L.otNo..
Zip
p Code)
Topographic/Land setting
❑Ridge ti2tlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
.y� �ZL35039, 15GN (18.24 ,V:52
4ZQ W
(degrees/minutu econds)
- Latitudc/lon rilude sourcr.PS❑To
K)o c4 ahc -ea L p! poeraphic map
Address Q 9 lrJta,
(Street or Route No)
PM A 40/L, >V - 287S2-
City or Town State Zip Code
(la)-GS2—J4,c /
Area code- Phone number
4. DATE DRILLED 6, -028 - 0 G,
5. TOTAL DEPTH: ) to 5
6. DOES WELL REPLACE EXISTING WELL? YES I+'NO 0
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 accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /Zi METHOD OF TEST f r
10. WATER ZONES (depth): ) 0 c p n9 h 1 /bo Teri
11. DISINFECTION: Type Cior.n4 Amount b CL
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 9/ FL (o Yq No PPC.
From 91 To 9 .3 Et. t ,) $tj C jV V
From To Ft.
13. GROUT: Depth Material Metho
From 0 To 620 Ft. 1 C ( _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 i/4
From To Ft.
From To FL
16. REMARKS: Bit
DEPTH
From To
- 11'6
riC]
BO
4G - 165
(check box)
DRILLING LOG
Fomtation Description
r1;r)
c,f lt bYut_ Csren;l?
CI we,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
DIV. OF WATER QUALITY
nr
OCT '0 t. 2006
Pk, ion
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
t.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Gro
27699-1636 Phone No. [phone], within 30 days.
dwateREtienPif*i6Jgail5eniceCe ter -Raleigh, NC
G CC �� VV GG LLJJ ♦ W-I REV. 07/2001
`orJ
OCT l 7 21.111
Asheville Regional Office
A.-...:s--

s
6-1
0 ":4 .1) N
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL. CONTRACTOR (INDIVIDUAL) NAME (print) ies ni S u$g-1 tC - CERTIFICATION It Zf5-0
uS4iCE t,. ceL. Dr;Lc iNc PHONE # (t9?Q)7ty-V,09
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT*
(if applicable)
WELL CONTRACTOR COMPANY NAME
(if applicable)
I. WELL USE (Check Applicable Box): Residential EKMunicipal/Public 0 Industrial 0 Agricultural O
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:ts�
Nearest Town: AIL A 14 O/3 County $4 4olaC(.C.
( LAek Forest ,r
(Street Name. Numbers. Community. Subdivision. Lot No.. Zap Code)
Address AMC I Q1c J fl#Na G�G'f vl
3. OWNER:
(Street or Rowe No.)
Mari Old C
fa1t4.f v^
2 975 L
(a C)- �T g�/-5K�OT g rip Code
Area code- Phone number
4. DATE DRILLED ta' 0 —O V
5. TOTAL DEPTH: (obS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO fire
7. STATIC WATER LEVEL Below Top of Casing: / S/D FT.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminted at/or below Ind surface requires a
variance in accordance with ISA NCAC IC .01IE.
9. YIELD (gpm): I METHOD OF TESTA' / 2
10. WATER ZONES (depth): /1,0•n P 5 r a`
11. DISINFECTION: Type EL®/2,me Amount 4OZ
12. CASING:
Depth
From To FL
From —To Ft.
From To 9j Ft.
13. GROUT: Depth
From To FL
Wall Thickness
Diameter or Weight/Ft.
Material
Material Method
From ! l l 0 Ft._ att
14. SCREEN: Depth Di teter Slot Size aterial
From To EL in in.
From__To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To FL
From
From
16. REMARKS:
TopogryphicfLand setting
°Ridge ®Slope °Valley OFIaI
(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
Q C> 60� �r gitsci f.—�
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.
Lk
La
Gtfr
DIV. OF RECEIVEDA R QUALITY
•
OCT '66 zoos
1 DO HEREBY CERTIFY TH
CONSTRUCTION STAN
THIS WELL VMS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
AND THAT COP CO HAS BEEN PROVIDED TO THE WELL OWNER
PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, G}oundwplft:.Setni on...Service enter -Raleigh, NC
27699-1636 Phone No. (919) 733-322 t, within 30 days. II fP''ii CC ll�� CC V t U GW-I REV. 07/2001
Asheville Regional Office
i

r n, C Y
3 y:: 0
WELL CONSTRUCTION RECORD
North Carolina - Department of Ewiromnent and Natural Resu mces - Division of Water Quality - Groundwater Sectionon,�/,
WELL CONTRACTOR (INDIVIDUAL) NAME (print) YYC.7 ` Id �wFi CERTIFICATIONS G/50
WELL CONTL%cToR COMPANY NAME TUMI GE i)lrIL(.w 9
STATE WELL CONSTRUCTION PERMITX_AREOCIATED WQ PERMITA
(if applicable) _... (if applicable)
PHONE 1 f 82R 70-eirr8
I. WELL USE (Check Applicable Box): Residential i3 Municipair'Public ❑ industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O IfOther, List Use
2. WELL LOCATION: ����,,��//' TogoBric/Land setting
Nearest Town: 64CFde7 County 0�delie 6 °Ridge USlope °Valley OFlal
y3 Arno It Ly6I.t (check annoy/am boa)
(Stout Name. NumbNimbus.mi canmy. Subdivision. Lot No.. Zip Code) Latitudelloigitde of well location
3. OWNER: Jo b/.1 it&. a=fut"Stti/Wtairt Poesilis: cLC okinc/minmes/secads)
Address iota tart
pG d Ara ( or Rowe No.) 29%t
Cityor Town State Le Code
(8]S)- v8ef
Area code- Phone amber
4. DATE DRILLED 7/n104,
5. TOTAL DEPTH: R 9G
6. DOES WELL REPLACE EXISTING WELL? YE 0 NO Pt
7. STATIC WATER LEVEL Below Top of Casing: FT.
(uce + irAbtneTopaaCaa%,g)
8. TOP OF CASING IS / Fi'_ Above Land Surface*
'Tot of casing terminated at/sr below tend swim moires a
rename is accordance with ISA NCAC 2C .rig.
9. YIELD (gpm): 75 METHOD OF TEST I g-
10. WATER ZONES (depth)_ 7 ff pM a -4 70
11. DISINFECTION: Type eiPRige Amoag 9 OZ.
iL CASING: Wal17hickness
Depth Diameter or Weight/FL Material
From To Ft
From 0 To
From$/ To
13. GROUT: Depth
From To Ft
From ) To 20 FL
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
Fro+rt__To Ft.
From To FL
16. REMARKS:
ley a se
siot Size Material
in.
in.
Material
Latitude/longitude source:OGPS°Topogtaphic map
(cheek bate)
DRILLING LOG
Formation Description
DEPTH
From To
0- Is
A 12sf-
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roach. Indmk the road
numbers and common road a.
it'll A
qq RECEIVED
.fritIV. OF WATER QUALITY
OCT 0-6 2006
CILDftiCk
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION STANDARDSAND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG
RE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Ground
Z7699-1636 Phone No. [phone], within 30 days.
DATE
Gw
OCT 1
-Raleigh, NC
I REV. 07/2001
Asheville Regional Office
Aquifer Protection

2 5
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ResYwaees - Division of Water Quality - Groundwater Section y�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Uc r I �\US}�''.e >) CERTIFICATION i'�`I5C (/
Sus- 'Cl', k.�'// %7ri//1, PHONE •'F 7.2 -957,
ASSOCIATED WQ PERMIT#
Ofapp)icable)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if a iplicable)
I . WELL USE (Check Applicable Box)Residential la/Municipal/Public 0 industrial 0 AI!rICUihUai 0
Monitorine 0 Recovery 0 Heat Pump Water Injection 0 Other Cl if Other, List Use
2. WELL LOCATIO ,ram n
Nearest Town: aid Tor 1 1 Counter /1 lCfJwe ll
neie %/. 20C/t- Lot 827
(Street Nmu& NNun*as, CCcuue-wiy. Subdivision -Lot No.. Zip Code)
3. OWNER: 1 /)7'1 Jirat.1 .IS' Z1 O F%w < Cry_ licit
Address P.o6oX 2/5'
Lr1, "" $or JC "°) 7 o f b7
City or Town Sense Tip Cede
( )-Uzi.-Ole
r
Area code- Plane number
4. DATE DRILLED 7-a f `OG
5. TOTAL DEPTH: /000
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing 47 5 FT.
Wm 'flagon TepofCas g)
8. TOP OF CASING 15 / FT. Above Land Surface*
`Tap of caiap tenanted athr below land wince requires a
variaoee L acmrdmce with ISA ZC.#IIIL /
9. YIELD(gpm): ✓z M OF1raI semi
10. WATER ZONES (depth): )IL Sri027 / '
11. DISINFECTION: Type dor, .,o
12- CASING:
DDi
From tj TTo h(.3 Ft.
From G 3 To a, 5 FL
From To FL
13. GROUT:
To FL '2Material
From 0
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To FL in.
15. SAND/GRAVEL PACK:
Depth Size
To Ft.
To FL
Amount S'o2
Wall Thickness
orfV ght/Ft
,/ G
From
From
16. REMARKS:
Method
Poniped
Slot Size Material
in.
in.
Material
Topographic/Land setting
G Ridge °Slope °Valley °Flat
(the* appropside km)
Lalitdeilongitudc of well location
35 32.7VSni UP2"o7.WOW'
(degees/mioui sfaaonds)
Latitude/longitude source:°GPS°Topographic map
Much box,
DEPTH DRILLING LOG
From To Formation Description
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.
RECEIVED
DIV. OF WATER QUALITY
OCT 0.6 2006
AFCGtrt le,(
t Oran
CONSTRUCTION STANDARDS, AND THAT A. COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
Submit the original to the Division of Water Quality, G
27699-1636 Phone No. (919) 733-32221, within 30 days.
adwt,SVED
7- 28-06
DATE
—Col Center -Raleigh, NC
GW-1 REV.07/2001
OCT
Asheville Regional Office
Aauifpr PrntaMl...,

WELL CONSTRUCTION RECORD
Nord) Carolina - Department of Environment and Natural ResourcesI- Division of Water Quality - Groundwater Section -
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 6e: r/ SL"; a CERTIFICATION Sat ISO
WELL CONTRACTOR COMPANY NAME Sus 4, -.e- Wo-1/ n/'i �• .nq PtwNE s 4=81 7r /-H.670$
STATE WELL CONSTRUCTION PERMIT* aCSOrtATED WQ PERMTFR
(if a Hume)
(if apt)irable)
1. WELL USE (Check Applicable Box): Residential lie Municipal/Public 0 industrial 0 Agricultural
Monitoring 0 Recovery Q Heat Pump Water Injection Q Other ❑ 11Other, List Use
2. WELL LOCATIONIo (f^ t
Nearest Town: d tort County in'po we //
lat qev 4iMk+4, Nf
(Street Name. Numbers. Communit; Stamm. tat lie. Zip Cade)
3. OWNER: SI.1 Los, 1„0 kit rnps
Address P. Y3oX 30(
^A aimsaimsa C NO
N�N
uh N a 876
(gar 9IS-9003
Area code- 4. DATERILLED-a3-O(o
5. TOTAL DEPTH: 05' 6. DOES WELL REPLACE EXISTING WELL? `YES 0 NO (5'J
7. STATIC WATER LEVEL Below Top of Casing: /DO. FT.
City or Town State Ztp Cade
8. TOP OF CASING IS 1 Ithm.a inn Topaf �)
FT. Above Land Surface*
"Top cfcasing ternleatet attar seism lead surface regales a
variance in accordance wide ISA NCAC 2C Alta.
9. YIELD (gpm): % METHOD OF TEST 5140p1
10. WATER ZONES (depth)_ /gIno fry 2Sot
11. DISINFECTION: Type do-,'n, Amount Y to r
12. CASING: WallT
hidmess
Depth
From—a_To g3 FL goor uFLPM�arrccial
From Q 3 To 1 J 3 FL 6 At . r
From To LS Ft Y PVG
_
13. GROUT: � Material
G� V
From To 20 FL_a£ e
From To FL
14. SCREEN: Depth Diameter Slot Size
MaterialFrom To FL
in. in.
From__ To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Frorn_____To Ft.
From To FL
16. REMARKS:
I DO HEREBY C FY THAT THIS WELL W r ( CONSTRUCTION ANDA � AS CO'NISF THIS RECORD
ACCORDANCE WITH ISA NCAC O7TIE , wai.
RDS• COPY OFTHISRECORDHASBEENPROVIDEDTOTHEWELL OWNER
SIGNATURE OF PERSON CONS7gucaac.THE WELL
Topographic/Land setting
IlRidge °slope °Valley DFIat
(check appnemat bee)
Lajigeleilimatitude of well 'passion
3 zl;Av 03z o7.ZoI
(dcgras/min uestsecomk)
Latitude/longitude sourcOEaG soTopogaphic map
(meet bead
DEPTH DRILLING LOG
From To Formation Description
B— /00 otieffgectt
/oD-i/o Syr /2oc
1/o- yor oviiie 6rd{{
Same Qerar ff
LOCATION SKETCH
Show direction and distance in miles from al least
two State Reads or County Roads. Include the mad
numbers and eozmnon toad names.
RECEIVE
a a DIV. OF WATER QD ALITY
AsS
4* 0
V
6 4 `#A
iliti
OCT -p 6 2006
pp DATE
Submit the original to the Division of Water Quality Grannfit ry
27699-1636 Phone No. (919) 733 3L31, within 30 days. �a' v Service Cater-Raleig(d, NC
GW-) REV.072001
24n
Asheville Regional Office
Aquifer Protecting

yfnf4c
0 v > a
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Grotmdwater Section CC
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L2: r ✓ TVs-f Cs?._ CERTIFICATION /50
W ELL CONTRACTOR COMN PANY AME OST,C P JCI-k.1/ Dr.11:43 PttoNE s $2l 12Y 95(/Ir
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMtra
(ifs ticable) (if livable)
1. WELL USE (Check Applicable Box): Residential ® Iviunicipal/Pubtic 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION-t
Nearest Town: rv2.% County l e l rJ% t✓L ��
$�Cytt 'j /21
(Street Nana. Numbers, Communiz Subdivsimt. 1.ot No, Zip Code)
3. OWNER:.JQNGj SG.1 PG4-Cty
Address ! 5' SG Coe sk rL; v c2 RI.
014 $ ttte (str�tFL& or Route Na.) 3 3 7
City or Town Stale 2ip Code
(151 r co ic.--6,5tog
Area code- (None number
4. DATE DRILLED it - 0 CP
5. TOTAL DEPTH: t f?5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 12/
7. STATIC WATER LEVEL Below Top of Casing= / 20 FT.
illsiekr if AbosareootCaortR)
8. TOP OF CASING IS ] FT. Above Land Surface*
`Tap of cram tnafntd ester blow land arises tnprdt s a
variance is acrordanttwit ISA NCAC IC.Off& ,l
9. YIELD (gpm): erf fa METHOD OF TEST /T !I'
10. WATER ZONES (depth): 2 Yd
11. DISINFECTION: Type./V/DK-t /L a Amount 25 OZ
12. CASING:
Depth Diarascr
From 6 To 3b Ft.l /)
From To Ft.
From__ To Ft.
13. GROUT: Depth Material
From 0 To DO FL 9 S I
From To FL
14. SCREEN: Depth Diameter
From To Ft. in.
From_ To FL in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft
From To FL
WI TNcmess
or
vL
T ��pppphic/Land setting
°Ridge 1 Slope OValley °Flat
(check appropriate box)
Latitude/longitude of well Imatioa
35° 3µ255N dR S v K)
(de ethe� mtaugtscotds)
tide
DEPTH{
From To
source: opographic map
(check box)
DRILLING LOG
Formation Description
®- &I bilLf
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
1Naaial numbers and common road names.
Method
rumperl
Slot Size Material
in.
in.
Material
L45
Got
*2.21
RECEIVED
OF WATER QUALITY
OCT 0- 2006
11ov
0-(1-& ry(AR't1
6.
16. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WF.11.
CONSTRUCTION STANDPRDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I �oL GO SIGNATURE iGNATURE OF PERSON CONSTR
Submit the original to the Division of Water Quality, Ground
27699-1636 Phone No. [phone], within 30 days.
DATE
OCT _ 72i
Asheville Regional Office
ACt tifor Prntorrtinn
Raleigh, NC
REV. 07/2001

.) A
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - pmundwata Section
WELL CONTRACTOR (I,NDIVIDUAL) NAME (print) f ' IOC - _ 2'C-
�{ / _ A CERTtFIGTION p �I J�
WELL CONTRACTOR COMPANY NAME \ t)S°I-r q . I Y , V .f„/ �ije PHONES ( ) 72CMC '
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERM(
(ifa liable)(if licabk)
1. WELL USE (Check Applicable Box): Residential Bat Mtmicipal/Pubiic Ci industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATiO "�'' ��``
Nearest Town:�w Count ,Y/J r(� aa
2113
(Stnxv Name. Numbers. .Community. WNW / , 14 4-,
/ n)c Subdivision. Lot No- rip Cade)
3. OWNER: SOCL 5 tlese/
Address ),7g soul` Sundt' i ,rri!p Dr
IV IStRct or 1rC No.)
/ q—Kot
1
City. or Tarn Sun: ay Code
t_,- Nig-01(5
Area code- Plane number IDLE?
4. DATE DRILLED " `� g ID CO
5. TOTAL DEPTH: 70X
6. DOES WELL REPLACE EXISTING WELL? YES NO Q-
7. STATIC WATER LEVEL. Below Top of Casing: 'An FT
8. TOP OF CASING IS 1 (Um me-H amaTap°Mariaa)
"Tap of casing tenalutcd attar blow land surface requires a
FT. Above Lam Surface*
in accordance with ISA NCAC Walt
9. YIELD (gpm): METHO
NOF 10. WATER ZONESt`M (�deptit)_ 11, in & IOL) 1 I e gip
Depth
From To FL
From d To 57 FL
From. __ To.$ Ft
13. GROUT: Demi'
From To
From U To Z v
14. SCREEN: Minh Slot Size
From To
in.
From
To is
15. SAND/GRAVEL PACK:
Depth Size Material
From __To Ft.
From To FL
I L DISINFECTION_ Type CL0,L%✓F Amami 43 OZ.
12. CASING: Wall Thickness
Diameter or Weight/FL Material
/f'C?
Material
16. REMARKS:
FL
Ft.�I
{er
Di
FL in.
Ft. in.
Nvc
/7,V/1%
Method
T c/Land setting
Midge Slope °Valley OFlat
(check appropriate box)
Latitude/longitude of weitjocation
3 _°/2:op2.ai o8r s rFw
(d bminuieslseamds)
Latitude/longitude sourer.CijGPSOTopographic map
(check box,
DEPTH DRILLING LOG
From To Formation Description
rt7 - Y3 p7l/
t$ Fos (ineA“ l!2
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
members and common road names.
RECEIV
DIV. OF WATER QUALITY
OCT 0 6 2006
p�(ce'a'2d
1 DO HEREBY�CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELLCONSTRUC N STANDARDS, AN I -: TA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,
27699-1636 Phone No. [phone],+within 30 days.
rrnialteetetVeirailSen
Center -Raleigh, NC
GW-I REV. 07/2001
D
d
(frolic_
OCT 1 7 23G
Asheville Regional Office
Aquifer Prntpe'tinn

F .1 n ♦ -
t7� N4 5
WELL CONSTRUCTION RECORD
North Carolina - Department ofEnviromnan and Natural Resources- Division of Water Quality - Groundwater Station
WELL CONTRACTOR (ItimVIDUAL NAME (print) C '( Tvc/1.!P CERTIFICATION la/50
WELL CONTRACTOR COMPANY NAME ays*ce I,l('// Dr-. )). nC PHONE l 1122)7.2 -05Vir
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERNIITF
n.., �.Q(ifa�tlicable) . (if applicable)
I. WELL USE (Check Applicable Box): Residential 4Eli
MunicipabPubliic Ei industrial 0 Agricultural O `
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: /
Nearest Town: C.) Li TO r f County %)'1 c ho
i 31 `idyl roan
(Street Name. Numbers. Community. Subdivision. tot Ha. Zip Code)
3. OWNER: S. 1CNL Vo4a-teez,
Address / 3 7 f;Qn
(Street or Roars NO3
OMi nie 2-8%%2
City orTown Siam Zip Code
ieGO-1SS)
Area code- Phone number
4. DATE DRILLED ' -
5. TOTAL DEPTH: 3 yi
6. DOES WELL REPLACE EXISTING WELL? YES g NO 121"
7. STATIC WATER LEVEL Below Top of Casing ) 7O FT.
(tke"+ if AboveTapeleauns)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Tap ofcasiue terminated at below bad sorbet regains a
variance in acrord.ase with ISA NCAC IC .0101.
9. YIELD (gpm): )0 METHOD OF TEST r
10. WATER ZONES (depth):
11. DISINFECTION: Type (
12. CASING:
n_ ((1/T ve Amount 8
}ronL 0 TDo h Diair
°'! FL
F /�iTo}L
To���!l/���
13. GROUT: Depthm
Fro To
From_a_ To 20
14. SCREEN: Depth
From TO
From___ To
15. SAND/GRAVEL PACK: To
Depth
From
To
From T
16. REMARKS:
Wall Thidtness
or Weight/FL M
Ft. la 4 I$S
Material
FL
FL flL
Method
QUt41pt2
Diameter Slot Size Material
Ft. in. in.
Ft. in. in
Size Material
Ft.
o Ft.
Topographic/Land setting
°Ridge °Slope °Valley OFIat
(check appoprae box)
Latitude/longitude of well location
350 344 slr, pj Fof112P Is.i(.3 LJ
otereesontmdesoeces40
latitude/longiwdesource:E PSOTopographicmap
ktrxk box)
DEPTH DRILLING LOG
From To Formation Description
0- /co ft4-
/cc- e5-0
/So- 3v5
trees, f-e
LOCATION SKETCH
Show direction and d1 lanrr in miles from at least
two State Roads or County Roads_ Include the road
numbers and common road names_
DIV. OF WATER QUALITY
OCT 0 6.2006
l DO HEREBY CERTIFY THAT THIS WELL WAS CON)NSTRUCI'ED IN ACCORDANCE WtFH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
AT(
SIGNATUREOF PE
Submit the original to the Division of Water Qua'
27699-1636 Phone No. [phone], within 30 da
REE$I DATE
, GroundwCater Mail
Off'' t ...
Asheville Regional Office
Aquifer Protection
ice Center -Raleigh, NC
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NT/N/�� anal Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME (print) rY J%�5f ! e CERTIFICATION p,12/JV
rYELL CONTRACTOR COMPANY NAME 1
STATE WELL. CONSTRUCTION PERMIT# ASSOCIATED WQ PERMMIT#
(if applicable) (if applicable)
H/
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring D Recovery 0 Heat Pump Water Injection 0 Other 0 I(Other, List Use
Car0571,(:Z IA-01 Dr, tf. n 3 PHONE # tn) yr r%— 95Y D
2. WELL LOCATIO/
Nearest Town: (YN:IndOE County /'I v
``--ttII (.0 e
(5 r eel ar»c Nun eq mu iry ws(trn,ttd No..
1 } N �v �pS, ('nf'-�typrd,�� � �t �r�
3. OWNER: Lpis h -k- Pi Ile I\SOn
Address 1 (c�eTh (��/•�� io `, t t 1
�� ,( .. (Street or Rowe No.) t (� 7 1!`? Q.'
1V C aV1 Co
City or Town ' Stare Zip Code
g59—fl a.L{c°
Area code- Prone number
4. DATE DRILLED 7 "Co -06
5. TOTAL DEPTH: 4406
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [a
7. STATIC WATER LEVEL Below Top of Casing: S'S FF.
t(ise --1-- if Above Top of Casing)
8. TOP OF CASING IS i FT- Above Land Surface*
"Top of casing terminated atter below land surface reclaims a
variance is accordance with 15A NCAC 2C .OIit
9. YIELD (gpm): jpnj METHOD OF TEST fi • r
10. WATERZONES(depth): FFI )7fft )25
t!. DISINFECTION: Type tier ,a? Amffn 4/ ount 2 G.
12. CASING: Wall Thickness
Dept Diameter or Weight/Ft. Material
From f) To is t Ft. t, Yy TO Pvt.
From 1;7 3 To 12 C Ft. ! �y 18 It 4All.'
From To Ft.
13. GROUT: Depth Material Method
From 0 Toff, FL rg E I pU,f7 I
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.
16. REMARKS:
tare Topog%phic/Land setting
ORtdge �Sbpe ❑Valle ❑
y Flat
Ale `, 1- • (check appropriate box)
Cede)
Latitude/longitude of well Location
35 32rJSl14 oS(2Ia. 747We
(degree4mi nds)
Latitude/longitude sourceflGPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
)20 (); rl
120- qG
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. include the road
numbers and cominon road names.
RECERVC
DIV. OF WATER OVA' TY
OCT 0-6 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
CON RUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
04
DATE
Submit the original to the Division of Water Quality, Crounp)vater �y
27699-1h36 Phone No. [phone], within 30
�� � V � �itt Ccu�
days.
r-Raleigh, NC
G -1 REV. 07/2001
OCT ) ?
Asheville Regional Office
-�.�__AQUifer

9 9 4) n,
Depth
From C To Z/ FL (a /d
From To FL
From To FL
13. GROUT: Depth Material
From__Q _ To 20 FL 7 one /
From To FLU--
14. SCREEN: Depth Diameter
From To Ft. in -
From_ _ To Ft. in-
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To FL
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment Namal Resources- Division of Water Quality - ptoundweter
WELL CONTRACTOR (INDIVIDUAL) NAME (prtat) Ci a ry t115i,C.P CERTIFICATn7N a,Q/SO
w ELL CONTRACTOR COMPANY NAME oslk P &h //
,nc
STATE WELL CONSTRUCTION PERMIT* (if 'rED WQ PF-RatfrR
. • . ticable)
—/ if livable)
1. WELL USE (Check Applicable Rot* Residential id Municipal/Public 0 Indus(tia! 13 Auicultutai ❑ Monitoring 0 Recovery O Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
Siren me. Numbers. C/o�mmunity, subdivision.s
3. OWNER: VapJ o\,d/.
Address W 0.t3OT, \k%•).
(Street or Rome No.)
�1actotr ►`iC- ' %15I
City orTowo I State Zip Code
(SIS)" 56-yyCtL{
Area code- Phone
4. DATE DRILLED e§ - 25 -o (o
5. TOTAL DEPTH: 4/0S-
County TO CT) `/ ORidge USiope OValley OFlai
C .X$r f3?. (cheek appropriate box)
Code) aLatit tm:in of well location
35 y2�N os2° o3.192 w
(deveannLatitude/longitude sourer. (cheek
map
DEPTH )
DRILLING LOG
From To Formation Description
3
4e'
PHONE * (Rn)774f-4/Syig
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Efe
7. STATIC WATER LEVEL Below Top of Casinv FT.
8. TOP OF CASING IS % (the"+d'AboveToo °Caooa)
FT. Above Laud Surface*
lap of casing terminated attar helms land serrate requires a
varianee in accordance with ISA NCAC ZC .0118.
9. YIELD (gpm): / 2, METHOD OF TEST R I it
I0- WATER ZONES (depth): _ /; ;.0 i./tlLe
11. DISINFECTION: Type (rid,-;nt Amotad Q c,r,
1? CASING: Wall Thickness
Diameter or Weigln/Ft. Material
i/() Pl/C
16. REMARKS:
Topographic/Land setting
"15
cior
^� Method
I Umpe d
Slot Size
in.
in.
AA, d - GnAcseC
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the rood
numbers and common road names.
W abhbw
RECEIVED wary
Materii)IV. OF WATER QUALITY
Size Material
OCT 0 fi 2006
7o MvP`ar-
y26
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NraC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LD n 4� QQ�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
O
DA
Submit the original to the Division of Water Quail
27699-1636 Phone No. [phone], within 30 days.
Gratz taw VED
ice Center -Raleigh, NC
GW-I REV. 07/2001
—ro Lnw41Vre
OCT 1 % 2QWs
Asheville Regional Office
Arn _ _.

WELL CONSTRUCTION RECORD " T R 4 :2
North Carolina - Department ortnviromntad and Natural Resources- Crj Ct
Division of Water Quality - Groundwater Section y
WELL CONTRACTOR (INDIVIDUAL) NAME (Odell ,/1,r� UST�/'c . CERTIF(C�AjT-�Ion s 2/S )
WELL CONTRACTOR COMPANY NAME 30g4;cs L,JO 1'�iP�ptL? 7ZY �
D r•�, PHONE s
STATE WELL CONSTRUCTION PERMITS TED WO PERMfla/
(ifapplitabkj (ifapphpble)
I. WELL USE (Check Applicable Box): Residential IIVMwiicipafipulic 0 Industrial 0 Agricultural °
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: 9
Nearest Town: OLD � County OA £Qsta1ecc_ / Topographic/Land settings
164-tie djAe 0.rde4\)C. Midge °Slope °Valley °Flat
(Street Naar. Numbers, Cmtyauoay, Subdivision. Let y(check cep rep box)
ea
rip ��'i/Q�77.��135�it�`l. 903udeeofwelllllocat n383 W
3. UWNER:CR%G tlttUdQ, �Pt.�glicJs `T���
Address 2.eN tb [Qi%?j- L1la7j'..[.1 t "' )
(watt or name No) 13� Latitude/longitude soureorPS°'I'opographic map
VLF cost- (eacc box)
City orToaa 711174 DEPTH DRILLING LOG
(Q2$ )• goo _ f8 5-7Tweak From To Formation Description
4. DATE DRILLED 2/ OGArea code- Phew 6, ,2.r-
Iee�-
5. TOTAL DEPTH: (.O 5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO /onO _ boS gx,axA-to-
7. STATIC WATER LEVEL Below Top ofCasing: J ft) FT.
8. TOP OF CASING IS ) (Usesad'AtewTop aroma)
FT. Above Land Surface`
'Tap aroaing terminated attar bebw bad surface reamer a
variance is accordace with ISA NCAC ZC •9115.
9. YIELD (gpm): 72 METHOD /�7OF� TEST Sian e
IQ WATER ZONES (depth): Vs. c1 p,.t "6ce'
1 I _ DISINFECTION: Type r.(or,nQ
12. CASING:
Depth
From., To 9/ F It
From // To 111 FL, .
From l// To II 3 FL
13. GROUT: Depth
From C) To
From To
I4. SCREEN: Death
From To
From__ To
K
15. SAND/GRAVEL PAC
Depth
From To Ft.
From To FL
16. REMARKS:
Amount S,'op
ter
Wall Thickness
L q 5'G4 L pv ;at
/e _ Sf0 ec
Alk
Material
Ft.
F)
Diameter Slot Size
FL in_ in.
FL in. in.
Medved
P°mPe,J
Material
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and conunot},toad names.
at-
G
DIV. OF WATER QUALITY
OCT OS 2006
) DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA war. 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
it /f�Mde9-Jo-oi,. / C.-SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Q
27699-1636 Phan Na [phone], witbin 30 da
r
Gria&Gailtilig DB6 Mail ice Center -Raleigh, NC
GW-1 REV. 07/2001
OCT I '!
Asheville Regional Office
A.uiter Protection

(Sheet Name. Numbers. Cammuoey. Subdivision. Lot No, rip Code)
3. OWNER:ryc(i4p Yai
Address 0? h { 41 4944 t6
ie60 N e 2 ex /
ty m Town Sane Zip Code
(-�-1- Y�z— iS21
Area code. Moot number
4. DATE DRILLED e- /g- 06
5. TOTAL DEPTH: 4'o5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO le
7. STATIC WATER LEVEL Below Top of Cashir FT.
(tom'" ifAbove Tap of Casing)
Z. TOP OF
CASING IS 0 FF.Above Land Surface*
'lea dumb* terminated atter blew land surface requires a
variance in accordance with ISA NCAC 2C.al l&
9. YIELD (gpm): METHOD OF TEST 4/ /2.
1 O. WATER ZONES (depth): altaday /jm
I1. DISINFECTION: AmountType(`/nr,ne u'o
tt,r
Wall Thie
WELL CONSTRUCTION RECORD
North Carolina - Department or Envhoanent and
/Natural Resources - Division of Water Q�lrry-Osormdw
W ELL CONTRACTOR ONDIVEDUAL) NAME (print) CDCr 3wSection
// 0sf'� cERni:rcATrSrona�/50
WELL CONTRACTOR COMPANY NAME &)5f. kJQj/ Dr Ell PHONE s OS) -771'1.41
STATE WELL coNsTRUCr1on Pawn/ 'rEp NQ PERMIT* (ifapolicab(ej
(if appiiabk) 1 ya
1. WELL USE (Check Applicable Bonk Residential M MtmicipaUPubiic 0 industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, Liu Use
2. WELLLOCATIOfr
Nearest Town: fr tr:On
r Cl;'-ii lost` 38
County m cpo
I2 CASING:
(Slim or Route No.)
Depth
From_ To
From iOet To Ft, (. g
From/t/y To 17) FL
13. GROUT: Depth
From C) To 7Q
F
From To
14. SCREEN: Depth
From To
Front___ To
15. SAND/GRAVEL PACK:
DepthFrorrt,To
From To
16. REMARKS:
CDtr o L
fitterial
5/O VC
- — c,Aly
FLJyvv / Method
Um
FL
Diameter Slot Size
Ft. in. in.
FL in.
Material
Size Material
Ft.
Ft.
Material
n
tft
�4.
Topomphic/Land setting
ORidge L7Slope ❑Valley ❑Flat
(check appropriate box)
`a�iortgnWlle of well lion
a 5'
15. �9/b6 �611VV U 8 l ,�7.3oq w
(degeennti )
Latitude/longitude source ` opowap j map
box)
DRILLING lLLtNG LOG
From To Fonnation Description
m- /3/41Di at4.
!S/5- *05
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads orCounty Roads. Include the road
numbers and common road names.
Lgt
�S a (o3
A
RECEIVED
DIV, OFWATER QUALITY
OCT OS 2006
( DO HEREBY CERTIFY THAT THIS WELL WAS COi
CON SI"f-^RUCTION STANDA'py9t��` AND THAT A COPY OF �D ACCORDANCE WITH ISA NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED
_ -
SIGATURE OF PERSON
Submit the original to the Division of Water Quality,
276994636 Phone No. (919) 733-32221, within 30 days.
ylg/-c�P
}p��� �\//�((�' DATE
ndwfitlh Ii3b'ItaSenice " cm -Raleigh, NC
GW-I REV.07/2001
OCT
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater S....tq....
WELL CONTRACTOR (INDIVIDUAL) NAME (print))j G o r y T J S ;i C P CERTIFICA7TON ad/SO
WELL CONTRACTOR COMPANY NAME —ct.).S -7 t C` Q / I.t./P // T
STATE WELL CONSTRUCTION PERMIT*
PHONE a I82%17 2V- NWWF
fifa licahMj MATED WQ PERMIT*
�... (ile)
I. WELL USE (Check Applicable Brock Residential 0Municipai/Public 0 Industrial 0 Aericutiurai 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 if -Other, List Use
2. W ELL LOCATION:
Nearest Town: q r-; Ors
>I ly At Post
c,C r 7 I,
•
(St LLtcet Name. Numbers. Cammuul^ty. )[ NSyyeltvi s. Lot No_ Code)
3. OWNER: KrzTktf Ufa C1 bUM
Address 1 71 54 li C r Po r t Rd
(Sneer or Rowe Na.)
Yficirl'on N. C ,2g7ea/
CityorTown Sure TipCode
(Zr cQ SZ. 72 /13
Area rode- Phime
4. DATE DRILLED '1 - 7-0 (p
5. TOTAL DEPTH: 50 5
6_ DOES WELL REPLACE EXISTING WELL? 17 YES�¢'NO 0
7. STATIC WATER LEVEL Below Top of Casing: n T.
8. TOP OF CASING IS / ( Use ibove Land SurCosinec
Above Lard Surfacer
lap afcasing termiaatd atter below laud shrine requires a
variance in accordance with ISA NCAC 2C AIIB
9. YIELD (gpm): / 2 METHOD OF TEST sic n e/
ID_ WATER ZONES (depth)_ y21rL-r7 geo
I I. DISINFECTION: Type F' JOr 'PP _/Amount k e
1? CASING: WWI Thickness
Depth Diameter �Weigit/Ft Marmot
From To 129 FL PVC
From 1 To i 99 FL t _kp _
Front it To1S1 FLIP 4/�jsair
13. GROUT: Depth Material Method
From O To 2) Et. Type / PUtnpej
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:
County fir Dowd(
Topographic/Land setting
°Ridge aSlope [Valley OFIat
(check appropriate bar)
LatitudeJlongity& of well location
35`'12.554 N o27c'61.ohl? W
Nearetimamaryisecoadd
Latitude/longitude source:MPSOTopogtaphic map
(cheek boa)
DEPTH DRILLING LOG
From To Formation Description
6- /4/0 4i2Fteocic
/to-20c law Arty Raft
200 - cos- ,t?C4 f Z l� /44-4.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads a County Roads. Include the road
numbers and common road names.
gantrett el 4
Slot Size Material
in.
RECEIV
in. DIV, OF WATER QUALITY
OCT 0 6 2006
Material
Fc'y
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
t,OL, q_ -7-06
S1GNARE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Ground
27699-1636 Phone No. [phone], within 30 days.
RECEIVED
OCT I 7 2063
Asheville Raninnni nu;-.,.
DATE
er-Raleigh, NC
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and Natural Resources- Division or Winer
WELL CONTRACTOR (INDIVIDUAL) NAME Quality-6tntficknoundwater Section
(P� C r, ..l T t /Cf i r e cERTtFICATION s 2/SO
tt' ELL CONTRACTOR COMPANY NAME tusl;ce Well Dr, fl:hr,
STATE WELL CONSTRUCTION PERMIT#
(ifappiicable) 4Ths TED WIZ PERMIT*
t
PHONE A Jrr28) 77 rF -Y SY
1. WELL USE (Check Applicable Box): Residential 5 MunicipaUPublic ❑ industrial 0 Agricultural ❑ Monitoring ❑ Recovery 0 Heat Pump Water injection 0 Other 0 if Other., List Use
7.
WELL LOCATION:
Nearest Town: Mar : o h County m owe ll
2%\7 Duke. Dr;vedartnn h\c 2R'15-3
(Stunt Name. Numbers. py,�b tot Na. tin Code)
3. OWNER: lGeor e .j-kIsh 514'
Address a VI Ve De- i V
(Strcu or Route No.,
�1nr't or` N C, 27\9irlFa
City or Tom State rap Code
-Lo59"31C)
Arcs code- Phone number O
4. DATE DRILLED `ND -O G i Za f7 i K�
5. TOTAL DEPTH: en 2 S
6. DOES WELL REPLACE EXISTING WELL? YES «NO Q �Z a ZS (4t,CiFx i
7. STATIC WATER LEVEL Below Top of Casing: FT
1
S. TOP OF CASING IS (De` .. ifotawarourfa Fr Abovefaod Surface*
*Top ce in
terminated mrar below bud satfoe regains
variance la accordance wkb ISA NCAC 2C.6I18
9. YIELD (gpm): )5? METHOD OF TEST /a; r
10. WATER ZONES (depth):
From /OS To 121 Ft PdG
Fro /m 2$ To J 3n Ft l 2I
13. GROUT: Depth te Material
k
From 0 Tolg_ FLJ:yrC. J
From To FL
14. SCREEN. Depth Diameter Slot Size Material
From To FL in. in.
From_ __,_ To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To FL
15 by Loa'
ll_ DISINFECTION: Type ("inn`na Amount C£ o7
12. CASING: WW1 Thickness
Depth Diameter ar Weigbt/Ft. Material
From 6 To )0g FL /
16. REMARKS:
Melhod
Pifrvipe i
Topographic/Land setting
afRidge OSlope OValley OFlai
(chat appropriate box)
Latitude/longitude of well location
2So yr�
2. CI N 092c 0437rj' 114
Latitude/longitude source: BGPSOTopographic map
Watt box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two Stale Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSIRLICTED IN ACCORDANCE
CON S7$UCTIONSTANDAR ND THATACOPYOFTHIS W EDTOA THEW WELL
}RECORD HAS BEEN PROVIDED TO THE WLOWNER
n_ii1 a-r" 9- /
(1 fDDATE
-SIGNATUREOF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,
27699-1636 Phone No. (919) 733-322I, within 30 days.
ndwiteeelieEtservice
enter -Raleigh, NC
GW-1 REV. 07/2001
DIV. OF
daft
ER QUALITY
OCT 0 6 2006
Z4.-zZ%
)To,ttc
S'
OCT 1 T2
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
3'
North Carolina - Department of Environment and Natural Resources- Division *[Water Quality - flroemdwaser Section
WELL CONTRACTOR (INDIVIDUAL) NAME tartan i -TUS }fee CERnncATtoN p 2/ Sa
w ELL CONTRACTOR COMPANY NAME 3u S�tL Were 0;tC NY PNONE . f9 yi 2
STATE WELL CONSTRUCTION PERMIT$ ASS CI TED WQ PERINIT#
(ifapplimbic) (ifapplicable)
I. WELL USE (Chock Applicable Box): Residential LVMtmicipal/Public 0 Industrial 0 Agricultural a
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: l�
Nearest Town: c4 county O Feet coty IAstat✓aL -
bb d (3 IH et e#Jct fcLt S d r-
(Street Name. Numbers, Community. Sandivitmy, totNa. rw Code)
3. OWNER: (`�A014 c&�f: !1A Rey.
Address Cot f{ 3 Nelegw,G4Its e44wlrAr.4 L
or R
4-&A gle4 (Street C "act 297G2
City or Tama State to) Cod
eta 1- 4C.o- Ms?
Ana code- flank mmwber
4. DATE DRILLED z 9- d 4
5. TOTAL DEPTH: . C
F Latitude/longitude sotnrc
DEPTH
From To
o -,jo
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ig- .3 c / 4p
7. STATIC WATER LEVEL Below Top of Casing: re FT. 1CIO . _ I/O1'
8. TOP OF CASING IS W1Aev-ifAsweToporCacixq)
FT. Above Land Surface*
'Temp at tasks *eradiated twee Wow Iaad surface regaaa a
vatoce to accordance with ISA NCAC 2C MIS.
9. YIELD (gpm): r 2 METHOD OF TEST 11i ✓1
10. WATER ZONES (depth): /c/a�, & Viit/ // ',an, ee
II. DISINFECTION- Type (tO � Amond _£ oZ
12. CASING: WallThictme$
� Diameter or Weigbi/&
From 0 To / o' G y o e
hlaiedid
From /0 To /4e Ft (O i �7DDoo- ,0 c.
From /'/tb To /$D FL 4-, l/4 edtll/
13. GROUT: Depth Material Method
From To Ft
From 0 To_7_ FL it,
SCREEN: Depth Diameler�/
14. Slot Size Material
From To Ft. in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth
From To
FTom To
16. REMARKS:
Size
Ft.
FL
Material
9D5- coy
,Topographic/Landsetting
620.idge °Slope °Valley °Flat
(cheek appmpritc box)
Latitudj `yo 4�lought. o©wg2owiony
o�
Negteee/mw / )
PSOTopoynaphic map
(check box)
DRILLING LOG
Formation Description
, uet,-A &4442--
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common toad names.
4.
DIV. ORECEIVED
F WATER QUALITY
OCT 0 s 2006
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDA ,i j . AND T1iAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Sl 1 NA Ti16LE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,
27699-1636 Phone No. (919) 733-32221, within 30 days.
R E C E I Ban Servicf Center -Raleigh, NC
1J GW-I REV.07/2001
OCT 172L"4
Asheville Regional Office

I ELL CONTRACTOR (INDIVIDUAL) NAME WELL CONTRACTOR COMPANY NAME-t,Jj{.(p UlP// .h f)N n�
PHONE it (Mt %,Ze%' S/1
STATE WELL CO:Ns-TWO10N PERMITS/
tifappiicable) A CLiT6OwQPERMrrtt
/ (ifal�licabM)
1. WELL USE (Check Applicable Sox): Residential 6d' Mlmicipaypublic 0 industrial 0 Agricultural CI
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other List Use
2. WELL LOCATION;
Nearest Town: o/f( rori County 74`f). 9lI
Ste. Z. air
(Street Name. Numbers. Commuaay. Subdivhiatx tat Zip Cade)
3. OWNER: eCiri/4 .lv�nSUn
Address
WELL CONSTRUCTION RECORD
North Carolina - Department of Ern/wotenent and Natural Resources- Division of Water w , •Quality - Oroaadvv� Section
tarICCITazN `S11
US.,teie cERTISICATroNea' 50
(Street or
Ro No.)
Split f
28?/�
City orTmva Sure rttp Code
(tone-?24-449
Area code- Phone number
4. DATE DRILLED.t
30 --
5. TOTAL DEPTH: 43
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below Top of Casing _
(the v-tfAbowTap of -mac)
8. TOP OF CASING iS� it Above Laid Surfaces
*Tap orcasiae tensioned aVsr bdru lead srfaa regains a
variance ia YIELD accord with ISA NCAC IC.dii.
a_ METHOD OF
9. (gpm):
TEST .i 1.md
10. WATER ZONES (depth):
11. DISINFECTION: Type_
I? CASING:
From O �
From GU To r` FLplater_
To 40 Ft !,/-
From W') To FL
13. GROUT: Depth u1
From_ To 2.0 FL o! f /
From To Ft.
14. SCREEN: Depth Dim
From To Ft. in.
From To FL in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
16. REMARKS:
Amount $o s
Wall Thief
or. a ht/Fr,
c
Pion
NO 0
Ff.
Slot Size Material
_ in.
is
Material
Topographic/Land setting
°Ridge Dtlope °Valley °Flat
(check appropriate box)
3s Latitude/longitude 9/u° 0ll 7.94'4/iJ
mesecesLatitude/longitude source: (topographic map
DEPTH )
DRILLING LOG
Front To Formation Description
0• 70
Di Ii. I-
7a-2>?s C.tifXe
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
members and cormeon road names.
et 44J
RECEIVED
DIV p
WATER QUALITY
OCT 0 6 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION ST ARDS. AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL. OWNER
1-
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,
27699-1634 Phone No. [phone], within 30 days.
_fI
DATE
dRr�1��
€�.Q4int Senige Center - Raleigh, NC
GW-I REV. 07/2001
OCT 12 Hub
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvironme Environment and Natural Resources - Division of Water
n
W ELL CONTRACTOR (INDIVIDUAL) NAME Quality - �Stx.2I
Ttvt.v`` G Rol/ SUS � 'C P cERT1FICATrorr d-Z �5®
Ns ELL CONTRA.CfOR COMPANY NAME —Sin Ts Ge � i / Dry )11 n1 PRONE a fft i 729-Vs*`
STATE WELL CONSTRUCTION PERMITS 7ED WQ PERMtTR
(ifa limbic)
— / (if 'gale)
1. WELL USE (Check Applicable Soak Residential td' Mumicipal/Ptblic Cl industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Hunt Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION4:
Nearest Town: (V Lt rr �nqJ� Copy CD�j y �, F I Topogrjphic/Land setting
�I % Arrn4.1[ flr, midge Lrlsiope Odalley OFlal
(Stow Name. Numbers. Community, Subdivision, Lot Na. rip Code) (check appropriate box)
p� yR Latitud trade of well lwalion
3. OWNER:1-e01.U.1 1'j';`j',`��(ya‘(: 50 9`i.78 QYI`S3.d 4/
Address fv7 4 itac .moo' rA. 13 r ( 0�1°u�a�/ )
(Street ce Route No.) l atitude/longitude souree:HGPSOTopographie map
••�•.- it) C �i;7St one& boa)
City orToaa Suter DEPTH DRILLING LOG
i- -73 r - From To Formation Description
Area code- Phone
4. DATE DRILL 31 -o
5. TOTAL DEPTH: 8'5
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below Top ofCasing:
8. TOP OF CASING TS (Us. ifAbedaTopofCanna)
ET AbmLaodSurfaces
'Tap of easing teraNatrl attar baNw laud serrate regains a
variance in accordatre ISA NCAC 2C .8Q118 E$T
10. WATER ZONES (depth): 5 METHOD
by se ./ a0 n
11. DISINFECTION: Type C ion'ne Amami 2' 07
12. CASING:
Depth
From_ To
From 4/ To
Front_ To
13. GROUT: Depth
From © To 20
From To
14. SCREEN: Depth
From To
From_ _ To
15. SAND/GRAVEL PACK
Depth
FromT
From To
16. REMARKS:
Wall Madmen
Dirtier' er Weight/FL Material
A PVC
GAIV
Material Method
FL .? £ / %&:+ire
FL
Diameter Slot Size Material
Ft. in.
FL in. is
Size Material
o Ft
F4
0 - ±r
5-
hint L CC IC
SC- a8S- C7gAN0'Le_
LOCATION SKETCH
Show direction and distance in miles from al least
two Sate Roads or County Roads. include the road
numbers and common road names.
{It /111F 112
„c-
�t,>i-Coot°
a
T2Ko sto
DIV.OEIVED
ATER QUALITY
0 OCT 06 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS., AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
dal
rQe,
SIGNATURE OF PERSON CONSTRUCTING
Submit the original to the Division of Water Qnali
27699-1636 Phone No. (9I9) 733-3221, within 30 days.
OCT
S° 06
DATE
ice Center -Raleigh, NC
GW-1 REV. 07/2001
Asheville Regional Office
As uifer Profrtinn

e:i6W1
Or
� Nonh Carolina- Department ofE
f Environment and Natural Resources - Division or Water Quality - Groundwater Section
OA
9WELL CONTRACTOR aNDIVIDOAL) NAME (print) &Airy 5o S)L/Gy�`-}f ��'ELL CONTRACTOR COMPANY NAME .T(}ST• t C` CERT)#CAnoil & 2,5 0
waL1 bra' L�,><I 9 PHONE (8� 72Y- �1Sy�
STATE WELL CONSTRUCTION PERMfftt
Of an licable) ASSOCIATED Wo PERMira
!i; applicable)
I WELL USE (Check Applicable Box): Residential f7 MtmicipavPetblic Li industrial 0 Agricultural [i
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town_ o e n F tp d` Count/t)
WELL CONSTRUCTION RECORD
i,. des. fide.�y
(Scree Name. Numhas. Commway, Subdivision, tut No.. yzp Cade)
3. OWNER
Address
(Street ;Crime No.)
L�futt AJ/s 7SiL'7
City or Town State rip Carle
(_)-
Area code- Phone et:Tuber
4. DATE DRILLED w'Z et S "0 G
5. TOTAL DEPTH_ tIO9
6. DOES WRt I RFDt AQE WE t ? YES0 NO
7. STATIC WATER LEVEL Below Top of Ca i
Z. TOP OFCASING ISnx
�tthev wAbbTanO �) FT.
'Tip of rasing terminated attar Wisp lead . AaLand Surface*
sulfate
Above ad
:tre .aaee )r aaardatee withtSA NGC 2C>Q/IB, �—
9. YIELD (gnat): 5 METHOD OF TEST 4 ' 2
W. WATER ZONES (depth): _,21n_3 / „—'—�-^
�/ Topographic/Land setting
aidge OS►ope OValley OFIat
(thee: appropriate box)
Latitude/longitude of well location
35-° 3543 y 0.)n82 tr.2s-ti(degreessmcef
Latitnd ilitde )
dlonS source: t�PSOTopographic map
mam bao
DRl IN t p
Formation Description
DEPTH
From To
11 _ DISINFECTION: Type
12. CASING:Depth
From—G_ To 0'
From Toldf FronrToir
13. GROUT: Depth
From To
From O Toe _
14. SCREEN: Depth
F
To
Frorom To PACK:
15SAND/GRAVEL PAC
K \.
Depth
From To,
From To
16. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
Submit the original t
27699-1430 tttiu
Wall Thickness
or Weight/Ft
FL e+ Y - aeased
FL-G�
Ft ��
FL
FL_ s., _ Q t ✓ Zr
Diane er Slot Size Material
FL in. in.
FL in. in.
Size Material
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads orCounty Roads. Include the road
numbers and common road names.
4fit!, & MA)
vlrt DIV. OF Wq EiR 4DgLITY
V
' OCTOB2006
WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAc 2C, WELL
(y�t"Y OFTH. • a♦ -rti BEEN PROVIDED TO THE WELLOWNER
vision of Water Salitp,
37.21., within 30 days.
A' OCT cil Mal $vice
Ce
Asheville Regional Office
Aquifer Prot?rtinn
ATE
Ner-Raleigh, NC
W-I REV. 07/2001

WELL CONTRACTOR (INDIVIDUAL) NAME (print) C
«'ELL CON IRACfof COMPANY NAME ` t
STATE WELL CONSTRUCTION PERMIT#
(ifaoplicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
-0 Sus -Vice
ASSOCIATED WQ,pyRMIT#
fifa Iicabie)
1. WELL USE (Check Applicable Box): Residential 0 NiunicipalfPub)tc 0 Industrial 0
Nlonitorine 0 Recovery 0 Heat Pump Water injection 0 Other ❑ If Other, List Use
2. WELL LOCATI
Nearest Town:
N:
County
IStreet Name, Numbers, Community, Subdivision, Lot No., Zip C
Address
Yin (Street or Rout rt No.)
11\ri (-
City, Town State lip Code
ASS)-1��i
Area code- Phone number
4. DATE DRILLED I_4-(j(o
5. TOTAL DEPTH: 5x_
6. DOES WELL REPLACE EXISTING WELL? YES O NO 7-
#2 /5 /6 C[
PHONE # 13;),E--i�tl "15 t8
Agricu tuna
OCT 1 '< <�4
►�� r_ f ( Topograph c/Land setting
DRidge Slop p pny{le[Bit�yionalOffice
" • • C (check arropnate
grl) Lalitudw7ongit Uifpf protection
350- 39 ..3-70 Ni 0 bi • 55. aai w
STATIC
WATER LEVEL Below Top of Casing: Zfl_._F-f
(Use "+" it -Above Top of Casing)
3. TOP OF CASING IS _ FT. Above Land Surface*
'Tap of casing terminated at/or below land Terrace requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gum): __ METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type lae __ Amount
12, CASING: 2_.
Wall Thickness
Depth Diameter or Yeight/Ft. Material
From 0 To_.Q20 Ft. CO is I- 0
From S l To cS 2. Ft.
From To Ft.
13, GROUT: Depth Material
From_ _ - TofFL
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:
1 DO HEREBY C£fi FY THAT THIS WELL
CONSTRUCTION ANDARDS. At
.1%S
Method
Slot Size Material
in.
Material
(degrees/m'nuteslsecands)
Latitude/longitude source:OGPSOTopoeraphic map
(cheek box)
DRILLING LOG
Formation Description
DEPTH
From To
Ai.
74- Z8 S' 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.
7 INN ar`k n
GacldyRet.
iN�S F res
?'�/�IV.O A 6LI�fY
ll r,
'Ir\:)CY if 6 2006
UCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
t'IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNAfEODAE
TE
F PERSON CONSTRUCTING THE WELL ' I CA
Submit the original to the Division o Quality, Groundwater Section, 1636 Mail Senice Center - Raleigh, NC
27699-1636 Phone No. [phone], w thin 30 days.
GW-I REV. 07/2001
uri ty

Submit the original to the Division of Water Quality,
27699-1636 Phone Na. [phone], within 30 days.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Neutral Resources- Division of Water Quality - Qzotmdwaya Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) an nil -70S{,'may CER77FICATION V 2I
%'ELL CONTRACTOR COMPANY NAMEMEJ�"f.GQ WQ n;II;1% PHONE a (nhl el- 95er
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT*
(ifapplitable) Of applicable)
1. WELL USE (Check Applicable Box): Residential 8—/ MmnicipatPubiic 0 industrial 0 Agricultural ❑ Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: A�
Nearest Town: // gr,'ol CmmtY/rt ut/f
1-iriden S¢r�ru�c Qr
Name. Numbers. Comm(Sweet Nat aY. Lot Na. Zip Cade)
3. OWNER: Ste_ tie_ 4 Ca.I Plant
Address 1(a.1 Z;on H;lI Pnsd
�rl (Street or Rohe No.)
)ll(tr;en N.C. ..28752
City or Town State rip Code
tin )- 442 a?o9 4
Area code- Phone number
4. DATE DRILLED 9- 2J-O(o
5. TOTAL DEPTH: a G
6_ DOES WELL REPLACE EXISTING WELL? O NO Er
7. STATIC WATER LEVEL Below Top of Caviar 6 FT.
8. TOP OF CASING IS 1 (Use-+-ifAbew Top *Mooing)
Ft. Above Land Surface*
'Top ofcasing semisolid at/erblow bad wince regains a
variance to accordance with ISA NCAC ZC Alt
9. YIELD (gpm): 30 METHOD OF TEST l];
PO_ WATER ZONES (depth): '3O gQ,n by d) 5
I I _ DISINFECTION: Type 0. 74.-; n(_ r ; Amount
1? CASING: Wall Thickness
Depth Diameter or Weight/-(. Material
From_ To (o 6 FL 4 t/O PVC
From to ToCni FL — GP/V
From______ To Fi.
13. GROUT: Depth 1
From O To 70 FL_
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
Frunj _ To FL in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
M
Perm el
Slot Size Material
in.
IR
Material
Topographic/Land setting
ORidgeSlope Malley OFlat
(check appmpnate box)
Latitud t of well location
35` Sl. tl/ woQIc 59.i8/it/
tde ninwwy✓/Qa.owk)
Latitude/longitude sourcriifGPSOTopographic map
WIC& eau
DEPTH DRILLING LOG
From To Formation Description
GO 161- is AAA).+
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.
,.<1„tus_fillIM
146 ,
Thei
RECEIVED
DIV. OF WATER QUALITY
22, I OCT 0 6 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRIION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G 9-.22-6e,
SIGNATURE RE OF PERSON V C DATE
d p R"raQi1636GM alalServicetester-Raleigh, NC
GW-I REV. 07/2001
OCT 17 2003
Asheville Regional Office
Aquifer Protect!on

RESIDENTIAL WELL CONSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATIONS 21 38
1. WELL CONTRACTOR:
JP -es W. Camt
W Ei. 'lontractar.(IndMdual) Name
Camp's Well & Pump Co. Tnc
ontractorCompan9Name
STFIr3 ADDRESS P O Bog 429
Ellenboro NC 28040
City orTown State Zip Code
^1). 453-7322
A,.. 'ode- Phone number
2.WE INFORMATION:
Sfi . WELL ID CI(applieabla)
ST.t.'E WELL PERMITIMI applicable)
DV' 3 or OTHER PERMIT #(If applicable.)
WELL USE (Check Applicable Box): Residential Water Supply Fa/
Dr. DRILLED CZ' 30 •0� —/
COMPLETED a LI5 AM ID PMIW
3. W LOCATION:
CI' ( Ati'M COUNTYIMC f1W
(St Name, Nu_mber!, Community. SubdMsbn of No., Porcelain Code)
TO : GRAPHIC I LAND SETTING:
❑t... DValey °Plat 1B'1�bge ❑Other
(check appropriate box) ']•
Lc_..TUDE Ali 3S 653
LO':"'.ITUDE '2 ?,'70 vs,
Lactude/longitude source: I$iPS OTopograpbic map
(lacatbn of wet must be shown on a USGS topo map and
attached to this form not ushg GPS) /'kqq11 Kt4. WELL OWNER
tit^, NER'S NAME S�UA.-&A �r —(DYP2y�IC0.
STrEET ADDRESS I -4 I e ✓ Te YYAr e
Rw r � ech 1JC 2g)3q
—y'ly or Town State Zip Code
IMay beta depea,
minutes, seconds or
in a decimal format
( }
Ara code- Phone number
6. W`LL DETAILS:
a. TOTAL DEPTH: 0 S
b. DOES WELL. REPLACE EXISTING WELL? YES p NO [4
c. 'EATER LEVEL Beam Top of Casing
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below lend surface may require
a variance In accordance with 15A NCAC 2C .0118..
e. YIELD(gpm): METHOD OF TEST CLCA
f. DISINFECTION: Type chlorine Amount !( 5
g, WATER ZONES (depth):
From To
From To
From To
6. CASING: ThlcWkessr
ADap+eter Weight Material
From O DTo IDY_Ft. Of SDR21 PVC
From To Ft.
Fran To .FL __
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
From To Ft.
From To FL
8. SCREEN: Depth Diameter Slot Size .Material
From To Ft. In In.
From To Ft. In In.
Prom To Ft. In In.
9. SAND/GRAVEL PACK: Depth She Malarial
Ran To FL
Ran To Ft.
From To FL
From To
From To
From To
10. DRILLING LOG
From To.
0LOB
C
rm n Des ptlon ei
i t r
ft)U �U5 • (1Lei(L tt
11. REMARKS:
r5.
CD .-,
per
I00 HEREBY CERTIFY THAT MS WELL WAS OON61RUC1ED N ACCORDANCE W0H
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
TACOPY OPUS
lath 1 C 9:21
SI L E OF CERTIFIEDE�—.
CONTRACTOR DATE
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Su b It te oriinal to the ty
1617 Ma lhServlege Center- Raleigh, NC 27 99 16•117 vidlort.of Water a(IPh nehNo. 9 9) 733 7 5 ext 568.0 . Mgt.,
:TOM GW-ta
— . Red. 7105

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N Reso t ' 'on of Water Quality- Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME ) /`.5d'---/r tut t 0 3�r3)
WELL CONTRACTOR COMPANY NAME r r /xJ d 4--)4--)' W di j. i /! �f—c PHONE aOf tY7 ! / -
STATE WELL CONSTRUCTION PERMIT. ASSOCIATED WQ PERMITS
(if applicable)
(if applicable)
. 41
1. WELL USE (Check Applicable Box): Residential Er—Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO yy/
Nearest Town: 1 >/ County / % /- ' --'( Topo ppd lial0V setting
y,, yv� d. ORidge kmpe DVallry OFiat
/7 ► '" e r,l-c-/ter (cheek appropriate box)
(Street Name, Numbers, Cammtm' , Subdivision, No., rip Code) Latitude/longitude of well location
3. OWNER:
Address
fat/ )"—City or Town
(Street arRoue.Dlo.)
State Tip Code
i_)-
Ares code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: if
6. DOES WELL REPLA E EXISTING WELL? YES 0�y+NO er—
. STATIC WATER LEVEL Below Top of Casing: 6
(Use "+" if Above Top of CLOW)
S. TOP OF CASING IS / FT. Above Land Surface'
"Top of easing terminated at/or below land surface regains a
variance in aecordaace with ISA NCAC 2C .0118. [
9. YIELD (pm): ,p METHOD OF TEST (J/�� LsL 10. WATER ZONES (depth):
/ LOCATION SKETCH
Sr� it 11. DISINFECTION: Type c Amount )r5 . Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth f t— or Weight/Ft. Maeerial numbers and common mad names.
From O To Fz/d
From i To Ft. 3
From To Ft.
13. GROUT: Depth Material f Method
From rap To9 f Ft. in 1;+4.fli
From I 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
4
(degc hnimrouheeooda)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
p (1111,1,_
1,b
From To Ft.
From To Ft.
fAirr
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL1tU IN ACCORDANCE WI;H 15A NCAC 2C, WELL
CONSTRUCTION STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN PRC VIDED TO THE WELL OWNER
/ d--// ` ‘2"
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 now Service Center - Raleigh, NC
!0694-/636 Phone No. [phone] within 30 days. OW-1 REV. 07/2001

RESIDENTIAL WELL coNSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & Puma Co. Inc -
Well Contractor Company Name
STREET ADDRESS P 0 Bo* 429
Ellenboro NC 28040
City or Town State
(B28} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#(sappBeable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Bac): Residential Water Supply isa/
DATE DRILLED t ` q • n 6
TIME COMPLETED a a 0 AM 0 PM ly
3. WELL LOCATION:
CITY: N COUNTYIS"
Zip Code
(S t Nanie, Numbers, Communay, Subdivision, Loh No.. Parcel;. Zip Code)
LATITUDE _ S_ tact . I0 alb
LONGITUDE_ n0 .9 r1 iA)
Latitude/longitude source: ❑GPS OTopographic map
(location of well must be shown on a USGS topo map and
attached to this lam l not using GPS)
4. WELL OWNER nn � ���---
OWNER'S NAME cz.b..
May be in deuces,_
minutes, seconds a
in a decimal format
TOPOGRAPHIC I LAND SETTING:
OSlope OValley OFlat badge ❑Other
(check appormatebed
STREET
�ADDRESS Ill 1
e
City or Town State
($21J- 9 Sit • LY U
Area code - Phone number
AthMk .RAC
Zip Code
5. WELL DETAILS: �^1
a. TOTAL DEPTH: A a_c
b. DOES WELL REPLACE EXISTING WELL? YES p NO Ci
c. WATER LEVEL Below Top of Casing: 1bQ FT,
(Use'+-. if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Lend Surface
Top c( casing terminated etlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1,0 METHOD OF TEST CQA'7.
St 1
f. DISINFECTION: Type chlorine Amount 2 /'./1„I1
g. WATER ZONES (depth):
From To ? t0 From To
Ran To From To
From To From To
6. CASING:
Diam
Fran 0 Depth__
6. Ft 6t eter
From To Ft
Ran To FL
Thickness/
SDR21 PVC
7. GROUT: Depth Material
From 0 To 20 Ft. Sackrete
From To Ft
From To Ft
8. SCREEN: Depth
From To
From To
Method
Hand
Diameter Slot Size Material
Ft. In. h.
Ft In. In.
From To FL In. k1.
9. SAND/GRAVEL PACK:
Depth size Material
From To Ft
From To Ft.
Ram To Ft
10. DRILLING LOG
From 5 9N
0
Formation [}�scr q�r n
S 3 :1l 5— SA/A) tit
at, S ;.a ako, GLdJv,. i
11. REMARKS:
100 HEREBY CERWYTWAT THIS WELL WAS CONSTRUCTED NACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND1HATACOPY CIF THIS
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
(\Jlfn , G) C*ntp 6
SIGNATDRE OF CERTIFIED CO RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30. days. Attn: info rmatlol.C.E I V E D Farm GWta
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. (9191733-7015 ext 568. . Rev. 7/05
FEB 0 7 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �,t
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Gaits r3 by+ic C CERTIFICATION°-% / J �+
vv'ELI. CONTRACTOR COMPANY NAME 3o$4t ea wELL Dr; 44-iIti PHONEf
STATE WELL CONSTRUCTION PERMIT° ASSOCIATED WQ PERMED!
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential GVMumicipal/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: OL t) Fort County NAG boral, CC-
489 Ah at sir t3LIW
(Street Name. Numbers. Community. Subdivision. tot N0. Tip Code)
YA
3. OWNER:
Ck. M S e,r fti#G,
Uf
Address Zit ,G 7
Q
rear A u t
(Street or Route o.)
&LbFbri A)e 29742
City or Town State Zp Code
(gze)- 64g- 1flF
Area code- Phone number
4. DATE DRILLED /YIA2Ch 2e b/.
5. TOTAL DEPTH: 5 CS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO litee
7. STATIC WATER LEVEL Below Top of Casing: / 70 FT.
(Use"+' if Above TopofCuing)
8. TOP OF CASING IS 1+ FT. Above Laud Surfaces
`Top of casing termiated at/or below land surface requires a
variance la accordance with ISA NCAC 2C.0118.
9. YIELD (gpm): / METHOD OF TESTAIR
10. WATER ZONES (depth): /r3Pnrt /y 41So'
1 I. DISINFECTION: Type t?LOt2 isle Amount 8 67
12. CASING: Wall Thickness
Depth Di. 7 or WciyhuFt.
From D To /t4 FL r (S
From /be To /2 S Ft
From /Z g To / 90 FL
13. GROUT: Depth Material
From To Ft.
From_ 0 Ft. or, 10-el b ora
14. SCREEN: Depth Diameter I Slot Size Material
From To Ft. in. in.
From______ To Ft. in. in.
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
16. REMARKS:
re87z t4y're
pographic/Land setting
dge °Slope ❑Valley ❑Flat
(chute appropriate box)
5e tttlr�e lon t de fHelllocati n
ij /L7JT ��++ d
(degrees/minutes/seconds)
Latitude/longitude source:OGPS°Topographic map
(check box)
DRILLING LOG
Formation Description
3 y.849 'Al
DEPTH
From To
O— /22 ldi2+
mi. - SAS (�rlgtq-d✓t,/G
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
ACOPY OF THIS RECORD, HAS BEEN PROVIDED TO THE WELL OWNER
Chat
Y SIGN 4/
F PERSON CONSTRUOING 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. G W-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) GNI 3 'V e6
W ELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(ifa licable)
era r0)
e/., v Ad r.
- Division of Water Quality - Groundwater Section C-7�
CERTIFICATION # Zit Dom 1
10C4C:Lrck riLLr�)i PHONE #IVQ0311V'flHr
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential D Municipalirubiic 0 industrial 0 Aericuiturai ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: t �
Nearest Town: 6 Li) Ann- County I" ;/Ulu et)--
!leraQ4',J tie t✓..0 44
(Street Name. Numbers, Community. Gubdivision. Lot No.. Zip Code)
3. OWNER: Lit
(L I (brit/ {
Address 1 30c rimy(. et- YL; 4)0 let*
MLA (Cr (Ai C 297/O
City or Town State Zap Codc
( trcti)- Zycrof,&r
Area code- Phone number
4. DATE DRILLED 7//l/ o4.
5. TOTAL DEPTH: 90
6. DOES WELL REPLACE EXISTING WELL? YES NO a 7 S Scr
7. STATIC WATER LEVEL Below Top of Casing: (ors FT_
e (Use "+- it Above Top ofCacina)
8. TOP OF CASING IS lFT. Above Land Surface*
`Tap of casing rermioatW atlor below land surface requires a
variance is accordance with 15A NCAC 2C .011E.
9. YIELD (gpm): 3 METHOD OF TEST
10. WATER ZONES (depth): fit/ de./ frau it
�6pographic/Land setting
®Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
16 38. 697 iv age O3- 8 0 to t-J
(degrees/minutcs/seconds)
Latitude/longitude sourer.❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
(Sweet or Route No.)
I I . DISINFECTION: Type C eat.. sie
12. CASING:
Depth
From To
From 0 To
From To
13. GROUT: Depth
From
From 0/mac,. f
14. SCREEN: Depth Diameter Slot Size
From To FL in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
Amount 630 Z- Show direction and distance in miles from at least
two State Roads or County Roa. Include the road
Diameter or Weight/Ft. Material numbers and common road na
Ft. �tr
16. REMARKS:
Ft
To Ft.
To id Ft.
f /L
6 /7Ax/i %2
Wall Thickness
(>.s l it
5tcriaa
Method4i
o
Material 14Mile �. 1
la
0-75
TG`a-hB2�
earl
1
ECEIVEWATER DUALiTY
OCT Q g 2006
I DC) HEREBY CERT;/(''Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTIOST NDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
RE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,
27699-1636 Phone No. [phone], within 30 days.
roundtyE$gtt' tjailSeni
DATE
Center -Raleigh, NC
GW-I REV. 07/2001
OCT 1 7 2&3
Asheville Regional Office
Ani aifm.

13. GROUT: Depth
From To Ft.
329762
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Di • i+:
WELL CONTRACTOR (INDIVIDUAL) NAME (print) "-y , 0544 fXv
_ /[ Q t�`wg
�lELI. COS-rRACfOR CO:iPANY NAME S�t (�� wC.rX Q^(-t t
STATE \YELL CaNSTRCCTION PERMIT* ASSOCLITED WQ FERMI -Tit
(if applicable) (if applicable)
of Water Dustily - Gratendwator Salina
CERTIFICATION if I SO
PHONE 2 ICJZV) 7251-vsgg
1. WELL USE (Check Applicable Box): Residential B Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection D Other 0 I (Other, List Use
2. WELL LOCATION:
Nearest Town: 'I\ O-c1 t71,) County {u�okt.k.U-
PLa o-,o,, Qc,t•?!
(Street Name_ Numbers. Community. Subdivilim- Lot No. bp Code)
s. OWNER: LI AO / i/ t4leLi
Address j00e PGitui.*-Fiofv 1o;•-)t
t5oavt or [Comte tio.)
rt Al ;Obi uc- 9R7s
Cty or Toren stave npCoax
tg1$ )- [o5-1-Y4s9
Area code- Phone weber
4. DATE DRILLED rn&1 04 O L?
5. TOTAL DEPTH: t4b
6. DOES WILL REPLACE EXISTING WELL? YES 0 NO 111,
7. STATIC WATER LEVEL Below Top of Casing: (e D FT.
(tile"+" if Abort Top offbi g)
S. TOP OF CASING IS FT_ Above Land Surface*
'Top of cosine terminated at/or below land surface repaints a
variance in accordance with 15A NCAC ZC out
9. YIELD(gpm): 4 METHOD OF TEST JS4 NAtt_
10. WATER ZONES (depth): /.yr nt i{ir o200'
l 1. DISINFECTION: Type &&Ola• Amount
12.. CASING: Wall Thickness
Depth Diameter or Weight/Ft_ Material
From To Ft.
From D To C/ o Ft (p'hi 110 CNC
From 9Ll Tog Ft in V14 (t. a (V
Material Method
From d Togo Ft �21 `Jw. a14. SCREEN: Depth Diameter r 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:
Topoglaphic/Land setting
DRidge DSlope ❑Valley ❑Flul
Rhea appropnate box)
Latitude/longitude of well location
3s°ca. it7iv oRI°58. go),"
(degeechnimttes/savndt)
Latitude/longitude source:NICiPSDTopographic map
box)
DEPTH DRILLING LOG
From To Formation Description
D- 90 t5i/d tF/2eJ t/o-k
rpte c//'t2.
go- woS
LOCATION SKETCH
Show direction and distance in miles from al least
two Slate_ Roads or County Roads. Include the rood
whdn.ta and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STMPARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
lAtA,SIGN RE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water WART, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No_ (919) 733-32221, within 30 days. GW-I REV. 07/2001

320766
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources- Division of Water Quality.=Groundwater Section
\\' ELL CONTRACTOR (INDIVIDUAL) NAME (print)� C� At. 5 S4 CE CERTIFICA,TIIONN Z(S
T O t�ELI. CONTRACR COMPANY NAME . tc5'I'2 Cr Wm-LLb r: LL; N°I PHONE I (rA�'4 Tiq. 4S/9
STATE WELL CONSTRUCTION PERMIT* fcSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Q Mtmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 II -Other, List Use
2. WELL LOCATION:
Nearest Town:Sit. O Forl County '(4 f babe ft-
CK2A•.aJo-L-CP(rt..`s SoL-
(Street Name. Numbers. Community. Subdivision, Lot No_ Zip Code)
3. OWNER: SA)p\Gn W Q.(Ce%J
Address ,c2 VL (, 1 c ac,ar P)1\) a .
(Street or Route No.)
1..o Park, aE
City or That Stair 474 C.r.zk
192%1- tole
Area code- Moor number.
4. DATE DRILLED 'I'Ifl- °(a.
5. TOTAL DEPTH: (-(o S
6. DOES WELL REPLACE EXISTING WELL? YES It NO 0
7. STATIC WATER LEVEL Below Top of Casing: go FT.
(Use "+" if Above Top of Casiog)
3. TOP OF CASING IS ( FT. Above Land Surface*
'Top of casing termiaatul at/or below land surface requires a
variance io accordance with ISA NCAC 2C .61Itt
9. YIELD(gpm): .2. METHOD OF✓1 TEST %�(
10.WATERZONES (depth): cQ'jfiv(,�
t (+So*'
•
11_ DISINFECTION: Type/ LOtL(Vt
12. CASING:
Depth
From 1127 To V
From /D7
Material
From To Ft.
15. SAND/GRAVEL PACK:
Depth Size Material
c_.._ T..
rtuiu to Ft.
From To Ft.
To /U7
From (4'7 To 10
13. GROUT: Depth
From To Ft.
From 0 To L1 Ft. 'f'l ft(
14. SCREEN: Depth Diamne//er
From To Ft in.
in.
0157L2
Amount t art'
Wall Thickness
or Weigbt/FL atrial
�co C— .JR
$.� P ✓G
Method
Slot Size Material
in.
IR
opographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
-3S`Sg.teiA/O ez.o7 ZOl W
(degrees/minutes/seconds)
Latitudellongitude source:❑GPS❑Topographic map
(check boa)
DEPTH DRILLING LOG
From To Formation Description
0- b(en Aiei•5Aiud
►ioo' ua5 (Qi4Ahi
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_ __)
c_
r-
n3
I6. REMARKS:
I DO HEREBY CERTIFY THAT TFI WELL WAS CONSIKUCTeD IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. T A COPY • F THIS ' * RD HAS BEEN PROVIDED TO THE WELL OWNER
N 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 - Departmhot of Environment and Nagnal Resources •- Division of Water Quality - Orotrodwder Seehon
WELL CONTRACTOR (INDrnIDUAL) NAME n .� }hS ' J. i� r I �: a c' �•tJ C�Crsnck lof
WELL coNTRAcroa COMPANY NAME 5 t- j l� c' - ` �;c ) " �� ' , �g,,,; , PaoHE a Li
STATE WELL CONSTRUCTION PEBMOTO ASSOCIATED WQ PER3WTh
(if applicable) (ifapplicble)
1.
I. WELL USE (Check Applicable Box): Residential C3` Municipal/Public 0 Industrial 0 Agticuluaat ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION;
Nearest Town: (Vet 11)- 1 Cotmty 7•f /2/i„r�y it
( e,nCam`aI®ny. Subdivision, -no Ore>
3. OWNER I ^h'//i 1�7 %Y.
Address T 7 ',7 f n r/i I a j
poise No.) . G
r
Oc'� �'a /-''A,/r.- fa,/(_z
Sneer Nam Noonan Subd(' " fSt No
(')/<l ` To
City cc ram State Zip Code
Ales aids- Phone melba j
� 4. DATE DRILLED 9 `%' 41
5. TOTAL DEPTH: / '76 '
topographio/Land setting
❑Ridge °Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degteeslmimaesiscaods)
/ ....pi
lye / Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0"�
7. STATIC WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface'
flop of casing tarmtetad at/v below Ind sautes requires ■
ransoms V aceardaace with 15A NCAC 2C .alUL ,
9. YIELD (gpm): /A METHOD OF TESTA/4 //`-Y
10. WATER ZONES (depth): / /
11. DISINFECTION: Type S C f ,-. % Amount / L
12. CASING: Wall Thicimess
Depth Diameter or Weight/Ft. Material
Fro To 5( Et
From__ To Ft
From To Ft.
13. GROUT: Depth Material
From j To `L )- Ft C /� near
From To Ft
14. SCREEN: Depth Diameter Sot Size
From To Ft in in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
•
Depth Sim 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.
10
Method �)OO`J����`l
��
RIG ��� 6
Mat ism OFF ,L.%
b1t
I DO HEREBY CERTL7Y THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION ST,tNDARDS, AND THAT A COPY OF THIS RECORD HL,S BEEN PROVIDED TO THE WELL OWNER
j: L./2-- G
SIGNATUREOFPERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
T76991-1635Phone`vo 'otol+33-:3+1within30 days. - - GW-; .._V

7
WELL CONSTRUCTION RECORD 3 a 9 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
\BELL CONTRACTOR (INDIVIDUAL) NAME (print) T'r a a 4 Tr L) S+i C E CERTIFICATION #a l/�� �"'J
elk 1)c1M HONE ( )7e Y-9 s�TT
#(
STATE WELL CONSTRUCTION PERMIT', ASSOCIATED WQ PERMITr
(i f applicable) (if applicable)
WELL CONTRACTOR COMPANY NAME
I. W ELL USE (Check Applicable Box): Residential IV 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: LIC, r3 1 County
,S3r7- Pir
(Sircet Name. Numbers, Community. Subdivision, Lot
3. OWNER:
Address I SIrl \) i/�/G�- - 1
c c®Fc t (st ecNt Or eo_ No.) 2976, 2-
City or Tovn State Zip Code
Area code- Mom number
4. DATE DRILLED A — a05
5. TOTAL DEPTH: 5 f s
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 131-
7. STATIC WATER LEVEL Below Top of Casing: 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 require a
variance in accordance with ISA NCAC 2C .01 t&
9. YIELD (gpm): 95 METHOD OF TESTA / Ft
10. WATER ZONES (depth): 9 � _etc/M e 7�
1 I. DISINFECTION: Type GI [OFLV NC Amount `e) O Z
12. CASING: Wall Thickness
q� Depthp�/ DiaDieter orWejghl/FL Jitaze
From V To 7T Ft. (FnD 'YO /r
From 3c To 36 Ft
From To Ft.
13. GROUT: Depth
From To Ft.
From 0 To S `I Ft.
Material
/86
Method
Meted
14. SCREEN: Depth Diam(er Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Topographic/Land ng
❑Ridge ❑Slope Iley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minulesfseconds) las
Latitude/longitude source:❑GPS❑Topograpat map
(check box) 1 ' ,..,
DEPTH DRILLING Mt
From To Formation Descri>nion P
0 2S ?Site"
2C 5Rs.S
C ANVI Ye
OLD
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. ,41 tie, 'ate
itericre
iTsy
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDD THAT A COPY OF .IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
%.'y
;NAT fiRE 0
n
ERSON 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: D7/200C, `.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisionoff Water Quality - Groundwater Section Ci
WELL CONTRACTOR (INDIVIDUAL) NAME (print) COAR D SOJ eCERTIFICATION a2/wf
WELL CONTRACTOR COMPANY NAME
! u 1ilc Lt9e4 3teiltsa` PHONE S I�DI tl/-4S41.O
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WO PERMITS
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential I Municipal/Public 0 Industrial 0 Aericultutal 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: 9,0aC�C..t-
, /
Nearest Town: /%l/9iZ011l County
)074* I/IAitt4 1JaL(;4:tL if
(Street Name. Nmubas, Common- . Subdivision. lot No.. rip Code)
3. OWNER: 14w-� L lie i7
Address (tiOglAy pH/ •
IStrtts ar Route Nt)
S.tlaa .E:L 2277(
City or Town
( )- St) u3- 7364
Area code- Phone number
4. DATE DRILLED 3 o- (No
5. TOTAL DEPTH: Di
2p Cade
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (V
7. STATIC WATER LEVEL Below Top of Casing: Leto FT.
S. TOP OF CASING IS (Use -+ dAboveTopofCasing)
FT- Above Land Surface
*Top of rasing termiaated at/or below Ind surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (pp): ist4pil) METHOD OF TEST SYN
10. WATER ZONES (depth): % S c p 1./ 366'
P/C
Amount 8 01
Wall Thickness
or Wright/FL Material
r'4{
13. GROUT: Depth Material Method
11. DISINFECTION: Type, tot tie
12. CASING:
th
From To Ft. rk iL(9
From To Ft A
From To � Ft.- I/D E
From To FL
From_ To 2 3 Ft. Ail FUWOJ
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:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well locytion
3530.940N 4Z M. 14 fit/
(etc s/minut&samats)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
0 - cos 6 '
LOCATION SKETCH,"
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common rpad na /f' ./
1 DO HEREBY CERT F THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION S7 DARDS, AN r T A , OPY OF THIS RECORD. HAS BEEN PROVIDED TO THE WELL OWNER
1
DIIGN
RE OF PERSON CONSTRUCTING THE WELL _.. DATE
Submit the original to the Division of Water Quality, Grolindwat r Section,.1636 Mail -Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. j} GW-1 REV. 07/2001

op WaL 4;
WELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and Natural Resources- Division of Water Quality - Groundwater Section [ELL CONTRACTOR (INDIVIDUAL) NAME (print) l »g y S 03'+1 C6. CERTIFICATION a —
ZI J 0
NV ELL CONTRACTOR COMPANY NAME
%\'3o S /" ice 1 WCI.4y/gUi 141 p�l� ,t, /�
PHONE a 1 7a An 9- 9.SC%O
STATE \YELL CONSTRUCTION PERMITY
ASSOCIATED WQ pERMITa
(if applicable)
(ifapplicable)
1. WELL USE (Check Applicable Box): Residential 2 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: At riot! County JVII CD( (,(,
i4Rnisrnon,G 5+wic. C i st a Lcheck!
3. OWNER: A nr15TRo►tfl P.Sk4-rl1 or
(Street Nam. Numbers, Community. Subdiviyioq tut No.. Zip Cede)
Address AR
(Street or Roixc No.)
/ I nr,cA) tU e
2 8752
City or Town State Zip Code
(eZe ). 659- 72Z w
Atca code- Phone number
4. DATE DRILLED JRN zq ZOgg
5. TOTAL DEPTH: 5175
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO lir
7. STATIC WATER LEVEL Below Top of Casing is, FT.
8. TOP OF CASING IS Oise if Above Top of Casing)
FT. Above Land Surface*
*Top nfcasiaa terndaated at/or below land surface requires a
variance is accordance with ISA NCAC ZC 18.
9. YIELD (gpm): .25s METHOD OF TEST_Al
10, WATER ZONES (depth): G GAI.PcrMiU sera. *Act
ZSSpfiv LOCATION SKETCH
11. DISINFECTION: Type / OZ 6tori MCAmount /(0 02. 7j , Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth r Diameter or WeigML Material numbers and cOnanon road names.
Topographic/Lan setting
❑Ridge ❑Slope alley ❑Flat
(check appropriate boxl
Latitude/longitude of well locattiion
Y7 .7
e O82 06.7/8N/
( /mhmteasecoodn
Latitude/longitude sourcefGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O ^ /S SAND 6rAt)ef.
2044.
R0 BRoeauSjieLC.
;O- S7S �rt4v QuAttfS
5Aet C.
Fr�_To_ L Ft. /2 SC4yo sift(
To Ft. t�
From 0 To 70 Ft. A- SC1 !gip Gf///
13. GROUT: Depth Material Method
From To FL
From_QTot FL 4pe 1 �UJrI/il
14. SCREEN: Depth_ Diarn�f(eyler Slot Size Material
From To FL in. in. 0
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY
CONSTRUCT]
Q1/404 ;Ate
SLR
Ral�� 1wro�
r
RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
STANDARDS, AND TJiA3 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
z
SIGNATURE OF PERSON CONSTIRUCTING T)#B. WEL(,.. _.._..._._.. _._ _ DATE
Submit the original to the Division of Water Quality, Grountiwater 1'
27699-1636 Phone No. [phone], within 30 days.
GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
Resources
r�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �� '''(1 i6 ST/ L6. WELL CONTRACTOR COMPANY NAME Su S+; cF_ W & CA., Dr.* LC; ri1((
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
CERTIFICATION # 1. /a0
PHONE # (8t?Z4-45V$
1. WELL USE (Check Applicable Box): Residential )9" 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: I14 AI ION County 6 C
ARM15d-t2oruCa F.sh Ala+chfry
(Street Name, Numbers, Community. Subdivision, La No., rip Code)
3- OWNER: /AaniSia0 risk µtfr}.t✓ r
Address tyt S1rpNhmo ROW
Suor Roo.)
MA , (N C 7. sz,
(shy or Town Store Zip Code
- (ws'43 z z
Area rode- Phone number
4. DATE DRILLED Pete 1(o - O (o
5. TOTAL DEPTH: 4/0 S.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO )Y
7. STATIC WATER LEVEL Below Top of Casiraw /0' FT.
S. TOP OF CASING IS 2 (use*** if Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated at/or below had surface requires a
variance in accordance with ISA NCAC 2C.01 it
9. YIELD(gpm): ZO METHODOFTES A'/2
10. WATER ZONES (depth): /S of I it1 r R' AcK
C COY A0 »$� 16 LOCATION SKETCH
11. DISINFECTION:
TypeAmount b7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Topographic/Land setting
°Ridge °Slope 04alley OFIat
(check appropriate box)
Latitude/longitudeofwelllocation
3S° i)7.65N o Q2 ° e 6 •Bos iN
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopogmphic map
(eheek hex)
DEPTH DRILLING LOG
From To Formation Description
o• /H
/'1- 34
39- yos
ANA. • 67 r4tl t- L
flock.
itow.va.OQ
eptAarke tLA/kt
Depth Diameter or WdsM/FL Material numbers and common road names. y,,
From_Q__ To I S- Ft / 2 Sot it$4.a - [ 01 5'w i eL
From To Ft
From_0_ To ‘tro Ft-___R514Y9 Ic V
13. GROUT: Depth Material Method
From To Ft.
From nn • lOsstOei
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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDAR.. /- ND THAT A COP . TH RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r
GNA R PERSON CONSTROC11NG 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 # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(IndhAdual) Name
Camp's Well & Pump Co. Tnc-
Well Contractor Company Name
STREET ADDRESS P 0 Bo* 429
Ellenboro NC 28040
City orTown State
( 828). 453-7322
Area coif d- Phone number
2. WELL INFORMATION:
S RE W ELL ID #(If applicable)
STATE W ELL PERMR#QrappBoable)
DW Q or OTHER PERMIT 6(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
PATE DRILLED R• III '/ 0 \'
TIME COMPLETED 4:30
3. WELL Lc V ATIION: �
CITY: 1. I.tJU. u A
Zip e
AMP PMg3
courant Vt.t au) iW
(Street N:.me, Numbers, dommuniry. SubdiNabn, Lot_No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope EvaIIet' OFlat ORidge El Other
(chock appropdatebox)
l:4TITUDE 311 ('''13pptk
LONGRU0E,QZL.S2
Latitude/longitude source: tt4PS OTopographic map
(location of well must be shown on a USGS topo map and
attached to this form► not using GPS) /'f
�D Apt
4.WELLOWNER —b eeyl ft
OWNER'S NAME stAdt.!t• ( �
STREET ADD ESS a I e v Ter P
Ruther{-Dt 'Few ( 2g 13`1
city or Town State Zip Code
May be la degas,
minutes, seconds or
in a decimal format
( }
Area cc.1e. - Phone number
5. V.'ELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES Q NO git
c. WATER LEVEL Below Top of Casing:
(Use'✓.If Above Top of Casing)
d. TOP CF CASING IS 1 . FT. Above Land Surface'
'i op of casing terminated et/or below lend surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): _ METHOD OF TEST Q.(Al
f. DISINFECTION: Type chlOrine Amount I (Lk A
g. WATER ZONES (depth): 1
From To From To
From To From To
From To - From To
6. CASING: mlolmessl
Depth Diameter Weight Material
Fran 0 To `;.O Ft. 6a SDN21 PVC
From To Ft _
From To _FL
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size .Material
From To Ft. In. In.
From To Ft In. In.
From__To FL In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From - To Ft.
From To Ft.
10. DRILLING LOG
From To.
0 j.,0
t_Fotm#twn Des ' tbn
oO VI, 5) Vv""4v _4
11. REMARKS:
I DO HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THATA COPY OF. THIS
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
W C t p 9- )g-66
E O
SI F CERTIFIED LL C NTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: Information Mgt.,
1617 Mall Service Center —Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mall Service Center - Raleigh.N.C. 27699-1838-Phone [phone] - r r\,
WELL CONSTRUCTION RECORD WELL CONTRACTOR' &I,vnd Ds «%w
WELL CONTRACTOR CERTIFICATION # : -2.J'G 9
STATE WELL CONSTRUCTION PERMIT # :
1 WELL. IISE (Check Applicable Box): Residential) Vl Municipal ❑ Industrial El Agricultural ❑ Monitoring 7
Recovery ❑ Heat Pump Water Injection n Other n If Other. List Use:
NFL l ! ()CATION (Show sketch of the location below)
Nnerrst town /VgAr on( County
/3DT%/:h-coj7 Agn/6
'Poad Name and Numbers. Community, �or Subdivision and Lot No )
3 OWNER 7».ni as C. /3.) A/'r
Address /it /3oiriehe: y t..nr1.'F
(Street or Route No.)
/l: COW CL
City or Town State
4 DATE DRILLED 9 -;2t-d c'
c. TC`,TAI_ DEPTH —St--
C' jTTINGS COLLECTED YES ❑ NO®
DOES WELL REPLACE EXISTING WELL? YES NOM
STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" 1 above Top of Casing)
9 TOP OF CASING IS 420 rz FT. Above Land Surface'
-Top o+ casing terminated atfor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
'(? vFit D (GPM): # METHOD OF TEST /in/4/1 h
t1 WATER ZONES (depth).
DRILLING LOG DEPTH
From To Formation Description
--7HLORI NATION_ Type
,ASING nenth Diameter
or Weight/Ft Material LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Zip Code
If additional space is needed use back of form
1d GROUT
Tn
to �l
Amount
Wall Thickness
Depth Material Method
rrnm To Ft
From To Ft
15 SCREEN.
Depth Diameter Slot.Size Material
From _ To Ft in in
r-nm To Ft inin
r'rim To Ft in in.
SAND/GRAVEL PACK.
Depth Size Material
L rim To Ft
From To Ft
o FMARKS
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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

He, 'ump Water Injection ❑
Other ❑
^ /6 a7 � i H �� �'� � or Subdivision and Lot No l
anod Narne and Numbers Community.
/vzr rytFv,� gR 9> 2
ree or ou e
Code
Zip
^itv or Town
State
OWNER •;tu A
Address p.
9-/1/- v W
DATE DRILLED
TCTAI DEPTH YES ❑
CUTTINGS COLLECTED N
N
• DOES WELL REPLACE EXISTING WELL? YES O
STATIC WATER LEVEL Below Top of Casing. 1—
FT .
(Use "+" if above Top of Casing)
G '� FT. Above Land Surface'
;� TOP OF CASING IS requires a variance in accor-
•
"np o1 casing terminated at/or below land surface `-N
dance with 15A NCAC 2C 0!118 METHOD OF TEST t�iy= --
1L YEILD (GPM):
11 WATER ZONES (depth).
v/V C+T� T •an.N
V u�" \1
•••• n�-•��ral Resources -Division 0. '•""- r: ..: -
iye
one (9191733-322t (j�. �(a
ECORD WELL CONTRACTOR:
A t
WELL CONTRACTOR CERTIFICATION #
STATE WELL CONSTRUCTION PERMIT # :
Industrial 0
Municipal ❑
.;, 8ox). Residential her If Other. List Use'.
1n1F I. i JCA � ION Shoff , 61N°f the location below) county
i.v Fit_
Nearest ¶cwn.
i
Monitoring
Agricultural
DRILLING LOG DEPTH
Description
From To
If additional space is needed iise back of f orm
-NI npini,A,TIQN- Type -- Wail Thickness
Depth ICFT ,H
Material Cate
• SIN" th Diameter or Weight/Ftfrom at least two slate
Q'� -- (Show direction and distance °rots)
To SZL"F t —�"" Roads. or other map reference p
To . —��t. —� �.--��
— To
-•nm
Freon
14 RC1trr
15
r .m ..-
Frnm
SCREEN
rrnm
rom To
16 SAND/GRAVEL PACK:
Depth
Depth
To — Ft
Ft
To
Depth
- To To
Ft
Ft
Ft
Amount s
Material Method
Diameter SIot.Size Material
n in
in.
in
in
Size
in
Material
2306
0•
11r
CAr
T r
Ft
°.nm —^ To To Ft
—� --
— WELL
I 00 HEREBY CERTIFY THAT THIS
QFMARKS. WELL
TO THE WELL OWNER
"S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2 ,
COPY OF THIS RECORD HAS BEEN PROVIDED LL O 51 e
CONSTRUCTION STANDARDS. AND THAT A DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality,
Groundwater Section within 30 da GW 1 REV 12199

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
153E Mall Service Center - Ralelgh.N,C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: go 11 ✓aid A 3o r & F S
WELL CONTRACTOR CERTIFICATION #
STATE WELL CONSTRUCTION PERMIT # :
ty
WELL USE (Check Applicable Box): ly ResidentialMunicipal E Industrial ElAgricultural ❑ Monitoring n
Recovery n Heat Pump Water Injection n Other in If Other. List Use:
2 WELL LOCATION: (Show sketch of the location below) Syr ! 00� (_ �o
-
Nearest town.
&Kd irony county.
WO 66 wv'c' Z i- A Rd LOG DEPTH
/a- / /2M
'Pond Name and Numbers, Community, or Subdivision and Lot No) DRILLINGFormation Hescription
OWNER AMYtV 1 S From To
Address Me / 6iPV) Zt " i2W
(Street or Route No.) g7
• vial Fe.,7- /v,<
City or Town State Zip Code
-'3P -o In
e DATE DRILLED `
rC)TAL DEPTH J0 4L
nuTTINGS COLLECTED YES ❑ N0 f ,,,,�
- nDES WELL REPLACE EXISTING WELL? YES NO I
STATIC WATER LEVEL Below Top of Casing: 43 FT .
(Use "4-" if above Top of Casing)
9 TOP OF CASING IS /i " FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C 0118
u' VEll_f)(GPM): 2,12t METHOD OF TEST /3/1ii.1-1"
• "WATER ZONES (depth)
12 CHLORINATION: Type
13. CASING. Depth
To t
To Gt
ro
nm
Mi74 Amount / Ai!
IA ;Rf(IT
Depth
To
Tn
fc.. SCREEN
Depth
c "cm To
From To
'nm __ To
1F SAND/GRAVEL PACK
Depth
To To _
i
Qom
r rom
REMARKS
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
-3e-o�
DATE
Ft
Ft
Ft
Wall Thickness
Diameter or Weigh l t. Material
G .a %+ PA a4
Material Method
Ft
Ft
Diameter SIot.Size
in
in
in
Ft
Ft
Size
Material
in
in
in
Material
If additional space is needed use back of form
�rL LOCATION SKETCH
(Show direction and distance from at least two State
Roads. or other map reference points)
FOR OFFICE USE ONLY
Quad No.
Serial No
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days 1 REV 12/99

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section r
1636 Mall Service Center - Ralelgh.N. C. 27699-1636-Phone [phone] e ,n- 3 • i
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /ry0/'i`Mid 0 ,L4'Al
WELL CONTRACTOR CERTIFICATION # :
STATE WELL CONSTRUCTION PERMIT # :
NELL USE (Check Applicable Box): Residential!_) Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery n Heat Pump Water Injection El Other El If Other. List Use'.
2 WELL LOCATION: (Shgw sketch of the location below) /,J �C Vow
Nearest town. l�'tl F�n� County'
G"/ /'Roy /V/oak-I= R d DEPTH
'Road Name and NNmbers. Community, or Subdivision and Lot No-) DRILLING LOG Formation Description
3. OWNER /V ila: f'/'rflN/t 1A., From To
Address 4,.6/ goy No-)
/Y)Ot'4'E /mad/
(Street or Route 8
did Fot.T N.�%
ytrz
City or Town State Zip Code
I)ATF DRILLED 3 /2 ` O Ir
Tr -JAI DEPTH 140
F CUTTINGS COLLECTED YES [1 NOQ
DOES WELL REPLACE EXISTING WELL? YES NF O{
c STATIC WATER LEVEL Below Top of Casing:
(Use "1-" if above Top of Casing)
8. T(n OF CASING IS 7`. FT. Above Land Surface"
"on o' casing terminated at/or below land surface requires a variance in accor-
dance with ' 5A NCAC 2C 011B �
1C YEILD (GPM): 3. METHOD OF TEST /� A
11 WATER ZONES (depth):
12 CHLORINATION' Type /%%f+ Amount LI—. 42-- if additional space is needed use back of form
Wall Thickness
LASING. Depth _ Diameter
r rnm To 5 G9 Ft or Weight/Ft Materials,LOCATION SKETCH
r� t s C
9. t7 (S how direction and distance from at least two State
rom To
rpm To Gt
14 (:R(lt IT
Depth Material Method
r r'rr,, To Ft
'nrn To Ft
15 SCREEN
Depth Diameter Slot.Size Material
, •nm ___ To Ft in m
r'om To Ft in in.
F.nm ____ To Ft in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
m To Ft
r .,lm To Ft
Roads, or other map reference points)
CC 1 cZ 2v06
17 REMARKS.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS- AND THAT A COPY' OF THIS R
ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99
FOR OFFICE USE ONLY
Quad No.
Serial No

1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Well Contractor Company Name
STREET ADDRESS 42,77 / 2 7 >74 h/' // ;O%
City or Town Slate Zip Code
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # r y ® cam}
Area code- Phone number 2. WELL INFORMATION:
SITE WELL ID #(ir applicable) Q 3
STATE WELL PERMIT#(d applicable)_�__
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply
eft
DATE DRILLED/ (1 - .2, - A
TIME COMPLETED H?LA AM 0 PM 0
3. WELL LOCATION:
CITY: .v/40,6 0 A) COUNTY 1. Q . 1e.i1
(Street Name, Numbers, Community, $ubdlnsion, Let No., Parcel, rip Code
TOPOGRAPHIC / LAND SETTING:
elope °Valley. Li Flat °Ridge °Other
(check appropriate box)
LATITUDE _ _
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: OOPS ❑Topographic map
(location of ere/must be shown on a USGS topo map and
attached to this tor) Knot using GPS)
4. WELL OWNER
OWNER'S NAME t �- - CC> Ko t�l ✓
STREET ADDRESS .3/44- y„
JCm Tewn ts A) State • G 2 y i s-" --y--
Zip Code
., c-2 ar'
Area code - Phone num
5. WELL DETAILS:
a. TOTAL DEPTH:
V rt
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑
c. WATER LEVEL Below Top of Casing: ie b FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING 15 FT. Above Land Surface*
•Top of may
a variancee inaccordancevd h 15A NCAC 2C surface terminated aVor below land 18.. require
e. YIELD (gpm): t7Zy7 METHOD OF TESTS 71c/ J ti
6. CASING:
f. DISINFECTION: Type
g. WATER..JJJ���ZONES (de
From' / V� To From To
From/ To From
To,
From To From To
DThickness/
Depth Hameter Weight M
Fromo_ Ft .f-v • "Zi
From To Ft.,
From To Ft.
333981
7. GROUT: Depth _ Material
Frcn To on Ft. Method
Fro{ / To Ft
From To Ft.
8. SCREEN:
From
From
From
Depth
To
_ To
To
Diameter. Slot Size Material
Ft. in. __ in.
_ Ft. in. in.
Ft. in. in.
8. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
ar; >- tW T__ QUA r
C-T2 4 [UU5
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WIN
ISA NCAC SC. WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ii
TURE OF CERTIFIEDWELL CON RACTOR
.n _O
i %f .Lf
PR NTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,
161T Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL. CONTRACTOR CERTIFICATION #
o
334012
1. WELL CONTRACTOR:
C'. ,` Glom k2
ell
Contra
ctor (Individual) Name
/UI F 1/-414 t e., II DJ-,', 1 j ;.J�
Well Contractor Company Name
STREET ADDRESS. 1/ d/ j f hM CD(:C/
City or Town State Zip Cale
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable) mare 0 3
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ©.�'
DATE DRILLED j 3j 0 a
TIME COMPLETED 5 y , iv: AM ❑ PM
3. WELL LOCATION:
S l Y e ti k' r u Al couNTYj/ (zci. 19n cosh
O/d f nA1- .ru a A /-Cv/ %1 a?f'1
(Street Name, Numbers. Comm ay, SubdMvelon, Lot No., Parcel, zlp Code)
TOPOGRAPHIC / LAND SETTING:
ifitSlope OValley ❑Flat ID Ridge ❑Other
(cheek appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑OPS ❑Topographic map
(locatton of well be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER
OWNER'S NAME/1/i., n 1, at I a`rAMY�/I ai'.
STREET ADDRESS 4.-1- --r _ es IA ,At. Sa. J li.)r ,21:
City or Town - State Zip Code
(�'271- 7P6j 3 5/
Area code - Phone number
5. WELL DETAILS: 7,
}
a. TOTAL DEPTH: ,/ V
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOe"
c. WATER LEVEL Below Top of Casing: �,rj- FT..
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated aVa below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST*" $ ; /
f. DISINFECTION: Type C Ih is 1X Amount 7`vt;' Or'2/
g. WATER ZONES (depth):
Frongt b d To O..j' From To
From — To From To
From To From To
6. CASING: Thickness/
Depth .„-76 D3m ef
Weight
FFrrainol>�$TO '/ Ft. (,• ,j.sal
To Ft.
From To Ft. - -
7. GROUT: Depth Material Method
From-�"'5..,1 Tom a Ft.re,/Jj.-
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size. Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDVGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
niV OF WATER i"11 it LiTY
NOV 0 G 200G
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
G1u‘/rr .3t_ 06
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
7.17. ae /L7 1 Llela
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone -No. [phone] ext 568.
Form GW-la
Rev. 7/05

334080
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N al Resources - Di ' 'on of Water Quality - Grotmdwater!motion their
WELL CONTRACTOR (INDIVIDUAL) NAME (print) dV/ &U.r1 E SUr+ CERT�CATICSI If
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT/
(if applicable
T'2 it- r 1rS O N LDr/( ki/ir3 PHONE / (gam I S-1 -n63'-
f applicable
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIOj C
Nearest Town: %/%/> try✓ County � = ial, I/(/
(Street Name, Number, Community, Subdivision, Lot No., Zip Code)
3.OWNER:,. /�`P lAreOy ekfhd
Address � c-/ /Tlr.r
(Street
Mari a< ic.c• ar%S^a—
orTown ,S
3-"`3�'9/Zip Cade
Area cafe- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /4
C
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER. LEVEL Below Top of Casing: CO Fr.
(Use "+- if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surfaces
'Top of casing tenuiaated at/or below land surface requires a
variance in aecerdauce with 1SA NCAC 2C .011a.
9. YIELD (gpm): / 5 METHOD OF TEST ,e n-
10. WATER. ZONES (depth): // rOd
11. DISINFECTION: Type . tit c-/c Amount / >4 .
12. CASING: Wall Thickness
Depth Diameter or WdghUFt G
Fromm n To Ft. F
From / To Ft
From To Ft
13. GROUT: �J
From %An To� 0 Ft (�
From (� To Ft
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft in.
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft.
16. REMARKS.
Topograpbic/Land setting
❑Ridge 00Slope 0Valley ❑Flat
(�k appropriate box)
Latitude/longitude of well location
(deweedttumoea/sam.M)
Latitude/longitude source:❑GPS❑Topogrnpbic map
(rbeck box)
DEPTH DRILLING LOG
From To Formation Description
13� G�Iv QUASP
oc 2, 70U6
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.
Slot Size Material ,,r�t
in. X%1N
in.
Material
7 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL 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. ii 72001

WELL CONSTRUCTION RECORD
North Carolina - Department of Envim®eat and N Resomcee - Di • of Water r t d
Vf/gmp Quality - Groundwater Section
WELL coNTRACaoa (INDIVIDUAL) NAME (paint) 6 CAI g 3v-11at-sI-,j cur'IIFICATION N .9?�5
WELL CONTRACTOR COMPANY NAME � a-1- Li to t ), 1) !(�)t-, J/ / PBONE s Ohl GTi1-93f
STATE WELL CONSTRUCTION PERMIT% OCIATED WQ PERMITS
(if applicable) Of applicable)
1. WELL USE (Check Applicable Box): Residential E / Mtmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCAl'tfO
(Sireet e, Numbers, C �uottY. Subdrvraoo, Lot No. Zip Code)
3. OWNER: 331*r T /3)W_
Address %/7 / - ti!✓
Nearest Town: Y� .0 '17r County / 1 / ' 4 v✓r f ( � � 8
alley ❑Flat
(cheek appropriate
Latitude/longitude of well
locution
Sereet g rout o.)
)- City mom& -smote ( Tap Code
09(4
Area eodo- Phone mmtber
4. DATE DRILLED Aril?3 O e
S. TOTAL DEPTH: /0 „3 r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cr
7. STATIC WATER LEVEL Below Top of Casing: % t FT.
(Use "+" if Above Top of Caring
8. TOP OF CASING IS t' FT. Above Land Surfaces
'Top of easing terminated at/or below land surface requires a
romance V aemrdaate ISA NCAC 2C.a11a.
9. YIELD (gpm): �[C METHOD OF TEST tint/ /tf
10. WATER ZONES (depth): 1/5,, ' + jj/
11. DISINFECTION: Type L /4 Amount / J-
12. CASING: Wall Thiclmess
Mar or Weight/Ft ptetiazi
Fro D To 2"/J Ft
F To Ft
From To Ft.
13. GROUT: Depth
From To (/ Ft
From To
14. SCREEN: Depth
From To
From To
13. SAND/GRAVEL PACK:
Depth Size
From To Ft._
From To Ft.
16. REMARKS:
Depth
Ft
Diameter
Ft. in.
Ft. in.
Method
Slot Size Material
in.
in.
Material
(dePodminweahatame
Latitude/longitude source:OGPSOTopographic map
(ebedc box).
DEMI DRILLING LOG
From To Formation Description
cove/9U
jOFNA
•
LOCATIONS ETC}r
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC IC, WELL. CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH4 WELL OWNER
SIGNA
---- ,p-23rd6
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..
C N-i REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - DeQMtmimt of Environment and N
WELL CONTRACTOR (INDIVIDUAL) NAstE
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT:
of applicable)
Reso
of Water Quality
1tSOCcA � applicable)
(i
1. WELL USE (Lbech Applicable Box): Residential f MamicipSUPoblic 0 Industrial ❑ Agricultural O
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION;,
Nrst To7 1 //Ar a r'
C/ g`
(Street Name, Maisbea Com , &Mesisidm, tat No., Zm code)
3. OWNER: 0'4-14-14 , (af=w 43 E /—
Address ((.Air.k n L.
(soma arts No.)
grown Sue Tip Code
Alma axle- Phone ember _ —`i 6
4. DATE DRILLED d /
5. TOTAL DEPTH- ,7 is 3
6. DOES WELL REPLACE EXISTING WELL? YES & NO ❑
7. STATIC WATER LEVEL Below Top of Casing.e , FT.
(Use "4." if AboTop QftaSv
8. TOP OF CASING IS 1 FT. Above Land Surfaces
-Tip of man tnwmmetd attar bedew triad serfage «ate a
variance in a«ardamea web 1SANCAC 2C MIS. /
9. YIELD (gpm): METHOD OF TEST (5�'c `
10. WATER ZONES (depth): `� 5 / 9r "
11. DISINFECTION: Type S -4-6.4
12. CASING:
Depth Diameter
From To Ft6
From. To FL
From. To Ft
County %V• C /)d w Y / C
htclLand setting
'dge ❑Slope ❑Valley ❑Flat
(cheat appropriate bit)
Latitudellongitude of well location
(eepeedmimmhecmdy
Latitude/longitude source:CIGPS❑Topographic map
(eheez box)
METH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Amotmt / 2-A Show direction and distance in miles east
fromatl
Wall Thidmess two State Roads or County Roads. Include the road
or WdghUFt numbers and common road names.
pre_
--- Cr »
13. GROUT: Depth � Method
From To 2'(1 Ft s—
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft is in.
From+ _ To Ft in. in.
15. SAND/GRAVEL PACK
Depth Side Material
From. To Ft
From To Ft.
16. REMARKS:
It
ok r
044 Sev it, it
1 DO FEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH I5A NCAC 2G WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HnS BEEN PROVIDED TO THE WELL OWNER
11jret/cam
SIGNATURE
PERSON CONSTRUCTING THE WELL
DATE
ft
Submit the original to the Division of Water Quality, Groundwater Sr Won, 1636 Mail Service Center - Raleigh, NC
7M00 e636 phone No.'019'1 '33_323., within 30 days. C -, n.,,..-.i,i<Gv:

WELL CONSTRUCTION REG
North Carolina - Depastmint ofBavhonment and Natural Resources - DivisIcn
WELLcoNT7tACTOH(Nn1YIDQAL) tacit (who liCn o r(e.5p -.
WELL CONTRACTOR COMPANY NAME
1 `h A r 125'4 PI \ e t ( Dr ` 11,n
STATE WELL CONSTROCf$ON TEYffiT#
(if applicable) 1 �r
I. WELL USE (Check Applicable Box): Residential 1 Mumicipal/Public 0 Industrial 0 Agtialdaal O
Monitoring 0 Recovetry 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
_ASSOCIATED WQ li
(lf gfPlieable)
2. WRY 1 LOCATION: A
�
Nearejt Town: t9 I ' r4 Coenity `e l U (s 5 _
C�1 ) a
(Street Name. Numbers, Cammimity,5ubdivifim, lot No., Sp Code)
3.OWNER O mOrQ4n.
Address i)n rdS L el/Sam or f1 p
6)(a ro1-0,-4-A)C No'
City or Town Sore Bp Code
(—_)-
Area code- Phone number
a. DATE DRILLED -I -di — 000
5. TOTAL DEPTH: 1<
5. DOES WELL REPLACE EXISTING WELL? YES NO 0
7. STATIC WATER LEVEL Below Top of Casing: hi FT.
(Ur'+- if Above Top of Casing)
3. TOP OF CASING IS / FT. Above Land Surface*
'Top of mina termfaated .Sr below Lad surface nq a
variant in amp ea with MA NCAC 2C .6ttt
9 YIELD (gpm): METHOD OF TEST ' e
10. WATER ZONES (depth): S
Vko
11. DISINFECTION: Type "5h o LI( Amount k\t,
12. CASING:
Wall Thickness
FromDepth or Weight/Ft. ,Mf31
To �� Ft o IJllt
From r To
From To
13. GROUT: Depth
From To ,Q0
From To
14. SCR:?EN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From To
Ft
Ft
Material
X Ft. in Fro F n.
Ft
Method
Diameter Slot. Size MU&tal
Ft _in. in.
FL in. in.
Size
Ft.
Ft.
Material
Topo hic/Land setting
:Midge QSlope OValley ❑Flat
(checkup amiate ben;)
Latitude/longitude of well location
(daredmirmes/seemds)
Latitude/longitude son rcc01GPS❑Topogtaphic map
(thee boa)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCR
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
r
p
LIAc k�twicid 2d
16. REMARK&
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC+ RDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF -PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater St ction, 1636 Mail Service Center - Raleigh, NC
+74e0.1626 Phone Yo. '919) +73-3221, within 30 days. GW-; r... 37i200i

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
J.C. Miller
Well Contractor (Individual) Name
Miller Well Drilling
Well Contractor Company Name
STREET ADDRESS 2291 Zion Hill Road
Marion,
N.C. 28752
City or Town State Zip Code
( 828 )_ 738-3716
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 Ja'
DATE DRILLED /L...2 C 6 (0
TIME COMPLETED ? l/ /-t. AM ❑ PM @J
3. WELL LOCATION:,
CITY>/2
gise/���{j fa es/� L` i tb v 12 567
(Street ame, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
COUNTY
TOPOGRAPHIC / LAND SETTING:
CI Slope ❑Valley ❑Flat 1Kldge ❑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 well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME "tit CL•'d rAfS
STREET ADDRESS j iL 3 ✓, 4 r t h (j%r Dye
City or Town State Zip Code
f r)- 339—n9 l c l�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S 6 2 F 7—
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO l
c. WATER LEVEL Below Top of Casing: ,// .JiL)3 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. 77
e. YIELD (gem): ‘6 METHOD OF TEST .Jef7
2803
335494
f. DISINFECTION: Type C/h.417t
g. WATER ZONES (deptth))
From To 'Pr
5YFrom To
From To From To
From To From To
6. CASING:
Amounytegut
Thickness/
Dept piamgJer Weight Me re
Fro ''�i,,�/ To FL (� Sri y i/e
Frond " To Ft. f af4(4 /'
From To Ft.
7. GROUT:
nDepth
�7 Material
Frogw-�yy To,x® Ft. eP✓44r4(3-
Frorl Y To Ft.
From To Ft.
8. SCREEN: Depth
From To
From To
From To
Method
Diameter Slot Size
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
Material
Material
Formation Description
RECEN LlURUrg
FR
€7 -LP-car
L+
OW,
11. REMARKS:
/.ee.if /6 %- C$e 41deer r f
a E s,,� /2 u q 47 th
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDELL OWNER.
S NATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

North Carolina — Department of Environment and Natural Resources —Division of Water 1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] Quality —Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): Residential � Industrial
❑Recovery❑ MunicipalAgricultural Monitoring
❑Heat Pump Water Injection ❑Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MARION County: MCDWL
136 SOMERSET PLACE
DRH,(Road Name and Numbers, Community, or Subdivision and Lot No.) From LINo LOG DEPTH
3.OWNER HENRY & HOPE WRIGHT Formation Description
Address 136 SOMERSET PLACE
(Street or Route No.)
MARION NC 28752
City or Town State Zip Cade
4. DATE DRILLED 11/21/06
5. TOTAL DEPTH 525
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 100 FL
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 8 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 14
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 90 Ft. 6-1/4" SDR21 PVC
From _ To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. is
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #226 N. FROM POLKVILLE. RT. ON HWY. #70 IN
MARION. RT. ON N. MAIN ST. LEFT ON GARDEN CRK. RD.
LEFT ON 1sr PAVED RD. STAY LEFT ON AIRPORT A 3-WAY
STOP. LEFT ON SOMERSET. 1/4 MILE ON LEFT.
RECEIVED
DIV OF WATER QUALITY
DEC 1 ?OF
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No
`ter <_ �! '?-1�J /f - A / - li ei
IGNATURE F PERSON CONSTRUCTING THE 1.L DATE
ubmit original to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(individual) Name
Camp's Well & Pimp Co. Inc
Well Contractor company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State Zip Code
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#OI applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply lb,'
DATE DRILLED l I, r>< X- 06
TIME COMPLETED I I • 3 (1 AM O PM [O/
3. WELL. LOCATION:
CITY: I VV-I& A4--�(JV \
iNea-
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope IValley ❑Flat idge CI Other
(check appropriate box)
LATITUDE , 5_ RR ()4 ).-
LONGITUDE1 p"1 J I1.1
Latitude/longitude source: aie1SS ❑Topographic map
(location of welmust be shown on a USGS topo map and
attached to this formnot using GPS)
COUNTY-,
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER 1,r
OWNER'S NAME 11 241
STREET ADDRESS
City or Town
tlAaJ
4't I4Jate .r-t GK
(V C tJ l /
Zip Code
State
( 6
Area code - Phone number
5. WELL DETAILS: A^t
a. TOTAL DEPTH: r,L `I S
1
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IA
c. WATER LEVEL Below Top of Casing: LID FT.
(Use -.I." it Above Top of Casing)
d. TOP OF CASING 1S 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): )J) METHOD OF TEST
OCLA
335450
f. DISINFECTION: Type Chlorine Amount Cit
g. WATER ZONES (depth):
From To From To
From To Fran To
From To Fran To
6. CASING: Thickness/
DiFrom 0 OTo .� Ft. 6o4N SDR21 PWeight VC
From To Ft. _
From To - Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From To Ft. in. in.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0
Formation Description
(II .24 S 1JAdl /rt1
11. REMARKS:
RECEIVED
!lt\/ nF \NATER QUALI I Y
DEC .0 5 2006
I DO HEREBY CERTaY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RE D HAS BEEN PROVIDED TO THE WELL OWNER
a e 11-30 0�
SIG RE OF CERTI IED WEL .. RAGTOR DATE
sines W. Camp
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 # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & Pump Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(Ir applicable)
Zip Code
STATE WELL PERMIT#(R applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED I l —13 • o4
TIME COMPLETED .2 y AM O PM i-
3.WELLLOCATION: f ��II�� (�
CITY: I VI &u Ara COUNTY II
I7 1I OU /AA
\\ J491,., Lu M LI a
(Street Name, Numbest. Community, SubdlAslon, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valleyat ❑Ridge ❑Other
(check appropriate box)
LATITUDE £ Vq ^^e2
LONGITUDE.4 SL 191,
Latitude/longitude source: CPS ❑Topographic map
(bcatbn of wet must be shown on a USGS topo map and
attached to this form snot using GPS)
May be in degrees,
minutes, secondsor
in a decimal format
4. WELL OWNER
OWNER'S NAME Cie n
STREE—ADDRESS 4g
City or
hen5k0y/�
1 )3Chlin (.;r Je
�9��i 9
State Zip Code
Area code - Phone number
5. WELL DETAILS: C�
a. TOTAL DEPTH: 34 J
b. DOES WELL REPLACE EXISTING WELL? YENOV
S 0 N0
c. WATER LEVEL Below Top of Casing: I DO
FT-.
(Use H Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)' S () METHOD OF TEST OLZA
335455
f. DISINFECTION: Type chlorine Amount e) C 1)6
g. WATER ZONES (depth): 7
From To From To
From To From To From To From To
6. CASING:
Thickness/
Depth Diameter We' ht Material
Fran 0 To �irJ Ft 67 SDR21 PVC
From To Ft. _
From To Ft. -
7. GROUP
Fran 0
Depth Material Method
To 20 Ft Sackrete Hand
From To Ft.
From - To Ft.
8. SCREEN: Depth
From To
From To
From To
Diameter Slot Size Material
Ft. In. In.
Ft in. _ in.
Ft. in. _ in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
0
cr
From To Ft. c...a
From To Ft
10. DRILLING LOG
From 13 5
Portion Description
Vc 34S CfLam.
11. REMARKS:
*COVED AL1( Y
AEU
1 DO HEREBY CERTIFY THAT TF115 WELL WAS CONSTRUCTED N ACCORDANCE WIN
15A NCAC 2C, WELL CONSTRUCTION STANna91A, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
E OF CERTI ED WELL CO VTRACTOR � / DATE D4
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & Pump
Well Contractor Company Name
STREET ADDRESS P O Bo*
Ellenboro NC
Co. Inc
429
28040
City or Town State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
Zip Code
STATE WELL PERMIT#(Ir applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential' Water Supply tr.
DATE DRILLED 1 1. $ '
TIME COMPLETED I G,1 S AM lfd' PMD
3. WELL LOCATION: (�
CITY:
Mit IL#Ctyvt COUNTY Y Y1 t E� GOwLQ o
Gt-14 ul➢ew P Ali= �ot ).S
(Street Name.umbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope Walley CI Flat CI Ridge O Other
(check appropriate box)
LATITUDE % C O l 3• fi 7 7
LONGITUDE I i '7.'710
Latitude/longitude source: COPS ❑Topographic map
(location of we! must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER (� r��
OWNER'S NAME PnJ�7�1 (VLt
STREET ADDRESS 4 G 0 - A O &Ie finn1 RA
Mo✓go_nfort /V Q?U5 -
City or Teton State Zip Code
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: d.1
b. DOES WELL REPLACE EXISTING WELL? YES Q NO t
e. WATER LEVEL Below Top of Casing: lD 0 FT,
(Use '+' if Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance In accordancecwith 15A NCAC 2C .0118.
e. YIELD (gpm): 1) 0 METHOD OF TEST QM
335447
f. DISINFECTION: Type Chlorine Amount Ind c91s
g. WATER ZONES (depth):
Ram To From To
From To From To From To From To
6. CASING:
Thicln ass/
Depth., ncDi eter Weight Material
From 0 To O Ft. 6t SDR21 PVC
Rom To Ft.
From To -Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size -Materiel
From To Ft. In. In.
From To Ft. in. in.
From To Ft. in. In. A
9. SAND/GRAVEL PACK: C.,
Depth Size Material
From To Ft. „ }
From To Ft. cm
From To Ft. —`'
10. DRILLING LOG
From o�
�. V
Formation Description
riA —sit
Su a s Gt-(LANA
RECENEU
nIV OF WATER DUALITY
11. REMARKS:
•
DEC 0 5. ?Om
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANDTHATACOPY OF THIS .
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S A RE 0 ERTIFIED WELLO TRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & Pump Co. Inc
Well Contracts Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC
28040
City or Town State
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #pr applicable)
STATE WELL PERMIT#(Bapplicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED I I— 6. 0 t,
TIME COMPLETED .2: 3 IA AM p PM Q
3. WELL LOCATION: ( n
O
CITY: 2k A t i0. , P c�-ek1� t if rn a a k:{
SA
(Street Name, umbers, Community, subdivision, Lot No., Parcel Zip Code)
TOPOGRAPHIC I LAND SETTING:
slope QValley ❑Flat ❑Ridge ❑Other
(check appropriate box) 1
LATITUDE .J _ .2)y (1Sb C
LONGITUDEIL. `1w
J 3
Latitude/longitude source: DPPS OTopographic map
(bcation of we/ must be shown on a USGS topo map and
attached to this loan I not using GPS)
4, WELL OWNER o0
OWNER'S NAME e Qt.. .Q Cf1411
ST,RAET ADDRESS _
(' IOYi(4472N
City or Tpwn State
May be in degrees,
minutes, seconds or
in a decimal format
( }
Area code - Phone number
5. WELL DETAILS: 1 S.
a. TOTAL DEPTH: L $ J
b. DOES WELL REPLACE EXISTING WELL? YES p NO I-
e. WATER LEVEL. Below Top of Casing: 1'1 0 FT,
(Use'+' 0 Above Top of Casing)
d. TOP OF CASING 15 1 FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 0 METHOD OF TEST 0.,1 A
335448
f. DISINFECTION: Typo chlorine Amount 2 «tP5
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Dept Outer Weight Material
From 0 To 13 Ft. 6# SDR21 PVC
From To Ft. _
From To FL
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft.
From - To Ft.
8. SCREEN: Depth Diameter - Slot Size Material
From To Ft. In. N.
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 1.1\
Form Descrjption
RtGENED lnl ITN
ON OF v4ATCR Ql
11. REMARKS:
nEC n 5 (00
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
C(mm,e Li) CRAW 11.3o_a&
SIG RE OF CERTIFIED WELL C NTiA TOR DATE
es W. Camp
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.
Fam GW-la
Rev. 7/05

11./1B2( 03 07:17 2634100
PAGE 01
Noah
on ,C Gp m Al EnAr en1 sad Natural Resounds - DW4hn W of dar puny . Groundwater Section
ten Mall RANIgh. N.C. *?sn-1471141fians (OM F33-022I
WELL CONSTRUCTION RECORD watt CONTRACTOR '7 F Id, •c -/7k�>
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITS: -
3 � 90
rj - ;
1. WELL US Eairoda mawseat Raldrliel9—Munklpal 0 Industrial Aprkultural0
Recovery ID Had Pump War I*clbn j] caw 0 II Other, Um Use:
2. WELL LOCATION: (Show Meth oI the location below)
Nast Tat fl7 .rlA: e. i. 1 b J . C cower
.. - ten art IL_S.... Oaanadh. r I�A1a . ands.) Lad N
3. OWNER CC z (r c a 2 -', 4
i.
1pMIFOr GSM No•I
feI 12-410 /-1 C—
OW er Tan date
4. DATE DRILLED
5. TOTAL DEPTH 5i O r
S. CUTTINGS COLLECTED YES 0 NO[a
7. DOEs WELL REPLACE EXISTING WELL? YES p NO[9--
S. STATIC WATER LEYNE. Rebw Top of Cadet: y p FT.
IMowTo. n, elCa
V. TOP OF CASING IS / 7i' FT. Above Land Surface'
'Tar N seshri I.rednelad OM Sow Mad swiees merlon s vfleea M stow -
Wines wale TM HCAG IC pet.
ID. YIELD(gpm): . 7V METHOD OF TEST /9c..4
11. WATER ZONES (deptt): /,Q
/-71
DRILLING LOG
From TO
12. CHLORINATION: Type it3h.., d MINN+ZA cn rlrh
13. CASING: .9i,
wrathy 0
G A&F WELSERVILr s,
AND PUMP Bus:ese �`
911 Htic, NC 28°,
DE+~-247-1
Fonra:n Daaayun
p „`nri:1l!yn
;F 'NAT`=R ODUALUTY
nIQ J 1 7 900E
1r sddlw W Was M nodal as bad el kr
wr Tlsdnew LOCJ�j�QN SKETI]I
Depth40i t>WhPlr dfa(rlcab el Wm WMN Mow *War
Aw.WmdWMrnoSow
Fm01�DTO 6 FL'7 � — ..�— halo, woos rre wraaece poles!
From To FL
From To FL
14. GROUT:
W
From 7114 To orb
From To Fi.
15. SCREEN
Depth Plameter Slot Slze Material
From To F1 _.__ In. _._,_. In.
FL .sue} .F1 ors/h x
Material Method
/on irgAs.e.d
From To PL
From To
IS. SANDIORAYEL PACK
oeplh
From To FL
From To FL
17. REMARKS:
M. In.
Fl _ In. In.
Eta Ma1,rW
A&F WELL DRILLING
A. a PUMP SERVICE, INr
11 Hwy. Business •
Bostic, NC 2801 @'
828-247-177r
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WEN ISA 'CAC N. WELL
CON$TRUC11CM1 STANDARDS. AND THAT ACOPYOF S RECORD WAS BEEN PROVIDED 101141 WELL Da\ER_
r 'iv,.-1 - 74 > �, ' S2 7-a 6
SIWNA111Rl CF sow ppHSTRUCTera tug wttl 0. Si
Sag t. aENeenAVMh11170an
Ge4 pa. WI
FOR OFFICE USE ONLY
Owed Nu
SAMNN.
24-2003 ION 11:31AM ID:
POrC • 1

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) GAD IIARINESS CERTIFICATION 2Cpt
WELL CONTRACTOR COMPANY NAME I-IIG(RY WELL ERIL N3 CO. PHONE # [phone]
STATE WELL CONSTRUCTION PERMITS.. ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residentia1R$ Municipal/Public O Industrial 13 Agricultural D
Monitoring D Recovery D Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: NFW County Mh)TTQFTT
463 PARADT.SF. (TR.
(Street Name, Nwnben, Community, Subdivision, let No., Zip Code)
3. OWNER IIIEIN FLNES +TAYNE TABI'LE
Address /f,3 PARA()TRF (TR
(Street Routs IVC 228752
City or Town State Zip Code
Ara code- Phone number
4. DATE DRILLED 06-19-06
5. TOTAL DEPTH. 205
Topographic/Land setting
❑Ridge OSlope OValley OFlat
(dna appropriate
Latitude/longitude of well location
(de*teedmimrestseomds)
Latitude/longitude source:OGPSOTopographic map
(chat box)
PIM DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES O NO GE
7. STATIC WATER LEVEL Below Top of Casing: Yl FT,
(Use w' if Above Top of Casing)
8. TOP OF CASING IS 7 FT. Above Land Surface'
'Top of wring terminated atler below land aarfee requires a
variance In accordance win ISA NCAC 2C A11R
9. YIELD (gpm): 6 METHOD OF TEST RY ATR 'TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type Hli-) TARS
12. CASING:
From 0 To
80 Ft_a___
From To Ft.
From To Ft.
13. GROUT: Depth Material
From_(__ To m Ft. cwi iT
From To Ft.
Amount 33
Wall Thidmess
or Weight/Ft. Material
FVC PLASTIC
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft._irt.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
Method
MUM)
Slot Size Material
in.
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common mad names.
1 Yfl
40,ethigred
\ o FF
I ' RFC_ /ED
NA, E.R QUALITY
VOV g 4 2006
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P - ..: T . STRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Maffei Refiurccees - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMOE' (print) Uhn �J/.�/)es5 CERTIFICATION # 7on0
WELL CONTRACTOR COMPANY NAME UIl C4 Jt f t 1.0 C // nit i.?Co, . PHONE q tZ n tv 329-f1
STATE WELL CONSTRUCTION PERMIT# () ASSOCIA'18D WQ PERMITS/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 12I- Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery o Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATIO
Nearest Town: NQ� Cotmty/�� l�i7/c/P1/ Topographic/Land hic/Land setting
/ Of #s b. OnSfhze/P {- %%�arr>rx A/C ❑Ridge (cheek appropriate
OVbo) OFlat
(Street Name. Nanben, Conuuwdry, Subdivision, tut No., )
0n Zip Cam) / Latitude/longitude of well location
3. OWNER:L/046 rtplt'S 0f/Y/n p/ ��00/Ne (�Pr4vmimda/aeeoads)
Address -.3/,9 (v�hi�n Latitudellongitude soutce:OGPSOTopographic map
(Street or Ra"sep ) (check box)
446 6bwv fox / t c -,:e2 &CS DE2111 DRILLING LOQ
Tip Cade From To Formation Description
City or State( - 413?- GYc///
Area code -Phan mother
4. DATE DRILLED t9S!
5. TOTAL DEPTH: /1.73
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 3.
7. STATIC WATER LEVEL Below Top of Casing: /GYJ' FT,
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of endue termiaaled at/or below land surface requires a
variance la accerdaace with ISA NCAC 2C AIM
9. YIELD(gpm): /0/J METHOD OF TEST/44-
TS*
10. WATER ZONES (depth): `,
11. DISINFECTION: Type A`1 /�' V./is Aunt
12. CASING:
Depth _
From 0 To )2 FL_ «f/l/(fit /ISP�iI.
From To FL
From To Ft.
13. GROUT: Depth Material (--fe�wd
From_ To 20 Ft. fr/71/.(>L j/�/ g�
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.
Wall Thickness
J.00ATION SKETCI
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road muss.
� N
6(iT 40
Nt6a
eAkAstS
i Meae-e vronl
C
RECEIVED
,A/"TER QUALITY
. NOV P 4 2006
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSO
TRUCITNG THE WELL DATE
Submit the original to the Divialon 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 Ft�
14. SCREEN; 1> erm
From__
rom __ To.
WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvirorm.ent and Natural
WELL CONTRACTOR (INDIVIDUAL)
WELL. CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT
if hcable OCIATF.D WQ
d livablePERMTTs
1. WELL USE (Check Applicable Box):
Monitoring ❑ Water To' Industrial ❑
2. WELL LOCATION: Other If Other, List Use
Nearest Town:.
(Shea Nam, Nwnav,
3. OWNER:
Address
Cray orTown State Zip Cede
County 'ij�
Area code- Phone number 4. DATE DRILLED
5. TOTAL DEPTH: _3rkS
6. DOES WELL REPLACE EXLfliNG WELL?
7. STATIC WATER LEVEL Below Top of Casing �pr
8. TOP OF CASING IS (Use '4"''rwbave Top tu g)
*Top °reiaa tam avae�berw � 'Above Land Surface*
9. YIELD akes
varinee Is accordance with ISA NCAC 2C As
11*. rendknit
10. WATER ZONES (depth): SOD OF TEST f
11. DISINFECf[ON; i
12. CASING: Amomu 1n�_
yp
Wall Thidnras
Depth
Fr%__T° Lie_ L
From To Ft,
13. GROUT; Depth
Front—� To_z2._ Ft
Ft In,
15. SAND/GRAVELPACK: gt —ia
From Depth Size
From Ft
16. REMARKS:
Slot Size Material
in.
in.
- Division of Water Quality - Groundwater Section
occ
CERTIFICATION a
PHONE • kerb .32f�s�3_1
Topographic./Land setting
Midge dope Malley OFlat
(Mock appro box)
Iantud4longitude of well location
Latitude/I (seaeesha )
engitude source:OGPSOTopographic map
&kat box)
Mari
QRQ.LINrs j&Q
From To Formation Description
LOCATIO--,a
Shotwo State direction and dance in miles from at least
County Roads. Include the road
numbers and common road names.
l tl
o
Material �LA.(pil
/1-0
�� fVr W. EKED QUALITY
S NOV 4 2006
I DO HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCIE0IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS }tECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGMAOF PERSON ERSON7NGTHE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Sectton,1636 Mau
27699-1636Phone Na [phone], within 30 days.
Service Coster-Raletgly NC
GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldweil's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(irapplicawe)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applic
DATE DRILLED I
e Box : Residential Water Supply
i9 6
TIME COMPLETED N AM 24'M
3. WELL LOCATION:
CITY: fl1 A 21 o rJ
COUNTY Cbe'LOk .
65S 4- Cj(.5 C4ACE1- 6LoAA
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANNSETTING:
❑Slope ❑Valley gnat 0Ridge ❑Other
(check appropdate box)
LATITUDE 3 5 45. 149
LONGITUDES 2 OZ. 444f
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: BCiPS ❑Topographic map
(locatkrn of weft must be shown on a USGS topo map and
attached to this form rnot using GPS)
4. WELL OWNER
OWNER'S NAME Dennis 6; Ider
STREET ADDRESS (p55 I1ri ks Chap e_
Marlin
NC-
City City a Tam State Zip Code
( $213 y. 15b- Do73
Area code - Phone number
5. WELL DETAILS: / r
a. TOTAL. DEPTH: 1 5 /
b. DOES WELL REPLACE EXISTING WELL?r YES d NO ❑
c. WATER LEVEL Below Top of Casing: k1 0 FT.
(Use "+° if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface`
*Top of casing terminated actor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 5 METHOD OF TEST RIG -AIL
i
f. DISINFECTION: Type__ Amount ?le
g. WATER ZONES (depth):
From I Z S-To 13 s From To
From To From To
From To From To
8. CASING:
From _.1..DTo I I (n Ft. epth 40
91alrt"
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From i To aD Ft. CwI'1�1$NT �VQe A.
From To Ft.
From To Ft.
Thickness/
Weight Material
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in,
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
Fromi '
11.1'— to '
Icy$`— ts
'1t01— tb5Z
11. REMARKS:
1,
(' J
Fopnation Descriptiioon
ICES-55 Gern
G2.ri..rrt 6
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
1v)ASlJ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
c
c
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Canpany Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City a Taws State Zip Code
( 828 )• 254-3581
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 B : Residential Water Supp
DATE DRILLED i I ei 6
TIME COMPLETED I (; IS mid PM O
3. WELL LOCATION: �/j
CITY: (, l A (L1 D rJ COUNTY 1 f �CaJOLDISNt,
�( C..20sse-of ©& Nig
(Street Name, Numbers, Community, Subdivision, Lot No, Pared, Zip Code)
TOPOGRAPHIC / SETTING:
❑Slope :Valley at ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5_ yg. bII
LONGITUDE 5 2 02.320
May be in degrees,
minutes, seconds Of
in a decimal format
Latitude/longitude source: Etr6PS :Topographic map
(location of well must be shown on a USGS topo map and
attached to Wis form T not using GPS)
4. WELL OWNER
OWNER'S NAME Ro J UA i 1 i N i
STREET ADDRESS 41 Ccos5eµ{
Mar
lin AIC 2fIi52
C ty or Tawn State Zip Code
% 0 O- 44a— tv 5 3
Area code - Phone number
5. WELL DETAILS: II
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES: NO
c. WATER LEVEL Below Tap of Casing: 6 © FT.
(Use `+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): %t METHOD OF TEST eta.
4Vtia)
T. DISINFECTION: Type 14T14 Amount A b 2.
g. WATER ZONES (depth):
From 12 a To) 2 5 From To
From To From To
Fran To
6. CASING:
Depth Dia
From 1— To I It Ft.
From To Ft.
Fran To Ft.
From To
Thickness/Wei
mere
DKal
7. GROUT: Depth
Material Method
From 1- To a2.1 Ft. C-eilkl C Pb uC2
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter
From To Ft.
From To Ft.
From To
Slot Size Material
in. in.
in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
Frwrir To / pn �Foati0n Desc rip6og
Ni
UOS'— IaD '
taYY—tas' • tots-" iC) Gf'a•1n
Iasi.— t65' (1(4*31—CC
11. REMARKS:
1 DO HEREBY CEHIIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(Lt4 C I/ /k
SIGNATURE OFERTIFIED WELL CON DA E
l
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Weil Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Weil Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Cade
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Appl'Residential Water Su
cable B : RppyQ"
DATE DRILLED hia 3 7° ca /
TIME COMPLETED t a., 0o AM ❑ PM L�j
3. WELL LOCATION: CITY: YYl A 11/4I O 14 11MM COUNTY 1Cdp0 W g l tr
A 2mstgaritaG CQ -P, gtAb
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE _a_ 5 10, ) 41
LONGITUDE H 2 cS. <job
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: g}6PS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form inot using GPS)
4. WELL OWNER OWNER'S NAME J o E'i 1-/awk5
STREET ADDRESS ` 4-2 Arnit erti Cree-k !?C(,
Ottafrk Mc.
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: ./
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ltd
c. WATER LEVEL Below Top of Casing: IiO FT.
(Use "+- if Abe TOp of Casing)
d. TOP OF CASING IS •A1FT. Above Land Surface•
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .01n(1�8,.�,,
e. YIELD (gpm): ) 5 METHOD OF TEST (ta ' A 1 a/
L DISINFECTION: Type Amount 16 aG
g. WATER/ZONES (depth):
From 51 To C D
From 3 Go To 3 4 S
From To
From
From To Ft.
From To Ft.
From To
From To
From To
7. GROUT: j Depth
From To ab
Material
Ft. C8—t•Nklerl
Rom To Ft.
Rom To Ft.
8. SCREEN: Depth
Fran To
From To
Rom To
Diameter Slot Size Material
Ft. in, in.
Ft. in. In.
Ft. in. _ in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
Rein
, T%
Sr'- IS 5'
��—ct
11. REMARKS:
Size Material
Formation Descripti
4SP-g1E
C7 RA'011-'S
(_+_p.:(3-4cAr - a. Grin
Ggm) L-1-6
l M-'Acc - 1 13 G-P»1
Ait-.3 VAS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
� )VZ41°6
SIGNATURE OF CERTIFIED WELL CONTRACTORDA
PRINTED NAME OF PERSON CONSTR C ING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center -Raleigh, NC 27699.1617 Phone No. [phone] ext 566.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Cornpany Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(i/applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable o Residential Water Supply Er
DATE DRILLED I VI/
TIME COMPLETED I '. C 0 AM IJ PM [g'
3. WELL LOCATION:/�(,,,y
CITY: 1 v ((t a..,t o laCOUNTYPY/' n1 `C-bo 011 i-L
RA is pot9 IA V i�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope 0Valley ❑Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3 5 38 652
LONGITUDES 2- GO, 353
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS 0 Topographic map
(location of wee must be shown on a USGS topo map and
attached to this town Knot using GPS)
0. WELL OWNER
OWNER'S NAME AR— - Wcrcls
STREET ADDRESS eanJolpii Dno�
Mit r on Alt -
City City or Tam State
(s 3."‘ Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a dS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2 FT. Above Land Surface'
*Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Rio METHOD OF TEST R(G"P'la.
Zip Code
f. DISINFECTION: Type kid Amount d IS Z.
g. WATER ZONES (depth+)
From CVO To R. O From To
From To Fran To
From To From To
6. CASING: Thiclmess/
Depth lJla W ' pat al
From To or D Ft to Mi yAv
From To
From To
7. GROUT:..tl Depth Material Method
From 1 To 2,0) Ft. !,.E shoi' o_ _i)
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ftin. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From / To Fanon Descr ptio0
So ' — C S I Chile( - Sln G c dr)
Q5 / a a5s r-rS
C-1
11. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS` BEEN PROVIDED TO THE WELL OWNER.
Cc I
SIGNATURE O ERTIFIED WELL CONTRACTOR
�vLt-1kidT
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
C'N/
CYZ
IteJ
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 - Division of Water Quality Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) kAkQ/4Q1 5 r
1 CERTIFICATION #424 oa
WELL
CONTRACTOR COMPANY NAME APPALAChttkN'(, I ��l''�µ ytrc/'i 1 10p
w T# PHONE # (8/W)tpp,3' p --
S'TATF. WELL CONSTRUCTION PERaiIT# C
(if applicable) ASSOC/AT WQ PERMIT'S C
(if applicable)
CC
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring LI Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use
2. WELL LOCATN: `' ",L,, tnt''
Neares Town: UA&< t1xA.t\L1{,� Connty't4CDDM/0l� �bpographic/Land setting
irgei N alr. . ire s Idge ❑Slope ❑Valley ❑Flat
(Sneer Name, bers, Community, Subdivision, Lot No.. Zip Code) (check appropnate box)
�/1_ L�},t de/Jgpgit ��jel;t�ofa��19� q
3. OWNER:y,�V'tAH {///�uI/�141�D �O� `7• JT W (�Ttol� ko.YO /
Address y' 0 aoye g3 1 (degrees/minutes/seconds) `/ E' ic 33(0 Q
Street. or oute N ).)
Latitude/longitude source:❑GPS❑Topographic map o
at'�` � u c a' I r DEPTH check box)
CI ty or Town Stare Zip Code DRILLING LOG
(_)_ From To Formation Description
Area code- Phone numbg
4. DATE DRILLED l �6 6�
5. TOTAL DEPTH:-�p
6. DOES WELL REPLACE EXISTING WELL? YES NO Q"
7. STATIC WATER LEVEL Below Top of Casing: %0❑0 FT.
8. TOP OF CASING IS (Use "+" if Above Top of Casing)
FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance tiih ISA NCAC 2C.0118. /7
9. YIELD (gpm): (p• a METHOD OF TES R • eON'( iAC
10. WATER ZONES (depth): CQ ( U
11. DISINFECTION: Type
12. CASING:
Amount
Wall Thickness
From DeTop11 �7 C Ft. Diameter or Weight/Ft. Material
L/
From To Ft.
From To Ft.
13. GROUT: Depth Material
From To Ft, ri
From To Ft. Q,
14. SCREEN: Depth Diameter Slot Size -{-� Mate al
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
in.
in.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AN THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WF.LI. /
Dei/O
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

Nnrtn Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1635 Mall Service Center - Ralelgh,N.C. 27699-1636-Phone [phone]
336519
%
WELL CONSTRUCTION RECORD WELL CONTRACTOR: / ?-L /}mil JhU
WELL CONTRACTOR CERTIFICATION # : .2wSL
STATE WELL CONSTRUCTION PERMIT # :
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitorinc l-1
Recovery ❑ Heat Pump Water Injection ❑ Other n If Other. List Use:
WEt. I. LOCATION 1Show sketch of the location below)
�earosl town
r11- r0 A% County /V%.r OwZ� Lr�
G i SC u AL /rL 4, (l 4
'Road Name and Numbers fCommmunity, or Subdivision and Lot No.)
3 OWNER DAD/ / OW y
Andress 2e It LA/AL �Fh
NE6 U ( tree o Rotite No )
"it‘, or Town / State Zip Code
4 DATE DRILLED i'"f`
-CTAI DEPTH //
n. TI:TTINGS COLLECTED YES n NOg],
:%Ti6S WELL REPLACE EXISTING WELL? YES NO154
'Lt" WATER LEVEL. Below Too of Casing. 0 FT
(Use "+" if above fop of Casing)
"'T° (_DE CASING IS ...144 q FT. Above Land Surface'
"or nt casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C 0118
10 YEILD (GPM): 7 METHOD OF TEST 174/�-''
11 WATER ZONES (depth):
/74
'3 "HLORI NATION: Type /001
CASING
��yy��
Depth // Diameter
Irnm.1,4r l0 6_ Ft 1"
TO Ft
to rt
'4 :pout{
;GREEN
Amount / 4
Wall Thickness
DRILLING LOG DEPTH
From To Formation Description
if additional space is needed use hack of form
or Weigilt/Fial
lt.)t. 104Mater1;r$j7C
Depth Material Method
To Ft
Tn Ft
Depth Diameter Slot. Size Material
To Ft in In
' -Om To Ft in in
''om .� To Ft in in
!6 SAND/GRAVEL PACK:
Depth Size Material
To Ft
I -rim To Ft
17 REMARKS.
LOCATION SKETCH
(Showdirection and distance from at least two State
Roads, or other map reference points)
RECEIVED
IDIV OF WATER OUALITV
IAN 8I 4 2007
! 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
ett43.e.. 'i ja-'; OC
SIGNATURKOF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
RJ 1w1 GW1 REV 12'96
GOR OFFICE USE ONLY
'brad No.
Serial No

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mall Service Center - Ralelgh,N.C. 27699-1636-Phone [phone] ��77
WELL CONSTRUCTION RECORD WELL CONTRACTOR. d At+iva( /7»r% �. r 3 3 6 518
/S
WELL CONTRACTOR CERTIFICATION # : t S 6 1
STATE WELL CONSTRUCTION PERMIT # :
✓YELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery n Heat Pump Water Injection ❑ Other El If Other, List Use:
`.r'Fl. l_ I. °CATION: (Show sketch of the location below)
'\I crest rnvrn / /at 6.V
County
_toa LJ.AId C'lOUCT /fd/YO&.0
Unad Name and Numbers Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER /0/ d And.; orb From To Formation Description
-. caress �'J wem Cj.D '�J r /(7IJohC
(Strea or Route Ro')
7av or Town State Zip Code
o DATE DRILL ED /ti'•/ )- u L
TOTAL DEPTH / —
6 CUTTINGS COLLECTED YES n N0n
DOES WELL REPLACE EXISTING WELL? YES n NO
STAT'C WATER LEVEL Below Top of Casing. /e 2 None FT.
(Use "1" if above Top of Casing)
9 r )P OF CASING IS '3i� FT. Above Land Surface*
'"op o' easing terminated attor below land surface requires a variance in accor-
dance with 15A NCAC 2C. 0118
Tp vrlln (GPM): /O r METHOD OF TEST b4•1.
VIVATFR TONES (depth)
+I 4RINATION_ Type Nth. Amount /.6 If additional space is needed use back of form
,ASING Wall Thickness
Depth Diameter or Weight/Ft. Material
To /gG Ft 6 . ,1 t. /PP,xa j 77 C LOCATION SKETCH
To Ft (Showdirection and distance from at least two Sete
1n �, Roads. or other map reference points)
Depth Material Method
7o Ft
°'on' Tn Ft
15 SCREEN
Depth Diameter SIot.Size Material
n To Ft in In
-,m To Ft in in
-mm __ To Ft in in.
'F SAND/GRAVEL PACK:
Depth Size Material
To Ft
rim To Ft
r•74FMARKS.
RECEIVED
ON, OF WATER DUALITY
JAN ft 4 zoos
DO HEREBY CERTIFY THAT 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.
FOR OFFICE USE ONLY
Quad No
Serial No
./- e-e'gr. /14:—‘—.9 /c,;>—cc
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
;'m.., GW-1 REV 12/9@

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mall Service Center - Ralelgh,N.C. 27699-1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: a%r�n� OA , 4 /nib ` ` $ JC 17
WELL CONTRACTOR CERTIFICATION # : 30 4114
STATE WELL CONSTRUCTION PERMIT # :
wE Ll USE (Check Applicable Box): Residential Municipal n Industrial ❑ Agricultural ❑ Monitorino
Recovery ❑ Heat Pump Water Injection ❑ Other( If Other. List Use:
'A/EL L LOCATION: (Show sketch of the location below) Nearest town: Ant hx O'a.f County. /I G C%O ✓a 44.
�37 WI S CAS; Pt 17d
Road Name and Numbers Community, or Subdivision and Lot No) DRILLING LOG DEPTH
3 OWNER /1/4"(Md j4J,L.$v
N From To Formation Description
Address /4/ 5744y Nita fu
(gfreei or Route No.)
M14 A• •ou N.C.
r:ay or Town State
i,ATF DRILLED //
1FOTH 90
• TTINGS COLLECTED YES ❑ N0J
DOES WELL REPLACE EXISTING WELL? YES NO
STAT'C WATER LEVEL Below Top of Casing: FT .
(Use "+" if above Top of Casing)
,r-'r' L,F CASING IS 624 »' , FT Above Land Surface'
"oc "-.asinq terminated aVor below fand surface requires a variance in accor-
a�� urth 'Ton, NCAC 7C 0118
°Fll n (CPM`: /24- METHOD OF TEST .29 i k/--6.
WATER ZONES (depth).
tr ('.HIORINATION: Type
ASING
14
Depth
29" To 30
o rn
;ROUT
1T. SCREEN
�P)ra
Zip Code
1'7Th
Diameter
Ft
To pt
To
Amount 1 `b
Wall Thickness
If additional space is needed use hack of form
or Weight/Ft Material
Q7, ' flc#,S 'L LOCATION SKETCH
(Showdirection and distance from at least two Sate
Roads, or other map reference points'
Depth Material Method
To Ft
To Ft
Depth Diameter Slot.Size Material
to Ft in n
Tr F' n in
__ Tn Ft In in
5 ANCTGRAVEL PACK:
Depth Size Material
L m To Ft
r -nm To Ft
1' REMARKS
RECEIVED
DIV. OF WATER OVAL IT'Y
JAN 9 4 2007
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
Ooad No.
Sena/ No
SIGNATURE OF PERSON CON TRUCTI G THE WELL DATE
Submit original to Division of Water Quality Groundwater Section within 30 days
GW 1 REV +7.9r

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mall Service Center • Ralelgh,N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /lo4nw 19',.4,0, /wt 3 3 6 516
WELL CONTRACTOR CERTIFICATION # : ,1444 4.
STATE WELL CONSTRUCTION PERMIT # :
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring I___,'
Recovery ('� Heat Pump Water Injecti ❑ Other n If Other. List Use:
'.NFL I LOCATION (Show sketch of the location below)
".Ina ^at tnwn /1{-/.VnJf 1O%r%
County
��/! DRILLING LOG DEPTH
OWNER /` a ink 4)-he via From To
address 43 Go p <!- 4'4AM! /?d
(Street or }route No.)
/Vo#'j.,vran/ N.c, 865t-'
y or rown State Zip Code
!)nTF DRILLED //—;o -D G
^TAL DEPTH /d'o
F CUTTINGS COLLECTED YES n NO[
DOES WELL REPLACE EXISTING WELL? YES n NOQ
STATIC WATER LEVEL Below Top of Casing: /.2 S FT.
(Use "a" if above Top of Casing)
rr f' `m CASING IS //itr/i FT. Above Land Surface'
"rr " _asIng terrnmaled atfor below land surface requires a variance in accor-
Ian�r Neh 'SA NCAC 2C 0118
r v F-It D (GPM): /ot METHOD OF TEST yatizz+ir2 A+
I' WATER ZONES (depth)-
i/SyA h J)jA/ f, rir AO AL7
'Road Name and Numbers Community or Subdivision and Lot No )
Formation Description
PINATIfNI Type /7%% Amount dirB If addibnnal space is needed use hack of form
aSIN(; Wall Thickness
Depth Diameter or Weight/Ft. Material
/8 7A4, 11ro 9, Ft L 2?, L Jaea5jr C. LOCATION SKETCH
r -om TO rt (Showdirection and distance from at least two State
`-ng, To F1 Roads. or other map reference points)
14 2RntIT
Depth Material Method
-^ To Ft
lbar, To Ft
IF SCREEN
Depth Diameter Slot Size Material
Tr Ft in in
__ To Ft in in
nm To Ft in in
f SAND/GRAVEL PACK.
Depth Size Material
FMARKS
To
Tn
Ft
Ft
RECEIVED
t:ilV. OF WATER QUALITY
lAN 0 4 2007
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
At.wt n / r- f er -0 6-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/0e

North Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
3335I4
WELL CONSTRUCTION RECORD WELL CONTRACTOR. / IOA/IA1d Q'`faci�
WELL CONTRACTOR CERTIFICATION # : 30tp L
STATE WELL CONSTRUCTION PERMIT # :
A/FLL LISE (Check Applicable Box): Residential Municipal ❑ Industrial E Agricultural ❑ Monitoring ❑
Recovery D Heat Pump Water Injection ❑ Other 0 If Other. List Use:
2 WELL LOCATION: (Show sketch of the location below)
Nearest town 71/2 w,6N County
/31. /hcU.S (f_Mf:re-AY /td
?Read Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3 OWNER 7ohivitcY 7., L G1 r $ From To
Address /3-L /t!'(J, 4 C �✓t �%nY 17 d
Street or Floute No.) _
City or Town State Zip Code
TT ATE DR II I FD /UD - J r✓
rnTAI DEPTH /stQ
6 CUTTINGS COLLECTED YES ❑ NOpzi
7 DOES WELL REPLACE EXISTING WELL? YES ❑ NO!
B STATIC WATER LEVEL Below Top of Casing: /o 1 FT
(Use "*" if above Top of Casing)
9 TOP OF CASING IS /9 4"
FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C. 0118
10. YEILD (GPM): /C T METHOD OF TEST aF7/A6-G'
11 WATER ZONES (depth):
DEPTH
Formation Description
c..uL ORI NATION: Type /V%7-# Amount / •' h If additional space is needed use back of form
Wall Thickness
Diameter or Weight/Ft Material LOCATION SKETCH
1'0 �t 1/' .27. ‘ ps.'4cri c
(Show direction and distance from at least two State
Roads, or other map reference points)
•vSING
1636 Mali Service Center - Ralelgh,N. C. 27699-1636-Phone [phone]
Depth
mm to
r rnm To
L. rnm le
1a •RPCl1T
Depth Material Method
nm To Ft
From To Ft
15 SCREEN
Depth Diameter Slot.Size Material
I--nm To Ft In in
From To Ft in in.
r.nm _ To Ft in in.
16. SAND/GRAVEL PACK:
Depth Size Material
'-ohm To Ft
om To Ft
REMARKS -
RECEIVED
Div, OF WATER QUALITY
JAN 0 4 2007
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
Ouad No.
Serial No
O /
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW 1 REV 12/99
/e _Koc ' L

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
J.C. Miller
Well Contractor (Individual) Name
Miller Well Drilling
Well Contractor Company Name
STREET ADDRESS 2291 Zion Hill Road
Marion,
N.C. 28752
City or Town State Zip Code
( 828 )_ 738-3716
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply El/
DATE DRILLED /2_2 O D 4
TIME COMPLETED ,7 Ar'./ nr•..0 AM ❑ PM 8'
3. WELL LOCATION: ((��
CITY: . R JIJ COUNTY 13% UAee./(
TaAde,la•1 s4 / M,SA° L7?�'G
(Street Name, Numbers, o munity, Subdivision, Lot No., Pa el, Zip Co e)
TOPOGRAPHIC / LAND SETTING:
-eSlope ❑Valley DFlat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER /7
OWNER'S NAME Y74 )ie £4 fU .AJ
STREET ADDRESS 3. b �� /e- 11 r-if $a a Z 77n
m ah,ts,() <J c. 27-7tV .
City or Town State Zip Code
(7R J" ¥ 2 9"1 9 t e e (f
Area code - Phond number
5. WELL DETAILS:
a. TOTAL DEPTH: / /b fit
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO fr
c. WATER LEVEL Belau Top of Casing: 4 :- FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): gie METHOD OF TEST ; /a h
2803
CAD
A9
CO
f. DISINFECTION: Type;"!S%1.4 Amount/1//' 2-/
g. WATER ZONES (depth):
From To/Cr .J From To
From To From To
From To From To
6. CASING: c� Thickness/
Front/ DTot9d FL"ia � er Weight• teQal
From To Ft. �3' 1/
From To Ft.
7. GROUT: Depth nn �iMaterrii"al Method
Froro Tot U Ft. 0 ,PI,L
FTo Ft.
From To Ft.
6. SCREEN: Depth Diameter Sbt 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
1. REMARKS:
LJ%V. Of V1111 v,� 4 q�i 1 T
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/► t
CL _ %,
SIGN URE OF CERTIFIED WELL CONTRACTOR DATE
tJ C /ti: f I 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 CONSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
335740
1. WELL CONTRACTOR:
James W. Camn
Well Contractor (Individual) Name
Camp's Well & Pump Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
E1lenboro NC 28040
City or Tavn State Zip Code
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#(II applicable) '
STATE WELL PERMIT#(8 applicable)
OW Q or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply G.--
DATE DRILLED i 2 .
TIME COMPLETED a. U. AM O PM Mk'
3. WELL LOCATION: r�
CITY: fw1 {{ COUNTY`Mt `J owl,U
(StreetL
Name, Numbers,. MIy.:il9ivIslon, Lot No., Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
❑Slope l¢dalley O.Flat ❑Ridge ElOUur
(chock appropdataboq
LATITUDE -3$ . 3'4 fl s
LONGITUDE ik__ se), 4614
Latitude/longitude source: MEWS OTopogaphic map
(location of wet must be shown on a USGS topo map and
attached to this form %not ushg GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
May be In degrn
minutes, seconds or
in a decimal Snit
0 AvX 639
y Nt�V- — 33
City or Tam
S
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NO a
e. WATER LEVEL Belau Top of Casing: \ 0 FT.
(Use '+if Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface'
casing a variancee naccordance with 15A NCAC 2C .01e may requirerequire18.
SoS
e. YIELD (gpm): METHOD OF TEST apt.
f. DISINFECTION: Type chlorine Amount A gap 5
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
From 0
ThkWbssl
DepthDlajneter Weight Material
.To 1 2n Ft 6* SDR21 PVC
Fran To Ft.
From_ To •Ft
T. GROUT: Depth Material Method
Frail L _To 20 Ft Sackrete Hand
Froth To Ft.
From To Ft.
S. SCREEN: Depth Diameter - Slot Size Material
From To Ft. in. N.
From To Ft. In In.
From To FL in. In.
9. SANDIGRAVEL PACK:
Depth Slur Material
Front To Ft.
From To Ft.
From To Ft
10. DRIWNG LOG
From To
o • 11.5
11. REMARKS:
FormatioAoes ri n
t'Cht,tivtU
01@y nFINAYFR DI IAI [TV
1AhFl2007
15A MAC 2C,CWECONsTUCTIOWNESTANDARDS, ANDTHAT ACOPPYY OFC5 WITH
.
: RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER.
� /3.JG.0b
SIG URE OFCERTIFIED WELC'CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mali Service
Centerinal to - Ralvision tali/Veer eigh, NC 2 699 16117 Quality witnehNo. (9 9) 733 7015 ext 68.ti Mgt.,
Form GW-la
Rev. 7/05

' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and NaturalResources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
333738
1. WELL CONTRACTOR:
James W. Camo
Well Contractor.(IndhAdual) Name
Camp's Well & Pumo Co. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City orToan ' State Zip Code
(828'. 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(1f applicable)
STATE WELL PERMIT#(6applicble)
DWQ or OTHER PERMIT #(If applcable)
WELL USE {Cheek Applicable Box): Residential Water Supply
DATE DRILLED t d -14 ' 0 I, /
TIME COMPLETED (. 3O AM In PM E1
3. WELL LOCATION:
CITY: (9^LOt"•
GOUWTV M £\ a^
�t1lsn91A U/'A,T
Street Name, Number, Community, SubdMNsion, Lot No., ParceLZp Code)
TOPOGRAPHIC I LAND SETTING: •
slope °Valley CIFIat ❑Ridge ❑Other
tensor appropnatab?s)
LATITUDE .5p�_ y) 4 q!'g
LONGITUDE,p,I S q h U
Latitude/longitude source: D&PS °Topographic map
potation
� o o �p ►nohownro GPUSGS topo map and
May be in depees,
minutes, seconds or
Ina decimal format
4.WELL OWNER �
OWNER'S NAMED] fl
STREET ADDRESS to X I It
!Nebo NC 2.9761
City or Tom State Zip Code
Area code Phone number
5. WELL DETAILS: 11
a. TOTAL DEPTH: J tors
b. DOES WELL REPLACE EXISTING WELL? YES p NO
C. WATER LEVEL Below Top of Casing: S a FT,
(Use"? If Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface*
low land surf
a vwlanca hgterminated at/or ac�cjordance with 1155A !CAC 2C .01 8 mey require
e. YIELD (ppm): _—METHOD OF TEST alit.
f. DISINFECTION: Type chlorine Amount 11fi
g. WATER ZONES (depth):
From To From
Fran To From To
From To - From To
6. CASING:
To
TNelmessf
Depth Diameter Weight Material
.From 0 .To t) 1.0 Ft. 6t SDR21 PVC
From To Ft. __
From To Ft.
From0
7. GROUT: Depth Material Method
To 20 Ft. Sackrete Hand
From To Ft.
From To FL
8. SCREEN: Depth
From To
From To
From To
Diameter Slot Sire .Material
Ft. In. N.
Ft. In. __ In.
Ft. In. In,
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From .To.
.0' J(7L•
Size Material
Fnta(io D cdptlon
AD
Ire(. .3teC &10 AMATT
f`rtltT iIbC lam-rFq ir,e
11. REMARKS: :AN II ft LOU
I DO HEREBY CERTIFY THAT TMS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS .
RECORD HAS BEEN PROVIDER TO THE WELL OWNER
l a 1�.
(JA �1,) (l CONf A�
SI TU EG( CERTIFI DWELC'CONTRACTOR bATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submit Mall the
ervle° Centerinal to - Raleigh, NC 2 699 1617 e Division of VVater Quality
Ph Phone No. (9 9) 733 7015 ext 5Information Mgt.,
Form GWAa
Rev. 7/05

828City} a Town453-7322State
(
Area code• Phone number
2. WELL INFORMATION:
SITE WELL ID #0f applicable) '
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT Cif applicable) —/
WELL USE (Check Applicable Box): Residential Water Supply I
DATE DRILLED la. 16 ' O L
TIME COMPLETED 1 3t
RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W Camp
Well Contractor. (Individual) Name
Camp's Well &_Pump Co. Inc..
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
Zip Code
AM O PM(0---
B. WELL LOCATION:
CITY:
CITY: YVM
neA .I.pA. COUNTY Vs.0 the, W
\
nbets, U>1w rod
(Steal No�CanmuH•bdNSlon,Lol No., Pane
.w_
I.
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley DFlat Lgrcrdge ['Other
(check appropriateb?x)
LATITUDE 9 5 3 3 (q3
LONGITUDE4)U, 63 '] i S
Latitude/longitude source: ❑ GPS OTopographic map
( attached to this lust of wet must be
shown
ot using G S) USGS topo map and
4. WELL OWNER (,"` OWNER'S NAME e
p Code)
May be In degrees,
minutes, seconds or
in a decimal Ramat
VTR ir.T ADDRESS J"
lv fY aR
City orT n State zip Code
Area code Phone number
LA. 43
.' O&LP EAT In R .
C_ fl c'
5. WELL DETAILS: 1
a. TOTAL DEPTH: L` a
b. DOES WELL REPLACE EXISTING WELL? YES p N0 b"
c. WATER LEVEL. Below Top of Casing: St) FT,
(Use we if Above Top of Casing)
d. TOP OF CASING 19 1 . FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST QA/r
330736
f. DISINFECTION: Type Chlorine Amount I Yt GAIT
g. WATER ZONES (depth):
From To From To
From To From To
From To Fran To
6. CASING:
Dept Diameter TNWei htebbssl Material
From 0 .To Ft. 0# SDR21 PVC'
From To \ Ft.
From To .FL
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
Ft.
From To Ft
e. SCREEN: Depth Diameter Slot Size .Material
From To Ft._In. In.
From To FL In. In.
From To Ft. in. Ht.
9. SAND/GRAVEL PACK:
Depth Slze Material
From To Ft.
From To Ft.
From To FL
10. DRILLING LOG
From ;Ti
0• x
Formatter;
kb -1 /VIA Description
RI ' Ltas _AAA Awn•
11. REMARKS:
t(tLtf,
nlll. OF vt/ATEI: fniAUT't
1 CC HEREBY CERTIFY TROTHS WELL WAS CONSTRUCTED N ACCORDANCE WTIN
CONSTRUCTION
RECORD HAS BEEN PROVIDER S WELL STANDARDS.
THAT COPY OFTHIS
itAnA
S&NATURE FCERTIFIEDWELL'CONTRACTOR DATE'
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit in 30
1617 MaihServicge C nter- Raleigh, NC 2 699 16117 inal to te Division of VVater Quality
Phone No. (9 9) 7Information Mgt.,
33 5 ext 68.
Form GIN -la
Rev. 7/05

FEBr ,, 2r)rl"
�� - rt,L!
RESIDENTIAL WELL CONSTRUCTIONRECORD
North Camlina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATIONS 21 38
336732
1. WELL CONTRACTOR:
James W. Camp
Well Contractor .(Individual) Name
Camp's Well & Pump Co, Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
Zip Code
City or Town Stale
( 828)- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID OOf applicable) '
STATE WELL PERMIT1t(8 applicable)
DWQ or OTHER PERMIT fr(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED ' a 5 • 0 1
TIME COMPLETED 4 14C
3. WELL LOCATION: (1�
CITY: l rl (Q f ) �fv� COUNTY at 41 (R.) gy
4 \5 wJ
(Street Name, umbers, CcmmunIty�SubdMabn .lot No., Parcel;.2ip Code) _
TOPOGRAPHIC / LAND SETTING:
tgerra OVaBey ❑Flat ❑Ridge El Other
(cheer appmpdatebox)
LATITUDE 35 . L` 9 „g
LONGITUDE,. _ 5 2 o 5 L
Latitude/longitude source: W PS ❑Topographic map
(location of we/ be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADD ESS
e�
May be In degrees,
minutes, seconds or
in a decimal format
AM PMW
AAJ c13 O
,gg 2-I ly le{ grace.
StateN C •Zip 8i31
City orTwm
Code
Area code - Phone number
5. WELL DETAILS: G
a. TOTAL DEPTH: s- 0
b. DOES WELL REPLACE EXISTING WELL?`YES ID NO TyBS
e. WATER LEVEL W Tap d Casing: L\ D FT,
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top d casing terminated at/or below land surface may require
a valiance in accordance with 15A NCAG 2C .0118.
e. YIELD (gpm):_ .5 METHOD OF TEST (ILC.A
f. DISINFECTION: Type Chlorine Amount 1 Gap
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From - To
6. CASING: Thickness)
Depth `I Ft
t. 6aaS
lrieterD21 PVC
Weight
From 0 To
From To Ft
From To .Ft.
7. GROUT: Depth
Fran) 0 To 20
From To
From . To
8. SCREEN: Depth
From To
From To
From To
Materiel
Ft Sackrete
Ft
Ft.
Method
Hand
Diameter Slot Size Material
Ft. in. In.
Ft. In. __ in.
Ft. In. In.
9. SAND/GRAVEL PACK:
Depth
From - To______ Ft.
From To Ft.
From To Ft,
10. DRILLING LOG
From To.
.o• 47
Size
Material
pFormeliggDescrip n
w D o 5 s AAA At, x"
11. REMARKS:
RECEIVED
rin/ erWATFROVA I�1rY
;" ,( r) 200I
I DO HEREBY CERTIFY
THAT THIS WWAS ELL
I5A NCAC 20, WWLONSTRUd7OSTANDAAND MAA COPY Ot THIS
-
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
44x,1A W C&m� )a 2.01
A URE OF CERTIFIED W ELL ONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mali Servicge Center- Raleigh, NC 2 699-16117 oriinal to te Division of Water a)lPh ne No. (9 9) 733 7015 ext 568 Non Mgt.,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
336731
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(Individual) Name
Camp's Well & PumD Co. Inc
Well Contractor Company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City or Town ' State Zip Code
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID kb appacable) '
STATE WELL PERMIT#(s applicable)
DWQ or OTHER PERMIT *Of applleable)
WELL USE{Cheek Applicable Box): Residential Water Supply13
DATE DRILLED 5. 6
TIME COMPLETED I ; 30 AM O PM l9--
3. WELL LOCATION: no
CRY: (�� A (C�OUNTY 'Nt C n wj tie
2 v1 �tS„tXwa u,
(Slroal Name, Nu_mbefa. Community, dMdon _Lot No., Pucal';Tlp Code) _
TOPOGRAPHIC / LAND SETTING:
❑Slope Maley °Flatge ❑Other
(check appropriatebox)
LATITUDE 35 �1 110
LONGITUDE. S.2151
Latitude/longitude source: iu6PS °Topographic map
(attached to this form If not using atbn of wel must he shown on PS)GS topo map and
4. WELL OWNER �n
OWNER'S NAME S- ,.1. �9ACX
STREET ADDRESS „.q. I Ty/qv TP YY'0.Le.
Rafiver =0rcfK NC l311
City or Town State Zip Code
May be In degrees,
minutes, seconds or
in a decimal format
Area code Phone number
5. WELL DETAILS: �^1
e. TOTAL DEPTH: 1
b. DOES WELL REPLACE EXISTING WELL? YES p NO li(
1
c. WATER LEVEL Below Top of Casing: `1u FL
(Use '+'If Above Top of Casing)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
'Top al casing terminated at/or below land surface mqy require
a variance In accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): `U METHOD OF TEST 0
T. DISINFECTION: Type Chlorine Amount
g. WATER ZONES (depth):
From To
From To
From To
6. CASING: Thblmess/
Depth it Dianeter W M Material
From 0 To le 3 Ft. 6t SD 21 ' PVC
From To
From To
From To
From To Ft.
From To .Ft.,
7. GROUT: Depth
Materiel Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft
e. SCREEN: Depth Diameter . Slot Slze Material
From To Ft. In. In.
From To __ Ft In. In.
From To Ft In. In.
e. SAND/GRAVEL PACK:
Depth Sim Material
From ' To Ft.
From To Ft.
Fran To Ft.
10. DRIWNG LOG
From To.
0 \5
Formedgg,n Dosed lion
h'F(;Fivro
DIV (IF WATGp !? NJ-
11. REMARKS:
JAN d dl2UU)
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 20. WELL CONSTRUCTION STANDARDS. AND IHATACOPY QETOP •
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Iw Cram )a4t, UL
SI( Jf TORE OF CERTIFIED WELL' ONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the Service inal to the Division of Water all e Center — Rale
igh, h, NC 27699 16117 Phone No. (9 9) 733-7 5 eat 68.tlon Mgt.,
1617 Mall
Form GW1a
Rev. 7/05

337446
WELL CONSTRUCTION RECORD
North Carolina - Department ofBnvuomneot and Nand Resources - Division of Water Quality - Cnnundcrater Section
WELL cot/macron (IIQDIYM IIAIa NAME
C, fl lws zrj c aTmacaTtoNn z 7 8 h�
wEwcONTRAcroa COMPANY NA to yea / wn %ie^ io// i /ZiAvorsoNB s
STATE WELL comma -non rEnaffr# ASSOCJATt®WQ Pirsaur#
(ifapolieable) (ifapolicable)
ilgaitt- ago
1. WELL USE (heck Applicable Box): Residential Ice MnoleipaUpublic ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pun Water lnjection 0 Other 0 If Other, List Use
2. WELL LOCATIOI�j, ` t
Nearest Tower U 6e County Mccio.rrI/
(Sine Name, rx mtm. Cmmohg, Subdivision, Iat No., 73P Code)
3.OWNER PN 0VAo. flntr
Address 94). wa1.k rA (Slum
CM, colt (�tJor RomnNo.)
CdyorTowa Stets rip Code
Arneode• Phone number
4. DATE DRILLED 1-era 0(0
5. TOTAL DEPTH: 3-`15-'
6. DOES WELL REPLACE EXISTING WELL? YES �7 NO er
7. STATIC WATER LEVEL Below Top of(\telt
Top of Casing)
S. TOP OF CASING IS 10 t FT. AbWee ove Land Surfaces
`Tap of casing terarWbd War below land surface requires a
variance b aeeor Me ISA NCAC 2C MIL
9. YIELD (gpm): 1 METHOD OF TEST 1;
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING``::y,
Depth
From LP To Aot
Front To
From__ To
13. GROUT' Depth
From (� To 3O
From To
14. SCREEN: Depth
From (9 To
From To
15. SAND/GRAVEL PACK
From W Tow
From T
TapompbaciLand setting
Oltidge H§lope (Watley (Fiat
Oink appropriate boz)
Latitude/longitude of well location
(assemmtimeasseeeneo
Latitude&longidtde sowce:(GPSO opograp c map
D DRILLING LOG
From To Formation Description
f�H
Ft.Diameter
Fk
Ft
Am000t 10 o r
Wall Thickness
«weight/Ft t twat
SDIt-- i VUL
mama,'lFt. taw c
FL
Diameter Slot Size
Ft in in.
Ft._in in.
01
•
laretinQingiatai
Show direction and dismnce in ndlcs from at least
two State Roads or County Roads. Include the road
members and common road names.
MMethodIJ—bod
et- id
Material
Size Material
o Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS
COON STAND
WAS CONSTRUCTED IN ACCORDANCE WITH I5ANCAC 2C:, WELL
TA COPY0imis RECORD HAS BEEN PRO ED TO THE WELL OWNER.
ifs ttfl
SIGNATURE OF ERSONCONSTRUCTING 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 CONSTRUCt1ON RECORD 337445
Notch Carolina - Dolt ofEnvi on ment and Natural Resources -Division of Water Quality - Groundwater Section
WELL corneecroatnmmvmIAL) NAME�t tw f Io atirristartorre Z 7 $ '!'
WELL CONTRACTOR COMPANY ru .— 'W gee / w/4 l4er (a// 4 a.r.craore s 6Y9- oy$0
STATE WELL CONSTRUCTIONPERMITS ASSOCIATED WQ PRAMUS
(ifappnable)
(1tnlmable)
1. WELL USE (Check Applicable Boat Residential ace MmicipaiPublic 0 Industrial 0 Agciwipaal 0
Monitoring 0 Recovery 0 seat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town' r .A County PA.
It nn or cove )50957-
(saasNanualumaeo. Cammmay, Sehdhe oa. taNw Tip Code)
3. OWNER: P , to L. W r 66
Address IlO
(SwearRouteNaa
Mr~noN act )R175.
City oTown Setae Tip Cade
Area cede- Phase master
4. DATE DRII.LIDD �{- e�- f) L
5. TOTAL D •
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0"
7. STATIC WATER LEVEL Below Top of Casing: it) FT.
/t (Use'tr tfAhoae Top of Cashes)
g. TOP OF CASING IS I)S FT. Above Land Surfaces
*Tap ofcdaatoneaat.d attar below lead new retakes
mien le monlawee with 15ANCAC 2C.01111. I
9. YIELD (gum) (u METHOD OF TEST L me
10. WATER ZONES (depth):
Ta hie/Land setting
ORidge l7Slope 0Vailey LiF1at
(cheek appropriate box)
Latitude/longitude of well location
uhareeemneeme
Latitude/longittde sourca0GPS0Topographic map
(e6edclea)
DIr1H DRILLING LOG
From To FommtionDeacription
11. DISINFECTION; Type C(_ H
12. CASING:
w From 12) To too' Ft fr
Fttrm__To Ft
From__ To Ft
13. �G.ROUT-y Depth Material
rmm_it__To ..)41 Ft En.I<rcl c
From To Ft
Amomt IC o z
Wan Thickness
a WeightiFt Material
VA-1 PUc.
Al_ TY
LOCATION SXETCi[
Show direction and distance in miles from at least
two State Reads or County Roads. Include the road
numbers and common road nay.
Method — '—
i, c t M i t 3 a
14. SCREBj De h Diameter Sloane Material
Fro(� To Frio. M.
From To FtL_in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From W To Ft
From To Ft.
1
v
16. REMARKS:
CERTIFY THAT THIS WELL W C ONSLRUCIED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ON STANDARDS, T ' OF , i .. RECORD HAS BEEN PROM TO THE WELL OWNER
t i ( . ✓ / /li, 6
SRiNA OF P CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Man Service Caner -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. OW-1 REV. 072001

FROM : MORETZ WELL & PUMP
FAX NO. : 7044621322
Feb. 21 2007 08:36AM P3
1. WELL CONTRACTOR:
Ashley T. Moretz
Well Contactor (tndividual)Name
RESIDENTIAL WELL CONSTRUCTION ItECOltu {
North Carolina Depanmon of environment and Natural Resources- Diviswn pf,Watea Quality
WELL CONTRA' CTORCERT1FICAT ON IJ 2586
Moretz Well 1lriIlino
Well Contractor Company Name
STREET ADDRESS 6159 HWY. 10 West
Hickory NC
City oe Town State
7( 04 1. 462-1322
Area code- Phone number
28602
2. WELL INFORMATION:
SITE WELL lO sae apo icable)
STATE WELL PERMIT$@ applicable)
Zip Cone
DWQ or OTHER PERMIT lief applicathe)
WELL USE (Check Applicable Box): Reg ential Water Supply'
DATE DRILLED //-2 )/-1Oi
TIME COM PLETED /rDV • Am PeAt
3. WELL. LOCATII%
CITY; / V th/ o COUNTY r(/
r
(Sveet Name, Numbers. Communey. Sued
TOPOGRAPHIC / LAND SETTING:
°Slope OVallcy ❑Fla( ge OOther
(check appropriatex
bo
LATITUDE >p, S�
LONGITUDE 2 S3: see VI
Latitude/iongitudesource: liscs oTopographicmap
fbcalkm of wet must be shown on a USGS topo map and
attached to this roan d hot using GPS)
4. WELL OWNER
OWNER'S NAME
STREETADDRESS
e-6
City or Town Slab Zip CaCod:
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: S,
b. DOES WELL REPLACE EXISTING WELL? YES O
c. WATER LEVEL Belo*. Top of Casing• Zj p
reef
Lot No., ' arced. Zip Cone)
May Ix L1 degrees.
minute's, seconds or
in a decimal lama'
NOV
(Use -.' fr Above Top or Casing)
d. TOP OF CASING IS FT eve Land Surfaces
-Top of easing terminated alior below land surface may require
a variance in accrvdance with 15A NCAC 2C .0118.
e. YIELD wpm): METHOD OF TEST_
f.
9.
To
o
6. CASING; Thickness/
Dep
FranT0p Toth 7 n l Ft,
From To FL
From To' FL.
T. GROUT: Depth Mele(ial c
From P � FL 2
From To r2!.
FL
From To FL
B. SCREEN:
Fran
Depth Diameter. ''.Slot Size.:: .
From / To,
From To
9. SAND/GRAVEL PACK:
Depth Slip
From To
From
From
M
FL in. in. t�
11. REMARKS:
Formation Description,
EE0
1 DO HERee( C€RM' THAT THIS WER WAS CO.",guCTED M 1.ANCCiC, WELL CONSTPUCTUN STANDMOS. IW01 CecORDnNC6'
RECORD KAS BEEN PROVIOF-0 TOTIIE WELL,OWN N1TeCOPY pgrynis'•
GNATU O CERTIPIED WELL,CORACTO ❑
NTn, . ATE,,
PRINTED I LAME OF PON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699.1617 Phone No. [phone] eat 566.(;
Farm GW4,?,
.. Rev.1/05'p ;R.

North Carolina Department of Environment and Natural ResourcesDivision of Water Quality -Groundwater Section
1636 Mau Service Center - Ralelgh,N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
+, a r
d<=1Mil
cj ArL..jAKq
WELL CONTRACTOR CERTIFICATION # : SO if 4
STATE WELL CONSTRUCTION PERMIT #
✓TELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ LI Recovery (� Heat Pump Water Injection ri Other If Other, List Use: g Monitoring (.J
OCATION (. how sketch of the location oelow)
^rarest town ) �, County
styli Phtsr b vc L-eT j 2/
r-rind Name a/n�ad, Numbers Community, or Subdivision and Lot No.) DRILLING LOG 01NNER I n wELC Gwc vQ DEPTH
'ants e A Our fr-4 OW From To Formation Description
�o « (Stree or Roue No I
_ 97 fJ+✓To.y /✓. C-- Qtr.
'h. or town State Z_io Code
TF 7RII_LED ��" / L
�IFPTH G
TINGS COLLECTEC YES ri NO(J
wELI REPLACE EXISTING WELL? YES NO 7C
'- WATER LEVEL Below Top of Casing FT.
,, (Use " " if above Fop of Casing)
E TOP OF CASING IS 1-Z FT Above Land Surface'
' or of casng terminated atfor below land surface requires a variance in accor-
lnncr ,Anth 15A NCAC 2G-0i IR
c,I -' /GPMI- METHOD OF TEST ILE#
TFR ZONES (denthl
DRLNATION: Type
-,ASI N• G.
'Cn1 iT
,9%{/
�� Depth Diameter
To 9Y) Ft. li
r- rt
10 at
D:1 C P II
Depth Diameter Slot_Size Material
'mm To Ft in.
in
c -om ___ To Ft in
°•rim To Ft in
in
;,nnIDIGRAVEL PACK -
Depth Size Material
To Ft
To Ft
AI CI O e eve, L'—
Amount !-. h
If additio nai space is needed use back of form
Wall Thickness
or Weight/Ft Material
2i•PAPsT•C_ LOCATION SKETCH
(Showdirection and distance from at least two State
Roads, or other man reference cointe!
Depth Material Method
o Ft
FI
- 4FMARKS
RECEIVED
ON. OF WATER QUALITY
FEB 2 u Mg
n0 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
'OR OFFICE USE ONLY
Quad No.
Serial No.
ant i'/4 , ttn-.-,._ A2 - 21- v [:
SI�NA RE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section wuhin 30 days DATE
GW I RFV ';'nr,

From: Scott Gantt 7044347212 To: Stephenie Wilson
Date: 2/8/2007 Time: 11:10:36 PM Page 1 of 4
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Well Contractor Certification # 2584
1. WELL CONTRACTOR:
ALAN SCOTT GANTT
Well Contractor (Individual) Name
CAROLINA WELL DRILLERS, INC.
Well Contractor Company Name
STREET ADDRESS: 522 GANTT S GROVE CHURCH RD
MOORESBORO, NC 28114
[phone]
Area code — Phone number
2. WELL INFORMATION
SITE WELL ID #(IF APPLIACBLE)
STATE WELL PERMIT # OF APPLICABLE)
DWQ or OTHER PERMIT # (IF APPLICALBE)
WELL USE (Check Applicable Box)
DATE DRILLED 12/16/06
TIME COMPLETED 12:40 AM ❑ PM Ei
3. WELL LOCATION:
Residential Water Supply p
CITY: MAARION COUNTY: MCDOWELI,
FAIRVEIW RD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
Latitude/Longitude Source: ❑ GPS ❑ Topographic map
LATITUDE 35.40.453
LONGITUDE 81.56.381
(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 DANNY FRISBEE
STREET ADDRESS FAIRVIEW
MARION NC 28752
City or Town State Zip Code
828-442-5518
Area code — Phone number
5. WELL DETAILS:
A. TOTAL DEPTH: 200
B. DOES WELL REPLACE EXIS ION WELL? YES ❑ NO El
C. WATER LEVEL Below Top of Casing: 42 FT
D. TOP OF CASING IS 2 FT Above Land Surface*
*Top of casing terminated allor below land surface may require
a variance in accordance with I5NCAC 2C .0118.
E. YIELD (gnu): 7 METHOD OF TEST ARDM
2
f.DISINFECTION: TypeHFPOCHLORITEAmt:8OZ
g. WATER ZONES ( depth)
From 182 To 182 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From + 2 To 62 Ft. 6 1/8 SDR21 PVC
From
To Ft.
From To Ft. _
7. GROUT: Depth Material Method
From 0 To 2 Ft. GRAVEL MIN GRAVITY
From 2 To 20 Ft EASY SEAL GRAVITY
From To Ft
8. SCREEN: Depth Diameter
From To Ft.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth Size Material
Slot Size Material
in in
in in
in in
From To
From To
From To
10. DRILLING LOG
From
0
57
To
57
200
11. REMARKS:
Ft
Ft
Ft
Formation
CLAY
CONSOLIDATED ROCK
RECEIVED
DIV. OF WATER QUAIL
FEB 0 9 2007
1 DO EIEFEEY CERTIFY THAT THIS WELL WAS CONSTRUCTED Dr ACOFDANcE WITH 15
NCAC 2c WELL CONSTRUCTSS STANDARDS, AND THAT ACOPY OF THIS RECORDH.AS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTRIED WELL CONTRACTOR DATE 1/1/07
ALAN S. GANTT
PRINTED NAME OF PERSON CONSTURCTING THE WELL
TY
Submit the original to the Division of Water Quality within 30 clays. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617
Form GW-la
Rev. 7/05

.-OJ4LUC,
rout as
teens Greene
°ij met tonecenet N.nn genuses' Minn a Wen Quoit/ . a.e.mwr« Sennui soma cos. Ns NC. 2Taoa/s3a-Rlwr. (gin 7337221
WELL CONSTRUCTION RECORD WELL CONTRACTOR .f� %e��--r 7,A ice. "17
WELL CONTRACTOR CUPTIFICATION is „I / "S
!PATS WELL CONSTRUCTION PERIM,
337731
1. WELL US !Son Appeals Ss*Rs.IdrmWDMuNelpai ❑ Indusdid ❑
Recess, la Best Pump War hjselbn 0 Ober p It Otis, Us Use:
2. WELL LOCATION: (Show okabh of he baton buow)
Nwaos Tine A h / .r) caw M G zinai ev/ cu
Aggiedu al O MoNbebq ❑
ism les sewn
3. OWNER CA, G -1/7
Add,
`lc,
cf,
W tal N•-)
Cie arlea are
4. DATE ORILLET `=
5. TOTAL DEPTH o T,
a. CVTTIFp3COLLECTED YES NO
Er DOES WE LL REPLACE EXIST1�'`
W EtaT YES Q NO
S. STATIC WATER LEVEL Osloe Tap of Casing: 0 FT.
N..es' IMine T..eCaw*
kg*
0. TOP OF CASINO 1S / `6 de FT. Above Land Swla it
"In M one Mnn.ol.d.WrInns Mel 4wless'-r- esvegans Minn
dense err I.A'CAO mane
ID. YIELD (Spmk MnHOD OF TEST /f,r °L
11. WATER ZONES (dept.: 1O % tr
7j CHLORIN/Malt Typo Anounllnlm,
13. CASINO: 6 se
ws we'..s
Ogigh a Oi nnla tWitinFt rw�r
/To FL 4, ! ls i1-
Fran---
Fen To_ _ FL
14. GROOT:
Cloth r Malodor Method
From 4.4. To .9 . f�' z. A r{/
Form __To FL
15. SCREEN
Dept Materiel
Front To
From To
From To F1.
11. SANOIURAV4EL PACK
Dept
From —_ Ts_
From To
17. REMARKS:
o1
DRILUNO 100
F,aa Ti
DEPTH
Fnasm 04anyam
n sddrlerrl epoos a rrtlsd uals b.aw lvm
Dlsnlsar Sol iil1S
Ft in. In.
FL In In.
h. JAN 31 ?DO?
LCJCAYIDN SNEZCIS
(Sow Wreaks and drama bum Ober I.. SI M
Rooda.arOINF _._I psYib!
Etc. Materiel
R.
FL
_red
RCC//++ iv
EIV
flu. OF WATER ; , AMITY
I Do Knew CERTWY THATTIOS WELL WAS CONSTRUCTED 04 ACCORDANCE WITH ISA NCACIC. WELL
CONSTRUCTOR $TANOANDS, AND THAT *COPY OF THIS RECORD N*S SEEM PROVIDED 10TRE WELL ComER
C i.e. // r B 4 . GCC7
FOR OFFICE USE ONLY
Owen*
WI Ne.
11115MANSiOF FiPION COMS11WCIM6 mal WELL WTI
816n11.40WW O SmW WSW QsooROa.rd+rr is WWII39 rays
Ott MY.1211
-24-20E13 10N 11: 31P1M I D:
PAGE:1

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
337527
1. WELL CONTRACTOR:
C/3C.ybSUSfc
Well ontract (Individual) Name
30Sfi Cu: Ue-1—C_ ‘>riC-L; Pei
Well Contractor Company Name 'r
STREET ADDRESS 3 S Q c l7 S tiC,L%Y7 CS}
IMi t/iY' t O fJ V‘i 2S7S7-
7r7City or Town State Zip Code
( �E [O } 72.9-Q1 9 yd
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(B applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED /0 --/ Z-c x0
TIME COMPLETED /7.Jr 0 AM 0 PM ID
3. WELL LOCATION:
CITY: /,4/1 4 /'I C7).t1 COUNTY 144 S Dour' LC-
0 C_. 0 Li,uu. CLC 2d 2 b?$t
(Street Name, Numbers, Community, Subchision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT
Slope °Valry ❑Flat 2Pidge pother
(check appropriate box)
LATITUDE .. 5j'O t,o
LONGITUDE O S/° 5— I?
Latitude/longitude source: PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form snot using GPS)
O. WELL OWNER _ /
OWNER'S NAME / o 114 Jiil'[f )nreta5
STREET ADDRESS (:d r�i' it(ttT'� A qqvCi v cs s t=• r C
`; I IS i; i P(.S(ryV. .tJi4
City or Town 2 State ` Zip Code
(`,9& )- %%1 �R 3C
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: cam.
a. TOTAL DEPTH: 01 S P
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LT
c. WATER LEVEL Below Top of Casing: 8 d FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top el casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): /Jr METHOD OF TEST
f. DISINFECTION: Type d LO/ZliUC Amount el O Z
g. WATER ZONES (depth):
From To From To
From ISO To /85' From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To Ft.
From 0 To 133 EtTi,,TR 410 eve.
Frani33 To 1'73 Ft. 6YS PyC p -
7. GROUT: Depth Material
From To Ft.
From -J To i73 Ft f4¢42/
From To Ft. /
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth - Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
o- 1(90 D,a FCpsE12vcLc_
160-2ZS _r(l�/ue Y7S,t12
11. REMARKS:
NtGEIVED
Uiv. C)F vuAitrruuALITy
JAN 2 6 200?
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
iSA N 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECOR HAS�BEEN PROVIDED TO THE WELL OWNER
<112-6
S t�A /O URECEI�ED WE CONTRACTOR DATE
A M U3'7 u '-Iv
PRIN NAME OF P RSON 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 # 2) 50
331''S?6
1. WELL CONTRACTOR:
A2Y c:E
Well Contractor (4dividual) Name
>1.3s4-ic; W PLL b triLea tuq
Well Contractor Company Name
STREET ADDRESS 3 Qt4 5 US 70 (A
uotooN lit° 237.5
City or Tam Zip Coda
(82e 1.723/4-45q&
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID 6(Bapgicable)
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PERMIT#(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED /2 (I S (t
TIME COMPLETED
3. WELL LOCATION:
AM PM
CITY: °'Q Ford' COUNTY nAsAwed,
G' slew t�P Lo l- 717- (a
(Street Name, Numbers, unky. Subeiedoe Lot No., Paces, Zap Code)
TOPOGRAPHIC / LAND SETTING:
13341ape °Vasey ❑FFdt ❑Ridge ['Other
(check teepro date box)
LATITUDE y3e?2 e`73N
LONGITUDE 2. /0 a '73
Latitude/longitude source: °GPS °Topographic map
(laatian of net must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER
OWNER'S NAME$Imt IMRIc AKe2S
STREET ADDRESS Vi - 9 tr..; rkt
City or Tatar Stage) Zip Code
Area code - Phone number
IMay be in degrees,
minutes, sends or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: /otoI
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing
(Use '+• #Above Top d Casing)
d. TOP OF CASING IS � FT. Above Land Surface•
'Top d casing terminated at/or below lad surface may require
a variance in accordancewih 15A NCAC 2C.0118.
e. YIELD (gpm)' METHOD OF TEST
NO 17
FT.
f. DISINFECTION: Type CL4144t Amount
g. WATER ZONES (depth):
From To
From To
Fran To
6. CASING:
goZ
From To
From To
From To
Depth Diameter
Fran To Ft
From 0 To 7(p
Fran 76 To 7Q FL Oil/
7. GROUT: Depth
Material
Thickness/
Weight Material
/29
From To Ft
Ran P5 To_go Ft Q%
Ram To FL
Method
/1UNri
8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft In. in.
From To FL in. bL
Fran To FL in. in.
9. SAND/GRAVEL PACK:
Depth
Fran To Ft.
Ran To Ft.
From To FL
Sae Material
10. DRILLING LOG
From To Formation Description
0- 7o {j j {_
11. REMARKS:
RECEIVED
DIV OF WAItHQUALITY
JAN 2 C 2007
100 HEREBY CERTIFY TNT INS W91 WASCONStfUC7® el ACCORDANCE WITH
15A ra'erar WELL CONSTRUCTION.STANDARDS. ANDONTA COPY OF MS
RECORD BEEN PRODDED TOTIE WELL OWNER'
li /S/06
SIGNA ARE QF t E'RTIFl® WELL CONTRACTOR - DATE
aT4Ef NAMEOS «`R'--
P OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev 7I05

337529
WELL CONSTRUCTION RECORD
North carotin - Department of Envitotunent and Natural Resources- Division of Water Quality - Groundwater Section
tV ELL CONTRACTOR (INDIVIDUAL) NAME (print/) r y IL ({�L , be CERTIFICATION Sa((,J/y�J
WELL CONTRACTOR COMPANY NAME -So S7t. GQ kk // Dr:ll Tel PHONE s Mk) 7%y- 7J lie
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMRn
(if icable) _ (ifapplicabfe)
WELL USE (Check Applicable Box) Residential S ivlunicipal/Pubiic 0 industrial 0 Aeficulturai 0
Monitoring 0 Recovery O Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATION: ,nAA
Nearest Town: l)lar,'Del County /rI Cf0+t 1 /7
gttg? ifS22.1Yv
(Street Nano. Numbers. Community. Subdivision. lnaNu. Zip Code)
3. OWNER: blue R.. c(�C,e S'ha.t/4. Q (maul
Address ¢?tf 9'1 V S'Lett to
t)'1 i/.0u (Seta 1u Cam)
City of Town State at Code
(ti.M) )- 7,5-1tr-'I(o5I
Area code- Phone number
4. DATE DRILLED /0- 7-0'
5. TOTAL DEPTH: / —/
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO t3
7. STATIC WATER LEVEL Below Top of Casing 'lr:, FT.
curt a ifAbermTopofCasinst
2. TOP OF CASING IS 1 FT. Above Land Suffices
'lap of casing terminated after belsw had surface rennin a
variance is accordance with 15A NCAC 2C.ollt
9. YIELD (gpm): Go METHOD OF TEST AI (
I O. WATER ZONES (depth): b es'.z. / / <, ...
I 1 _ DISINFECTION: Type
1? CASING:
From d To i/[r,
From To
From To
13. GROUT: Depth
From C1 To
From To Ft.
From To
14. SCREEN: Depth Diameter
From To FL in.
\ *
From To FL in.
15. SAND/GRAVEL PACK:
Depth Size Material
Ft.
From To Ft.
Cinr int Amount Qu cy
Wall Thickness
Diameter or Weight/Ft. Material
FL/ ®' SCAYe) .5r eJ
Ft.
16. REMARKS:
Ft.
Material
FL .0
Me
Pt)m
Slot Size Material
in.
in.
z
1424 erf
Topographic/Land setting
ORidge OS ope lai alley ['Flat
(check appropriate box)
C Latitude/longitude of well location
35 y7.s N o2.2.a 07.242v.!
(thweestmlaucesiseconda
Latitude/tongitude source PSOTopographic map
(check boa)
DEPTH DRILLING LOG
From To Formation Description
o-'2,Sesr f/�
- ,S Gi2Aiee e
/49 - /50 ea," CSt. .d
LOCATION SK CH
Show direction and distance in miles from at least ✓-et-k
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
DIV. OF WATER DUALITY
JA fi 2007
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OFTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
9-26`OG
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit tite 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 # r:/ / SU
1. WELL CONTRACTOR:
Gc v auaSu57;rP.
Well Cufu(Individual) Name
liare. tai/ Dr. llu ri 5
ea Contractor Company Name
STREET ADDRESS 33y5 U$ 70 LJQSi
r;on N.C. ST757
City a Tam State
(9tg )-M711-1511
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID #II applicable)
Zip Code
337535
STATE WELL PERMITSWapparable)
DWQ or OTHER PERMITMW app8ualrte)
WELL USE (Check Apphc to Bag: Residential Water Supply e7
DATE DRILLED tope/ o co
TIME COMPLETED /2 ;oa AMID PM I31-•-
3. WELL LOCATION:
CITY: NI cr.Orl
COUNTY ill enOWe- /I
e Opt.. Pato 4.. F/ skis`/
(Street Name, Numbers. Cononmrfy. Sobditla1 WING- Parcel.Z4 Coda)
TOPOGRAPHIC! LAND SETTING:
DSlape OVafey OFl L DOOR
(check app prpra bad
LATITUDE
LONGRLDE_
Latitude/longitude source: OOPS DTopographic map
(fonaaon of waif must be shown on a USGS typo map and
a#ached to this front not using GPS)
4. WELL OW7IER
May be in degxves,
minutes, seconds or
in a decimal best
OWNERS NAME Al , rue, Eft 2 4 (l - bu LOADS
STREET ADDRESS
City or Town )State r.
6. WELL DETAILS: //�1
TOTAL DEPTH: 2 Tb S
C as15114
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO le
c. WATER LEVEL BelowTop of Casing: 40
(tlse'+' I Above Top of Casing)
d. TOP OF CASING IS ) FT. Above Land Surface'
'Top of casing terminated attor below land surface may require
a variance n accordancewrit; 15A NCAC 2C .0118.
e. YIELD (gpm): /a_ METHOD OF TEST /T(/ `-
lT.
f. DISINFECTION: Type CIO r%fQ Amount gn7
g. WATER ZONES (depth):
Fran /$C7 To Zoo From To
From To From To
Franz dO To £ 40 From To
6. CASING: �}�?tar Thickness/
O
From f) ToO/OS FL en /q ip Weight l/.
From)05 To)07 Ft(6Yq ./Qg CAIV
From To Ft.
7. G pMaterialMaterialp�
From
an To To.2G Ft c
.2
Fmm To FL
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From To Ft in. _ in.
From To FL in.
From To FI. in,
9. SAND/GRAVEL PACK:
Depth ' Size
From To Ft
From To FL
From To FL
al
irk.
Material
10. DRILLING LOG
From To Formation Desvrytion
O- 97 DiIL/ - Roca-
97 - 2 AS ly eNN:Z¢�
11. REMARKS:
RECEIVFD
DIV. OF WATER MUAI 1TY
JAN 2 6
WO HEREBY CERIWY THATLa3 WELL WAS Ca1SmUCrED NACCORDANCE WITH
NSA NCAC 2C. WELL CEN51RUCanN STANDARDS.
1NATA COPY OF mis
RECORD HAS BEEN PROJpE0 TO THE yVELLLOWNER.
SIGNATUREIOFC IFIED WELL CONTRACTOR eE
tF
PRIED tVF .t OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
NC 27000-1101 i Piar Ha_ pig) 733-7001S exit 568.
Fain GW-ta
Rev. 7/05

-y(6v5ED
WELL CONSTRUCTION RECORD
From-7 9
From To
13. GROUT: Depth
From C To 9,6
e. 4
North Carolina - Department or Environment and Naturalt" e
Dept Resources -Division or Water Quality - Cirouttdwater Section
WELL CONTRACTOR (INDlVIDUAL) NAME (prtat) L+ rrr/ �1 US-J.l P CERTIFICATION la/,5/n v WELL CONTRACTOR COMPANY NAME < S / . f P G )`// Dr: 111,99 PHONE a �2`3) ]J41.' o sip
STATE WELL CONSTRUCTION PERMIT# ASSOCtaTED WO PERMITT
cablel (if livable)
1. WELL USE (Check Applicable Box}: Residential M"Municipalritublic 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: hI F bn Co,nttyn� ("Data, /
nsr fnP Forest D rYe f774(
(Street Name. Numbers. Community. Subdivision. tat No.. 2p Cade)
3. OWNER: CT g. F'J 7) AM C op s l a.
Address ( a tl (a in JV y RA
(Street or Route No.) /
>v1vf:ett � ZR75Z
City or Town State Tap Code
Alt! code- Phone
4. DATE DRILLED lumbar, I4 -a 63
5. TOTAL DEPTH:.2 4 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0"
7. STATIC WATER LEVEL Below Top of Casing go FT.
(Uw �a�ifAkanTopofcacio
8. TOP OF CASING IS 1 FT_ Above Land Surfacer
*Top arcsiag IermSated utter hew laad sarface requires a
variance is accordance with ISA NCAC 2CAII8
9. YIELD (gpm): / 2 METHOD OF TEST A ' r/S
In. WATER ZONES (depth): /L 9�Ot., (� 2%)
•
II. DISINFECTION: Type tint-, op_ Amount S(o7
12. CASING:
Depth Diameter
From O To 7 k Ft /nM/
To VC FL /,. /5[
FL
Material
FL .2f%
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Wall Thickness
or Weight/FL 1/6 �M
IRN GAL('
FL
Diameter
Ft. in.
FL in.
Slot Size
in.
in,
Method
i�lar,re
Size Material
Ft.
FL
Material
(
TopogI�p hic/Land setting
ORidge filtlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
_35' 39 3276/ C}Asl° g5 (26,I W
(desreesininutnisecondst
Latitude/longitude source:0GPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 - 7o lJi��
'TD— 74' /osEPocjc
7.44 2FSS (7,Awe f--t?
LOCATION SKETCH
Show direction and distance in miles from at least
two State. Roads or County Roads. Include the road
numbers and common toad names.
p
RECEIVED
F WATER QUALITY
ZOO
4.
s
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI4 I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
is -0 (to
SIGNATURE OFPERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Sectiion,1636 Mail Se nice Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
ZZ6

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ° WS°
337533
1. WELL CONTRACTOR:
el -
Well Gorltractor (kidMdual) Name
So$3ica f. ttL-(rr1Cinlq
Well Contractor Company Name
STREET ADDRESS 38EIS us i/wv 713 WY$T
MarOrJ IN t Z8152-
City or Town State Zip Code
(e28 )- 1-9- fl90
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID *orapplicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED ro —/ 7- 06
TIME COMPLETED /J oo AM PMp�
3. WELL LOCATION:
CITY: /Ve60
COUNTY 114 5136/WG(L
aei, f GviASo4L riC1ers, Dr
(5 e. Numbers. Community. sion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Pt -cm °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE _3_ Lc) 35' 3 (0 la
LONGITUDE 0 t1m 5r5 (7 `tf
May be in degrees,
minutes, secondsor
in a decimal format
Latitude/longitude source: t ❑Topographic map
(location of we? must be shown on a USGS fopo map and
attached to this form dnot using GPS)
4. WELL OWNER "
OWNER'S NAME C7a6l 6Atli s
STREET ADDRESS a c r utied
Mat 6I/ m e 7Sz
City or Town State Zip Code
(828 )- GS5 —Z68S
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH: 3 </S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO g
c. WATER LEVEL Below Top of Casing: 50 FT.
(Use 'e if Above Top d Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): S ° METHOD OF TEST xtoe
f. DISINFECTION: Type C CO/2/tit Amount f?O Z
g. WATER ZONES (depth).
From /00 To /Z.O From To
From To From To
From /s To ? A O From To
6. CASING:
Depth
From To Ft
Thickness/
Diameter Weight Material
From 0 To iSZ. Ft. C/O t/ G
From @Z To 8<-1 Ft. !p N /ge GA/✓
7. GROUT: Depth Material
Fran To Ft.
Fran tO To </0 Ft. T-lpe, Oarn,oe!
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
Fran To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth - Size Material
From To Ft.
From To Ft.
Method
From To Ft.
10. DRILLING LOG
From To Formation Description
0- 55 CreAA7i fc
11. REMARKS:
C.7v44N/
HI CEIVED
JTflV flF WATER Cat IAUT'
iAN 2 c ZOO
1 DO HEREBY CERTIFY THAT TISIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C WELL CONSTRLICODN STANDARDS, AND THAT A COPY OF THIS
REC. - ot. BEEN PROVIDED TO TIE WELL OWNER.
GNAT EKED WELL CONTRACTOR /O DATE-06
GA/4E SIS,S kc
PRINT D NAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Cont(Individual)L ractor Name
�VJ-tt lit' L)e-LC U(I IL; Al et
Well Contractor Company Name
STREET ADDRESS 3 `T / 4) C 7 0
oil 4noft'
t 1375 -
City or Town State Zip Code
(62S' - 72q'-41S-ti
Area code- Phone number
Z. WELL INFORMATION:
SITE WELL ID */ applicable)
STATE WELL PERMR#(dapplicabw)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply @�
DATE DRILLED /1- 2/'cGo
TIME COMPLETED /2 : 00 i9 err AMID/ PM ❑
3. WELL LOCATION:
CITY: /}LA For)('
COUNTY /115 Wwe'LL
M'kwfv? Lg 6JC--41 North.'
(Street rie. Numbers, Community, Sion, Lot No., Parcel, Zip e)
TOPOGRAPHIC / LAND SETTING:
y °Slope oVally ❑Flat idge ❑Other
U 7 3 7 (check N,propdate box)
LATITUDE 3 , 32, 90,t/
LONGITUDE 6 re° /O65-t4i
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Lg6PS °Topographic map
(location of we/ must be shown on a USGS topes map and
attached to this form d not trig GPS)
4. WELL OWNER
OWNER'S NAME Qom//, "Q%K-&
STREET ADDRES
oiAle
—
City ovm State
(Gz/5 >- 8—Exfc
Area code - Phone number
Zip Code
5. WELL. DETAILS: n r-
a. TOTAL DEPTH: C'
b. DOES WELL REPLACE EXISTING WELL? YES //NO L
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' it Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance it accordance with 15A NCAC 2C .0118. �t
e. YIELD (gpm): / METHOD OF TEST IS/ 1 /r7 h:
021 o
337532
f. DISINFECTION: Type e=LVCit(i P Amount 8 o2_ 74
g. WATER ZONES (depth):
From /C1C) To ZOO From To
From To From To
From 794.7 To 79/0 From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To Ft
From a To 7/ Ft.-'�--. S_
From To '7�3 Ft. / �1 r-n¢///
7. GROUT: Depth
From To Ft.
From Q To 20 Ft i/s*.C>/
From To Ft.
Material
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Rom To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth .
From To
From
From
Size Material
Ft.
To Ft.
To FL
10. DRILLING LOG
From To
r1'2 - a7
ee- /p4/
64'- 8 o5
11. REMARKS:
Formation Description
aez).:rr —aoris
q corff
REF:FIVEV
DR' OF t»»ATrp L111A1 11 Y
TAN 2 6 Loo7
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 . SEEN PROVIDED TO THE WELL OWNER
SIGN +. RE RE OF ERTIFI WELL
CONTRACTOR DATE
OAR/ c
PRINTED NAME O: PE ON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

CZ/Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE a. j' -33. 07N
LONGITUDE 05 kJ
Latitude/longitude source: Ie6PS ['Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form snot usrrg GPS)
4. WELL OWNER Ai
OWNER'S NAME Akin£ t4#k eet.c-1 µc+ ?h
STREET ADDRESS `10/ _(a.hhV./;t Y9e 2A st-�
e-Pal CY1 P L_ 3 % AD -
City or Town State Zip Code
(eZ8 )_ 192— dy4q -
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: �©
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Pi
c. WATER LEVEL Below Top of Casing: /..:1Q 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.L1
e. YIELD (gpm): 1 METHOD OF TEST4 / tt
a,rl /44ff; tt
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 ISo
1. WELL CONTRACTOR:
G , Sus 7ti'c-c.
W ell C tractor ' ( Ind
ivdual) Name
Su4I;rn_ kit rr Dr;
Well Contractor Company Name
STREET ADDRESS 3 S(yrj (J,5
0/1 4 (-,'o n IV. 0 .
City or Town State Zip Code
(5(28 )-7. f-'{Sgg
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
�4
70 .)
al752
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE (Check Applicable Box):!� Residential Water Supply ❑
DATE DRILLED %/-;g-Q(0
TIME COMPLETED ) 2 • oo
3. WELL LOCATION:
CITY: CL6 tat, -
Corner of mi'i-n
(Street Name. Numbers
AM ❑ PM I2(
COUNTY Fa
middy, Su ipn ��«« ddo.. Parcel. ' Codej tl1
TOPOGRAPHIC/ LAND SETTING: ew.. 4 \'}� -Deve\ D 0. DRILLING LOG
From To
T. DISINFECTION: Type P/n„ne._
g. WATER ZONES (depth):
From 440 To jp9 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter WNyyhl Material
From (1 To )2/ Ft. �s/ 1�O PVC
Fromj 31 To./7 / Ft! VP ?'ni PpC
Frorn)7/ Tol7Ft. /.%9 .125 (:Alb
7. GROUT: Depth Material Method
From 0To:2O Ft. Type__f Pu#vipelY
Fran To 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.
33P
Amount 9" L Z
9. SAND/GRAVEL PACK:
Depth ' Size Material
From To Ft.
May be in degrees,
minutes, seconds or
in a decimal format
From To Ft.
From To Ft.
Formation Description
542
o• Rao xecic
//no- z D} CTPe4W/r
11. REMARKS:
not/ Olz IPoIATFR °LIAO `t..
IAN 2 e 200?
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED el ACCORDANCE WRH
ISA 2C. WELL CONS1RUCTION STANDAyR2DS, AND THAT A COPY OF THIS
REC HAS BEEN PROVI9EB10 THE WE OWNER
1' lyde
SIGNATURE OF C RT WELL CONTRACTOR DATE
Gray So(er
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

fktcb
Ik('tu 1j 4ti) C
City or Town State
(Sae)- 1Ly-�ts4Q
Area code- Phone number
2 WELL INFORMATION:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
�f)2N D. SoS4; cc
Well Contractor (Individual) Name
—CUf1 �'- WCL( �trr LC(sc: e/
Well Contractor Company Name
STREET ADDRESS -' 4 5 LI S g W `f' '1 (-3z f)C —
Zip Code
SITE WELL ID 8(ir applicable)
STATE WELL PERMIT#(8 applicable)
DWQ or OTHER PERMIT#(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED // - w - 0 c+
TIME COMPLETED /2 u AM0--PM 0
3. WELL LOCATION:
CITY: ®Lb (c)r4- //��CO'�UNTY /'1 t dC'L+.'TXf`
4LA7t.4e- 2LL;M'R.L 4ot09
(Street Name. Numbers, Canmunity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑FW ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 J ? S /) /U
LONGITUDE Z__u j y. �d 9
Latitude/longitude source: DGES ❑Topographic map
(location of we/ must be shown on a USGS lops map and
attached to this form dnot using GPS)
4. WELL OWNER n--
OWNER'S NAME /Gel (jet ( "A/ hie Igire
STREET ADDRESS gSex 0 SeAUahtt Gs'/;4i4
De t, a,- e&, ►C 33 VQk
City or Twin State Zip Code
(54/ )- dig/- 2.4f
Area code . Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 9 O
b. DOES WELL REPLACE EXISTING WELL?
e. WATER LEVEL Below Top of Casing:
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated affor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.11n
e. YIELD (gpm): METHOD OF TEST 6 L L.0
May be'n degrees,
minutes, seconds or
in a decimal format
YES ❑ NO l7
FT.
f. DISINFECTION: Type etor. pe Amount
$62_
g. WATER ZONES (depth):
From To Fran To
From To From To
From To From To
6. CASING:
Depth Diameter
From To FL
From 0 To 8 j Ft
From LC To 7 Ft
7. GROUT: Depth Material
From To Ft.
From CO To j o Ft
From To Ft.
Thickness/
Weight Material
I & C de
ere
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth - Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
rh •- 5O h i tt ?'
44/
11. REMARKS:
or WATOi? QUALITY
•
I.AN `'A $ int
I DO HE BY CERTIFY THAT TOO WELL WAS CONSTRUCTED N ACCORDANCE WITH
• 2C. WELL CONSTUCR(NI STANDARDS. AND THAT A COPY OF THIS
SEEN FROV®EDTO THE WELL OWNER
GN — RE 0 C FIED WELL CONTRACTOR DATE
PRI TED NA E OF PERSON CONSTRUCTING THEW WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

337539"
WELL CONSTRUCTION RECORD
Norm Carolina - Department of Environment and Natural Resources -
Division of Water Quality - Groundwater Section
WELL. CONTRACTOR (INDIVIDUAL) NAME (Fiat)Ger y (t s �-; CP CERTIFICATION*% ISU
w ELL CONTRACTOR COMPANY NAME S 0 .5 # (Z W i I i 1)
STATE WELL CONSTRUCTION PERMIT* A_SSOCIA7'ED WQ PERMIT*
„Cif ap Itcable _ _ K 4 ffapplicable)
PHONE C (92I) 724 45 13
1. WELL USE (Check Applicable Box) Residential te Municipat/Public ❑ industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 111 c r ton County /'VI Tr, [a (1
52D Al Wen Se/' '.,vy5 »r
(Street Name Numbers, Community. Submassim. Lot)to., Zip Code)
3.OWNER' 1(L`%Lk. E 1�FSA�t&L I{/2Kfratra144G
•
Address 3':,o Hid el P J Ste; Nos gn
(Street or Rome No.)
jNA> <'nit eve z $4-1 z
City or Town State Tweak c
)- 9/4Z--IA$f,) — c/4Ly0Yfs
Area code- Plane Bomber
4. DATE DRILLED /O -/I -O G
5. TOTAL DEPTH: i/a -S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO M
7, STATIC WATER LEVEL Below Top of Casing: 6 O FT.
Noce `1 ifAbnwTgofCasio&
8. TOP OF CASING IS ) FT. Above Land Surface*
`Top of costae tenanted actor below land surface requires a
variance is accordance with ISA NCAC 2C .0118
9. YIELD (gpm): ? METHOD OF TEST fit
10. WATER ZONES (depth). ) 9 wm LY 3 el 5
•
11. DISINFECTION. Type Clor;nt
12. CASING:
Depib
Front C1 To9U
Diameter
Ft. & '74
From To FL
From To FL
13. GROUT: Depth
From 0 To50 FL
Amount 7(c
Wall Thickness
or Weight/FL Material
c fo PV(
From To FL
14. SCREEN: Depth Diameter
From To Ft in.
Front__ To FL in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
Me
pvmyt
Slot Size Material
in.
in.
Material
From To Ft.
16. REMARKS:
I DO HEREBY CERTI -Y l� AT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION ST ARDS, AND THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Topographic/Land setting
❑Ridge I Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
35` 5/-.27Y N 08/4 57. 027.3
(de /rniowes(sxomFs)
Latitude/longitude source:OGPS❑Topographic map
(check box)
DEPTH. DRILLING LOG
From To Formation Description
nr -4&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.
We,;
V
a
2:2/
Q
f,ff t 1 EC EIVft'{}
/A. _R QUALITY
J Ri 'r f 2007
OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, I636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
1

-4
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # „ 9I 5 O
337538
1. WELL CONTRACTOR:
3us4icE
Well
lCTContract(Individual) Name
-J05.1`tCE \ L'O y--1 LC NC,
Well Contractor Company Name 1
STREET ADDRESS 38 4s V S 7 D ui
YvvQr30a N C $1.5 Z
City or Town State Zip Code
(5321a )- "72M —ill 514 u
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(/applicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 1'2-" ILL—
TIME COMPLETED 12,0b
3. WELL LOCATION:
CITY: vim for 4-
kx d— (0 0 91
(Street Name, Numbers, Community, Sub6vision, Lot No., Parcel, Zip Code)
TOPOGRAPHI / LAND SETTING:
❑Slope ley ❑Flat Ridge ❑Other
(check approplate box)
LATITUDE 3 Cc 32.11 ti
LONGITUDE 2-° I I W se
Latitude/longitude source: ®.ciPS ❑Topographic map
(location of we/ must be shown on a USGS fopo map and
attached to this form /not using GPS)
4. WELL OWNER ,d.
OWNER'S NAME RQa''�1 y fi tf Pe3
$,TREET ADDRESS 5(d/o Ng Rd
auL)\a/sls. SC. airRS-
City or Town Stale Zip Code
1.o1 - q(10
Area code - Phone number
AMO' PMQ'
COUNTY i.� UG Luse&
May be in degrees, I
minutes, seconds or
in a decimal format
5. WELL DETAILS: a. TOTAL DEPTH:a/ CI 5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO W
c. WATER LEVEL Below Top of Casing: I FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/ar below land surface may require
a variance in accordance��TTwith 15A NCAC 2C .01/1�8.
d , ,/�
e. YIELD (gpm): 0 METHOD OF TEST I f2
f. DISINFECTION: Type (1 Lb(L)Ne- Amount Q O2
g. WATER ZONES (depth):
From To From To
From 0 To From To
From To From To
6. CASING:
Depth Diameter
From O To /1i. FL_ 9 r
From 0 To 7 FL /f7Y
From 75 To %S Ft. '
Thickness/
Weight Material
4/d r�-
Y0 xi i/2
7. GROUT: Depth Material
From O To 12 0 Ft. +1 PO- 1
From To FL
From To Ft
8. SCREEN: Depth D}i?�!��er Slot Size Material
From / To I( FN /!/ in. VC/ in. %A G/Z,4crt
From To Et. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From 0 To j65 Ft. jik ki4 ir/Z/Juei
From To Ft.
10. DRILLING LOG
From To
7e/- / 55
/S-S- 160
/60-- IbS
Size Material
Formation Description
/-%szr
6-jertyw ,
/4aa!/-t
rCEIv'EU
DIV. OF ;WWA7t-R OuAll i rr
•
IAN ? ?UO7
11. REMARKS:
Aiavite Le/4 % - ,Q -A r
!dP'1'Lj .f A t prete,./
1/ S ar,y
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED eon ACCORDANCE WTM ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU7IF1E
ED WELL CONTRACTOR DATE-DA VE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

WELL CONSTRUCTION RECORD
North Cantina - Department ofEnvironment and Nasal Rcsowces-DivisionofWaterQuality-GroundwaterSectiionn�/
west. CONTRACTOR (RiDIVIDIUtONAME Octet �\US/.!P CERTIFICATION F2_�6
WELL CONTRACTOR COMPANY NAME rt,s , ce h/2 I) D r-...) ). n PHONE a MI6 7-7y-411/1
_ASSOCIATED WQ PERM
Of
I. WELL USE (Check Applicable Bonk Residential Ei Aix E Industrial L3 Aerkalhrtal D
Moeitorog C Recovery 0 Heat Pump Water Injection 0 Other 0 IfOthcr, List Use
2. WELLIACATIONt:I
Neatest Town: 6IA Forf COMO']N`howed
r-voi .n.tE,
(Baca Name. Nemba.,Ceamwo,d r.SaS*Co E,LoOta. Tde)
3. OWNER: irea ria rot / a
1 Address 1 S 7 fLtl: rat,
WA rod- Istam�tearclto) 2-9142
CoyorTawa saes rep Cede
(a} 4o-iq )
Area axle- Phone member
4. DATE DRILLED ?-Y-OG
5. TOTAL DEPTH- 3 ¶P
6. DOES WELL REPLAEXISTING WELL? VEs E NQ t�
7. STATIC WATER LEVELBdowTop &C ) 0 FT_
tun
stfruvotereporinoseo
8. TOP OF CASING IS A Fff.Abovelad Surface*
"Tap stoat sermiaMattar 4bands e6mnpdnaa
aalaesi ameimef_with ISA NCAC2C.111Ii
YIELD j(J
9.(w* ME 110DOPTEST A+'r
10. WATER ZONES{dapt4
11. DISINFECTION: Type r. int, /LP Amowt B Dj
12. CASING Depth a�¢ Wa Maness
F t(
D Q T caIy,
r e To
T80
A
13. GROUT: Depth
°�--� - Materiel
14. SCREEN: Depth Diameter Slot Size Material
Fran To R. in. in.
Frog To Et, in. irk
15. SAND/GRAVEL PACK:
Depth Size
Front. -.__To FL
From To Ft,
16. REMARKS:
Tapog aphie/Land setting
t7Ridge OSiope OValley OFIat
tankoppeapure ben)
Latitudlocation
35° sw ,28 well
143 W
( )
Lat longiSesoluce.:l9l»sftbpoglaphicmap
(rhea We
MEER DRILLING LOG
Flom To Formation Description
0- /oo 9fK)
/to- /SO
/SO- ?4S
ft/?s epode
LOCATION SKETCH
Show tauten and ofistance in miles from at least
two State 1 or Coamy Roads. Wade the road
omateas and cowman coed maces.
RECEIVED
OF WETTER QUALITY
IAN r; i 2007
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANcE WITH ISA NCAC2C, WELL.
CONSTRUCTION STANDARDS, AND TTfATACOPY OP IIISRECORDHASBEENPROVIDEDTOTHEWELLOWNER
7-4 -06
SIGMA IUKROF PERSON C1ON1S/RUC-MTHE wax DATE
Submit the original to theDivisistsefWaterQuaity.GroundwaterSalian,K361MaiServieeCider-Rakig1,NC
27699-N36 Phone Na (!DI 733,3L4 within 30 days.
GPM REV. 07t2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
071Sa
337536
IZg3Ff
1. WELL CONTRACTOR:
Well ja
ntractor (Indiv
idual) vidual) Name
-1u vzr to6(c/L(�i
Well Contractor Company Name
STREET ADDRESS b 3C 05 --)O u-29. S'k
AA AnovJ tl & . Z9752
�28 City or Town State Zip Code
( )- ?zit- 9S413
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/0 applicable)
DWQ or OTHER PERMIT#(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED / 2- I 'j - C 4
TIME COMPLETED AMID PMO
3. WELL LOCATION: A, A
CITY: y1R.e oN /N COUNTY N✓owe
(Street Name, Numbers. Community, Subdivision. Lot No., Parcel. Zip Code)
TOPOGRAPHIC/ LAND SETTING:
p Slope Malley ❑Flel ❑Ridge ❑Other
(cheek appropriate box)
LATITUDE 3 � y5. N9
LONGITUDE, grO/. 2(v /1%
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ESI PS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form Ind using GPS)
4. WELL OWNER /�� /
OWNER'S NAME kg, Z t/h)�C
STREET-AnnRESS ? O. �3 O y 2331
i ckei N jai l'.9 e7 sz-
City or Tc9rn State - Zip Code
( ta25 )- (Q S 2- 2106 I
Area code - Phone number
5. WELL DETAILS: 11
a. TOTAL DEPTH: 1 5
b. DOES WELL REPLACE EXISTING WELL? ,.YEES ❑ NO (y
c. WATER LEVEL Below Top of Casing: I ; 7 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminal at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. pp
e. YIELD(gpm): —METHOD OF TEST A/ f
f. DISINFECTION: Type ELoAMe Amount AQ2-
g. WATER ZONES (depth):
From To From
From /06 To / -C3 From
From To From
To
To
To
6. CASING: Thickness/
Depth Diameter Weight Material
From To Ft.
From 0 To_47_ Ftf— cf0 ?//l'
From 67 To (bl Ft. /&1 6)446,
7. GROUT: Depth Material Method
From CO To 70 FL .,tt 'f el
From To Ft Air
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth ' Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0- GO Ariz(`
- /65- Ci ittescr
11. REMARKS:
nn/ or RECEIVED pD ALn ti
14 N 2 6 207
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
1SA 2C. WELL CONSTRICDaN STANDARDS, AND THAT A COPY OF THIS
RE.. HAS BEEN PROVIDED TO THE WELL OWN
t 2-IS Ob
IGURE • CERTIFI et WELL CONTRACTOR DATE
C/Jay 3vS ( E
PRINTED NA E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvimmnent and Natural Resources- Division of Water Quality- Groundwater Section
WELL CONTRACTOR tESDtVIDUAL) NAME
337550
/ ] CER7IFTCAT[ON #J /5/`��
WELL CONTRACTOR COMPANY NAME USI.'te 1A.t)( hr iirloq PHONE A(g2S1 7.2 y-9Syr
STATE WELL CONSTRUCTION PEBMITa •1
(if ) ASSOC(if WQ PERhitTm
1. WELL USE (Check Applicable Box): Residential l MimicipaiiPublic 0 Industrial 0 Agricultural D
Monitoring 0 Recovery ❑ Heat Pump Water Injection C Other 0 If Other, List Use
2. WELL LOCATIO•i
Nearest Town: aid for T county f'fbO/,
%1- £O4t Lot 82
Motet Name. Numbers. Cameu r.Subdivi ion. Lai NIL Z.Code)
3.OWNER: 1nt IrLeantretat%j1°F <e0.Tot
Address 2IC
7 el b7
City or Town Sean rpCot
(%)-72/—SS6r
Area code- Phone number
4. DATE DRILLED 7- i -06,
5. TOTAL DEPTH: /000
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El/
7. STATIC WATER LEVEL Below TopofCasing 37 FT
8. TOP OF CASING IS / Fit Above Land Surface
*Trip of eadma *insatiate., attir 4anr bad surface requires a
variance is ae tenla ee with ISA NC{tC 2C a1Ia.
9. YIELD (gpm): Yz pd
10. WATER ZONES (depth)_
OF1es
1/Lgmin
11. DISINFECTION: Type Cfar; „r Amount 102
12. CASING
From d To�63
FromSa3.__To /. F4
From_._ To R.
13. GROUT: Doh Material
From_a_ _ To 20 FL 2 F
From To
14. SCREEN: Depth
From To_
Emit__ To
15. SAND/GRAVEL PACK:
Depth
From To
F
Wall Thidmess
Pbbliethri
Diameter Slot Size Material
FL in. in.
FL in. in_
Size Material
ft.
Topographic/Land setting
;Midge °Slope °Valley GFlat
Rhea appwpee tea)
rt� u,2i nde of well location
3$ 32.7PSn, OP2c09.WoW
(degeestraunaesoewnds)
LatitudeJlongitude sourcc0GPSGTopographic map
(click bur[)
DEPTH DRILLING LOG
Formation Description
From To
®- ys D/ as-
YS— /040 4,z4,, fie..
LOCATION SKEfCl{
Show direction and d» in miles from at least
two Sure RBIs orCounty Roads, inelade the mad
mmtbers and common road names.
n
PcULIVED
','*.(Ep oUA1
dAN 2Q07
16. REMARKS: aoFcattgl
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONS7RIKTED IN .(o tit GKr! Y
CONSTRUC710NSTANDARDS AI�THATACOPY OFTEBS ACCORDANCE ISA TOT THE
WELL
•
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
• FI 7- zg-0
SIGNATURE OFPERSO
�NG� WELL DATE
Submit the original to the Division of Water Quality, Groundwater
Section27699-1636 Pbuae No. (919) 733 J231, within 30 days. ' tMali Service
636 Centec-RUdgb, NC
GW-I REV.072001

WELL CONSTRUCTION RECORD ,, ," 1
North Carolina - Department ofEnviousness and Hama Resources- Division oWVVaterQuality - Cirormdwater Section
/�o
WELLCOYTRACTOR (INDIVIDUAL) NAME (PIS ,VSTiGe- crarrincnnon
WELL Co macros COMPANY MIME 21.54. tL Wall nV1 nT PHONE A ft b /21 -Ua7D
STATE wetscce'S[RDCt10K reissue
J
aastrtaTED WQ P6aattlr
I. WELL USE Klink ApptitableBeek Residentiali' Maicipalfrabbc 0 iwdmtriRi 0 Ashes 0
Monitoring Recolery 0 Heat Pump Water lejectiom0 (Idler 01fOduer,List Use
2. WELL LOCATIOlti
Nearest Tonne b d tort CountyMID0 ll
let ?at tenets*" IatP
(Saes Name. Nimbus. Cthethe a.s ltheisiaatangs- Alta*
3.OWNER wa_liquat
Address ta.a gen jol
CatioN i r ' - a 8?6!
orlon Sim 2}Cede
$ZIS-4003
Atha cads- 4. Mane
ibis- s-ob
5. TOTAL DEPTH- On
6. DOES WELL REPLACE DUSTING WELL? 'VES 0 NO me
7. STATIC WATER LEVEL Below Topert /®Or FT-
. l•rit aa.aTydt7:eai
8. TOP OF CASING1S 1 FT Above Land Seat**
flan moss rermieYdveins adsmlendsa.ieesepaeca
mlaaeei amr1... MS ISA ICACW.Wla.
9. YIELD (win): / METHOD OF TEST 5714nvi
10- WATER ZONES (depth): /e i*. ger ?St
.
11. DISINFECTION: Type C/min Animal Yor
12. CASING: 7bietaeas
Dept orSPeielniF . Manna'
From a To y3 FL : 40 PVG
Frommsro 113 R1$4 $U — riot
13. GROUT:
From 0 TToo .90 Ft a£1 p
Fran__ To Ft
14. SCREEN: Depth Diameter Slot Sae Material die
From__ To Fim.15. SAND/GRAVELL PACKC-�m. tar Depth rase Material
Froth________To Ft
Trim To Ft.
16. REMARKS:
I DO HEREBY
CONSTRUCTION
S
opolitRidge �_ M�lat
trLdaappmplaaebee)
n-5 2/ode oflocation
3it/ well
2 o7.2®t
(treat ballethecorth
Latitudellonsitade aoommEG SRropogaphicmap
tresetheed
wit rnuwNG LOG
Form To Formation Description
®- /ob Dye. /Foci
/o0-no Syr Roc*.
//o- vas- le.son* toe-i(
San (fowl r
LOCATION SKETCH -.
Show Woke and Waste in miles from al least
too Sere Tab ort yRadsladndeticmad
mica and common road name'. REGEIVED
of i lF WATER MALTY
e 1AN 2 0 2007
Chi Sr.
J
SIGNATUREOFPERSON COT67R(EflNGTHE WELL DATE
Submit the odgiWle the DirS*Rofwale QsaTty.Gaead+raterSectien,Ie mom SwtaeOnler-Sddee,NC
27699-1636 rite phis, (fl9 73332-1. within 30 days. GW-1 REV. 0712001
•

• RESIDENTIAL WELL CONSTRUCTION RECORD
North Carofma Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2) 5a
1. WELL CONTRACTOR:
GA2Y 5osa-ic .
Wed Conaactar (ki &viduel) Name
7asi-ics \ )eut b1-tLL.Luq
Wei Contractor Company Name
STREET ADDRESS 3 $45 US70 W
liRt iosi Le. 4ESZ
Set? 47Z44451i8
Area code- Phone number
2. WEL QiFORMAT)Ott
SITE WELL ID spy amicable)
STATE WELL PERMWT9(a.�G
DWQ or OTHER PERMITS ff spit able)
WELL. USE (Cheek Applicable Ha* Residential Water Supply sit
DATE DRILLED - 1 Z'2G Ct(s
TIMECOMPLETED AMO PM.❑
3. WELLLOCATWIt
CITY: in a ai t7 fJ couNre IYI9 2 ^ oujtLt"
(jO k.e *-t- fLJ }ntAr to
(seat Name. Ne',em',. Commonly, Su63romr, tot No.. Panel.Ip Code)
TOPOGRAPHIC! LAND
°Slops EIVehey. El Fiat °Other
(Meek appr{mdale I
LATITUDE. 1 r1 S
LONGITUDE$ 2 a/
Latinuellongitude sounx:"HL6PS_ aTopograNuc map
favaiiar of twat must be shown on a USGS typo map and
attached to thisform tnot wig GPM.
4.WELLOWIE(L
OWNER'S NAME➢0aPtt _p�p� L IM
STREET ADDRESS.. '40 -P
Allesj
My or TOM B
($Zq )- titt2-.917Z
May be a depees.
mimes.=mod[Q
St ie ',decimal e.
ILA
Cade
N�
Sale de
Area code- Plena number
5.WELL DETAILS: _
a. TOTAL 0.25
b. DOES WSJ- REPLACE EXISTING WELL? YES ❑ NO iv(c. WATER LEVEL- Below Top of Casing 4/0 FT-..
- - (Use NJ' &Above Top of Casing)
d. TOP OF CASNG IS 1 . FT Abram Lard Surfaces
*Top dawing ianilatid#krtelmlaidsufa inwseizure
avaiance in wooden* 1M NCAC 2C.0118.'
e. YIELD(gpm}: 3 METHODOFTEST Ai(
-
IV 16(0-yoit
pi; Pc
337546
f. DISIFECTIO t Type ctac,AC Amount $ OZ
g. WATER ZOtES (deperr
From !00 To // 0 From To
Fran j j a Tom Fran To
Fran rAd To / get Fran To
A CASING: Thickness/
Depth Diameter Weight Material
Frorn_To Ft Fram_o__T0 i_Ft. fall
am�ToM_Ft. (r / Frr/ . J%Sf 614)1(
7. GROUT: Depthn.. Matxal Method
From ElTo. b FL 2£ I PU4.d
Fran To Ft.
From To R.
A SCREEIt Depth Diameter Slat Size Materiel
Fran To R i t in.
From_ To Ft._ .. bi.
From To Ft In in
A SAtafGsRRAVELPACS:
Depth - Sme Maw
FrmL_To Ft _.....
From To Ft.
From To R
10. wuLLNG LOG
From To
0— 7e
jo- 75-
74 /
/ga) -ZZS
11: ;REMARKS:
Fomlaibn Desoto' bon
tine
sit fincric-
meI i-a 5.4int lock
F2E WIUtU
imArrFS? Of PHI I I
AN , ( 2001
I Dollleissri)orilrentirlitelaMeselosetestumEo 141CCORDAPICEVOM
ISA rt$C2C. VMwl LSlmlw Calli SoAPDS aenaracorrOFnn
Irns 6®IW{OemEOTe7aEWW01nrel
Submit the original to the Division of Water Quality within 30 days. Attn: Information llyL,
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Pam GW-ta
Rer.710#

WELL CONSTRUCTION RECORD
North Carolina - Depanarnt ortmimam pt'andN���� Natural T cal Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME "'n'n////�'''. W S Lace— CERTIFICATION 02 ISO
WELL CONTRACTOR COMPANY NAM£3US4. G Z. WQ 11 Dr. ,1. -3 PHONE a tra17 at- 9Si%S
STATE WELL CONSTRUCTION PF,RIMTE ASSOCIATED WQ PERMITS
(ifapplicable)
1. WELL USE (Check Applicable Bonk Residential ii3" Mttaicipa(iPublic 0 Industrial 0 Acricultutal 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: ,N
Nearest Town: J$ar On County rr/k hOweit
}iidebn SPPr:^� s Dr -
Name Numbers. cruoom�y.Sddv�m.tet
(Sucre 4 ^ No.. To Code)
3. OWNER: S4tt/e.G9.I Phint
Address )t.2i 2.: oft WM Fend
y�/� three or Rome No.)
Yeah; on N.C. .28752
City or Town Sean Try Cede
(721 i- 442 a7091(
Area code- Phase number
4. DATE DRILLED 9-22 -ore
5. TOTAL DEPTH: aL5
6. DOES WELL REPLACEEXISTING WELL? 1111 0 NO 6'
T of O
7. STATIC WATER LEVEL SNOW
Top Casing FT.
pan ammrepatOamat
& TOP OF CASING IS 1 }-f.I
aud Surface
lap actin ternduated attar Wen hat seduce reoishar a
rarimee acordamewits ISANCAC ZC Dli8.
9. YIELD (lean): 30 METHOD OF TEST 11: r
10. WATER ZONES (depth): 'in .%P)1 'h 42,2 5
11. DISINFECTION. Type e /or; n Amount rev
12. CASING:
Depth
From 0 To (oGI Y 0 PVC_
From (,G To GB FL/a q G /
FrontTo FL
13. GROUT- Depth
___
Diameter ca. Waglu/FL Material
33 545
Topographic/Land setting
ORidge Eglope Malley OFIat
(cheek appaprtate (tor)
Latitredolommitude ofveell location
350 51.9191v 07i 5 //8/
(degeedmkaiaaa�)
taiiiSe/!oagitud_PSCITopographic mapin)DEPTH(oast b
DEPTH - DRILLING LOG
From To Formation Description
4 0
itt
GO- -16S
GKrtua�
RECEIVED
JAN A 6
LOCATION SKETCH
Show dircction and distance in miles from at lean - - -
two State Roads t County Roads. Include t6c road_ -
numbers mad common road names.
R1 McRd�V
4 LJ
From D To TO FL lynx ( Pyre¢ d / t
From To FL
14. SCREEN: Depth Diameter Slot Size
From To FL in. in.
From To Ft_ in in.
15. SAND/GRAVEL PACK:
Depth Size
From To FL
From To Ft
- 16. REMARKS:
Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRON STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEIL OWNER
9-22-at
S1GNA RE OF PERSON CONSIRUCIINt3 THE WELL DATE
71
Submit the eig)nal to the Division of Water Quality Groundwater Secftioa,1636 mitaservice Center -Raleigh, NC
27699-1636 Phone No. (9t9) 733-3224 within 30 days GW-I REV. 07/2001

RESIDENTIAL WELL CONSTRV CTJON RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
337544
1. WELL CONTRACTOR:
W el ontractdr (t clividual ame�
lus4 `Lie_ )u J
Well Contractor Compariy Name
STREET ADDRESS 3 A Ks— FJ lam'"' y
/14 40 hit
City or Toast State `2, Code
(8Z8 )- 7Z41-4/4"40
Area code- Phone number
2. WELL INFORMATIOlt
SITE WELL ID 901 applicable)
STATE WELL PERMIT/fdapplicable)
DWQ or OTHER PERMIT#(d apprraway
WELL USE (Check Applicable Sac):.. Residential Water Supply Q
DATE DRILLED ]/- 30of0
TIME COMPLETED 12 700 AM I3 PM ❑
3. WELL LOCATION:
CITY: aI3 ree-ci COUNTY W. ©bL./Ca.
/ol.. UE,'a4QEnDr-
(Stoma
Name. Numbers, C��e��wrkry, knit No_ Parcel, Z4 Code)
TOPOGRAPHIC/LANDS G
❑Slope °Valley ❑Flat fridge ❑Other
(check appapriab box)
LATITUDE 3 , Sit 1.14 4,1
LONGITUDE gt_
Latitude/longitude source: V43PS °Topographic map
(location of we/ must be shown on a USGS topo map and
attached to #ds loam l not using GPS)
4. WELL OWNER
OWNER'S NAME / M-kPlsp S'c//Arj
STREET ADDRESS 24 OR' t tt. QA .:..
Cniudter
May be in degrees.
minutes, seconds or
in a decimal Tomat
jt)2ft
City or Town State. Zip Code
(gZ3 )- 335-033S
Area code - Phone numbs
5. WELL DETAILS: en C
a. TOTAL DEPTH: SQJ
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ert
c. WATER LEVEL Below Top of Casing: t S 0 FT.
(Use '+' 8 Above Top of Casing)
d. TOP OF CASING IS t FT. Above Land Surface'
'Top et casing Laminated at/or belay land surface may require
a variance it afwd>c. un.with 15A NCAC 2C .0118.
e. YIELD(gpm): yl�a METHOD OF TEST lain
f. DISINFECTION: Type Q Loc. 4tz
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
Amount 8 D 2
6. CASING:
From 0 �Too� InFL
From To / T( Ft
From To /Q/ FL,
7. GROUT: Depth
From To
From 0 Tot_
From '.Q(1 To PM
8. SCREEN: Depth
Fran To
From To
From To
Material
Method
Diarneter Slot Size Material
Ft in. lo.
Ft it R
FL in. in.
9. SAND/GRAVEL PACK:
Depth . Sim
From To FL
From To Ft
From To Ft
10. DRILLING LOG
From To
©--/ go
Jgo` Pi05-
11. REMARKS:
Material
Formation Description
Qi ocy1 ✓tact-
rdAitke
I00 HEREBY CERTIFY TNAT MIS WELL WAS CONSTRUCIW N ACCOfWANCE WITH
15A NCAC 2C. WELL COta:IRUCIION STANDARDS, AND 1 W 1T A COPY OF lla3
RECORQ/�A5 BEEN PRODDED TO THE WELL OWNER
/Ho-%
SIGNATURE•OF C FIED WELL CONTRACTOR - DATE
&ay 0 SOSW C
PRINTED NPIME 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

4(46, /17(
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
C1nti 3Usi-iOr
Well tract (Individual) Name
3054i er W eu. d C1 Lun(.rel
Well Contractor Company Name
STREET ADDRESS 32g5 U S Phu u)
PNatrrtod ,1 e_ 287st
City or TownState Zip Code
(829 » 'Mt-44540
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply LK
DATE DRILLED J0/27 / &G
TIME COMPLETED IZ:oo AM O PMB"-
3. WELL LOCATION: t� CITY: M yYrlc 3 COUNTY YJIS�JButLt-
(Street Name, Numbers. Sun, Lot No., Parcel, Zip Code)
T9POGRAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Other
(check approp date box)
LATITUDE 3 L/Z,•74/v
LONGITUDE QQ / A Yc 3, 44te
Latitude/longitude source: QFPS ❑Topographic map
((cation of we/ must be shown on a USGS tope map and
attached to this form /not usng GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME Allikfij$6. idater
STREET ADDRESS (*)nX
4 .3
City or Town 1 State 411Zip Co
de
(2.i- a93- y l a-Ci
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l3"-
c- WATER LEVEL Below Top of Casing: FT
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 'j METHOD OF TEST {-1 1 r
f. DISINFECTION: Type df 4012j& a Amount Qr OZ
g. WATER ZONES (depth):
From 9'1 O To 244, From To
From To From
To
From To From To
6. CASING:
Thickness/
Depth DWeight eriat
From O To G� Ft. 6r Diameter 4-o /-
From 62 To L.4 Ft. 0 /y jeg grgcv
From To Ft.
7. GROUT: Depth Material Method
From 1') To 2 D Ft -kelte / (/4
er
From To FL
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ftin. 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- g7
.45" -lD ea '
/0G -2 to
Zyo-380
s8- AI to
11. REMARKS:
Formation Description
Di let
S ti fiecf 1-4704 "..e/S
"frCt Qt rt`S`' .4 4x/t
RECEIVED
Div. OF WATER QUALITY
)IlNL 9 LDU!
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 SEEN PROVIDED TO THE WELL OWNER.
SIGNA UR F CE IRE ELL CONTRACTOR DATE
PRINTEb NAM
•
OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION /1
�ue556
1. WELL. CONTRACTOR:
Glief��Jcta (Individual)
Well
Su54; c. g lie(. r i LL;r.�
Well Contractor Company Name
STREET ADDRESS Z @I SO S » t. ?
(dVl airtorti IL)C 2 S 752-
City or Town State Zip Code
(S29 )_ 7V1- 5w
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/hiappliwNe)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Der
DATE DRILLED JO//4, 0G' /
TIME COMPLETED /Z t' La ca AM ❑ PM t
3. WELL LOCATION: , �1 i�
CITY: AA inU VV COUNTY t44 !Dowel —
(Street Name, Numbers, Community. Subd is)on, Lot No.. Parcel. hip Code)
TOPPGRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge ❑Otter
(check appropriate box)
LATITUDE .J SL , t til
LONGITUDE On GS,Sp7
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we# must be shown on a USGS fopo map and
attached to this form d not using GPS)
0. WELL OWNER
OWNER'S NAME A:IC-e (j'lo0
STREET ADDRESS 3 q q put rtr Dtky+ Ael,f
City or Town State Zip Cale
(928 )- '?2
Area code - Phone number
May be in degrees.
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: i6,5
b. DOES WELL REPLACE EXISTING WELL? YES 7NO 0
c. WATER LEVEL Below Top of Casing: t.-0 FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
- *Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): /5 METHOD OF TEST 4/It
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From /00 To j20 From To
From To From To
6. CASING:
Depth Diameter
From To Ft.
From�(To e{`7 Ft.
From To
7. GROUT: Depth
From To Ft
From 0 To 60 Ft. 2/
From To Ft.
Material
Thickness/
Weight Material
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth - Size Material
Frorn To Ft.
From
From
To FL
To Ft.
10. DRILLING LOG
From To
iyi(o- f2:i
/20-- 15-5
11. REMARKS:
Formation Description
r it.oc-r•d./L'b
t
5 li4c^ F
Oti.e.
DU ®ECEIv p
QUALITY
C$ ur Cc� e rt7b#C N / ,4,C..
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF *11S
RECORD BEEN PROVIDED TO THE WELL OWNER.
�l
SI NATURC TiFIED WELL CONTRACTOR i0-DATE
sleet
PRI ED 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

337427
WELL CONSTRUCTION RECORD
North Carolina -Department ofEnvironment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACYOR(RIDIVIDUAL) NAME (,p�L� /�/Dcl ins Zr caRTJFICAnoN re 270'V
WELL CONTRACTOR COMPANY NA11�-� w �e e f w /� f L�/' ,Q f/ NONE R in
6 5(9=ogg0
STATE WELL CONSTRUCTION PERMITS ASSOc1ATID WQ vn rri1
(if applicable)
Crfapplable)
1. WELL USE (Check Applicable Bon): Residential O ithmkipaWPoblic 0 Industrial 0 Apiculture! 0
Monitoring 0 Recovery 0 Heat Pump Water hgection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: o County q c I
(Lite.IA4:r Sti�r4. cite) 11.
(Sinn Naraa.Nambn Cammmay. Sabdivisaa, L ANa, Tip Code)
3.OWNER: 5 5h1elL
Address bal. 5 tc.n t yy Nu 4 RA
praetor Rowe NO
Htitatnond:Ile rUt 2o1/
aeyorTaws Sine¢ Tap Cada
Ana cafe- Phase camber
4. DATE MULLED 1'A o 6
5. TOTAL DEPTH:, ay,,
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 17
7. STATIC WATER LEVEL Below Top of Casing FT.
., (User
& TOP OF CASING IS 1 FT. Above Land Surface'
`Tap of eadaveraditated eNR below Mad sedan regobea a
variant Y ate web ISA NCAC 2C JUL II
9. YIELD (gpm):�U METHOD OF TEST Ti .r r/C'
10. WATER. ZONES (depth):
1I. DISINFECTION: Type %( h
12. CASING:
From 0 Ft. /
From.....To Ft
From_ To Ft.
13. GROUT• Depth Material
From al To 30 Ft Cc:nr(c t-t t,�c M
From To Ft
14. SCREEN• Depth Diameter Slot rae Material
From 0 To Ft._in. in.
From To in.
15. SAND/GRAVEL PACK
Size Material
From ® Two Ft
From To Ft._
Amount /C Z-
Willtdckness
n
ar
setting
Midge l7S7o [Walley targi
wet apptopdat boa)
Latitudellongitide of well location
Latitude/longitude samccOGPSOTopogaphic map
(check boa)
DE MI MILLING LOG
From To Formation Description
LOCATION sicerC}L
Show direction and distance is miles from at least
two State Roads or County Roads. Include the mad
mambas and common rod names.
RECEIVED
DI` , OF WATER QUALITtf
JAN 2 a 2007
16. REMARKS:
I DO HEMS CERTIFY THAT THI3;WEIL W CONSTRUCTED IN ACCORDANCE W1T1L 15A NCAC 2C, WELL
• ON STANDARDS, T71ATl COPY0PflUS BEcORD HAS BEEN PROVIDED TO THE WELL OWNER
Hill C
(NATURE OF P
CONSTRUCTING THE WELL DATE
Submit the original to the Divine' of Water Quality, Groundwater Section,1636 Mali Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

337431
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural9Resources - Divisionioof WaterTQuality - Groundwater Section �+
WELL CONTRACTOR (INDIVIDUAL) NAMCE4rtot) nit n 0/ P A O LI PS D. /j CERTIFICATION a Z 7 O
WELL CONTRACTOR COMPANY NAzc- ' W p e t tA) IR /Yr Wei/ 7 / LtrPRONE # OSZ tTS (25'%O fJO
STATE WELL CONSTRUCTION PERMrf# ,ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential le Municipal/Public ❑ Industrial ❑ Agticultwal ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 0 Lb / tnf" County MC 44IdSZL
L.Dt 2
(Street Name, Numbers, Community, Subdivision, tot No., Zip Code)
3. OWNER: 60,4e way wft.r( 5
Address 1312 Or+' Ade. Alt
(Street or Route No.)
Sf. /rtrrsLt1 FL . 3 390 3
City or Town Star Zip Code
Asa code- Phone =ober
4. DATE DRILLED 7-2 6 -O C
5. TOTAL DEPTH: 30 i
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL Below Top of Casing.
t/ (Use "+" if Above Top Cuing)
8. TOP OF CASING IS 1 2' FT. Above Land Surface*
'Top of easing tenulaated atlas below herd surface requires a
variance in aecerdenwith ISA NCAC 2C .0118.
9. YIELD (gpm): 3 0 METHOD OF TEST T,.t
10. WATER ZONES (depth):
Topog�rpphic/Land setting
❑Ridge [Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/mimosa/seconds)
Latitude/longitude source:❑GPS❑Topograpbic map
(check boa)
PEFTH L)RTLLING LOG
From To Formation Description
11. DISINFECTION: Type C(1-1
12. CASING:
meter
From iv TDo�k%D Ft �i/Dita
y
From__ To Ft
Front__ To Ft
13. GROUT" Depth
From t% To 3 0 Ft.
Amount /D oZ
Wall Thickness
or Weight/Ft. Material
SOlt-21 puc
Material Method
!Ponca -It U.t Picot
From To Ft
14. SCREEN: Depth Diameter
From 0 To F1_in.
From To Ft in.
15. SAND/GRAVEL PACK
Depth Size Material
From 0 To Ft.
From To Ft.
Slot Size Material
is
in.
LOCATION S1C.E•FC1)
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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL1r:U IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON 9tUC ION STAND S, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(, , . 7fr76 06
" test"T' a 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
LITV

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-rc'�Division of Water Quality
pl
WELL CONTRACTOR CERTIFICAT ON # E) 9
3 I 209
W COjNTRACTOR:
W I1 Contractr'ndjvidyal)rNam
�YR , O1.1111v'$ Lk WE 11 &'A Lan pi LLC.
Well Cjntractor CompanyryName �c
STREET ADDRESS / A„ 1.
C�itES-fxR C a8ili4
City or Town f State
(ps r 5W419&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #lir applicable)
STATE WELL PERMIT#br applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED
TIME COMPLETED % Aso 0 AM PM
3. WELL LOCATION:A'�A ,,//
CITY: ' /q/k M4'J4 JOUNTYRCA(4)..€4/
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPPQGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDES/ 3 S L 2„yr,z//
LONGITUDE' / Yt ]/Yy
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STR T ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
&diver a,re (.o
>0� V� Ps,f'i
%I, 9�ds�
/
City or Town Stale Zip Code
(asa)- 6(59- C/s 1p
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
5 YS r
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing:
4414 (Use "+- if Above Top of Casing)
d. TOP OF CASING IS
e. YIELD (gpm).
FT.
FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
METHOD OF TEST
f. DISINFECTION: Type ehlos me
Amount /Val
g. WATER ZONES (depth):
From To 3 VO From To
Rom To yso From To
From To From To
6. CASING: Thickness/
��
Depth k Diameter Weight Materialeyk
From D To —Ate_ us us
From To Ft.
From To Ft.
7. GROUT: Depth //77 Material
From 0 To le Ft. t.�Dicai
From To Ft.
From To Ft.
Method
6. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
"-/ Clay y_
yr a / 1d
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROyIDEO TO THE WELL OWNER.
Als
SIGNNAATU%RuE�O,hrCEJCTtIIFFIE/rSW 4,CONTRACTOR 7D
PRINTED NAM //F PERSON CONSTRUCTING UC ING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD 3 416 7 9
North Carolina - Deft ofEavimnmmt and Natural Resources - Division of Water Quality - Groundwater Section watt CONTRACTOR (ATURYmuAL)i� �rL /1 C 7?X O6iias al —CERTIFICATION 0 2 7 8�/
WELL CONTRACTOR COMPANY W +Ee W At f er Wi/ 4 apraorms awayszatego
STATE WELL CONSfnucnoN moans ASSOC/ATED WQ PERMIT*
(if applicable) (ifapplicahle)
1. WELL USE (Check Applicable Boo Reuel IaMunicip.VPublic 0 Industrial ❑ Agriculonai O
Monitoring El Recovery 0 Heat Pump Water Injection 0 Other 0 If Oth ,, List Use
2. WELL LOCATION
Nearest Town: ( AID county 1AlEt°Rid' ge °rope Malley t
(cbe* spptcpsiatebox)
(SteaetName,Nambea, Cooney. Sab&,iaon. LelNq DP Code) Latitude/longitude of well location
3. OWNER: C'7PCedrE—Ty
(deaneaatm)
Address Latitude/longitude soutee:0OPSOTopographic map
(Street eRatite Mt)
NL -87I z . B IIi ` PR-D.LINGL
CdyorTown apcode From To Formation Desraipti.
(__)-
tun tale- AlaoeaambC
4. DATE DRILLED 12— ?�0 —SPP
5. TOTAL DEPTH: 1S .
6. DOES WEIL REPLACE EXISTING WELL? YES NO liri
7. STATIC WATER LEVEL Below Top of Casing Z FT.
n{� a (Use 'rtfAbove Top aquae
8. TOP OF CASING IS j(t FT. Above Land Surface*
flop of ases onsYWd who below taadswfaea empires a
wtaace b a000raaie with ISA NCAC 2C .911R
9. YIELD (gpm): S it METHOD OF TEST 11F-j a.D
10. WATER ZONES (depth):
11. DISINFECTION: Type Amoaot l i) t�Z
12. CASING: Waft Thk mesa
From To v Ft. t c ora' V t.
FromTo Ft
From_ To Ft.
13. GROUT: Depth:%�Ere-a
To Ft hIJI
GROUT:
Ft
14. SCREE{ / Depth Diameter Slot Sit Mat rist
Fro To Ft.�m, in.
From To Ft, in. in.
15. SAND/GRAVELPACK:
Depth Sine Material
Fro To To Ft
From %% To Ft.
Show direction and distance in miles from at least
two State Roads or Calmly Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISANCAC2C.WELL
CONSTRUCTION STAND ' • • THAT A COPY OF Tins RECORD HAS BEEN PROVIDED TO THE WELL OWNER
%Z-j6 -6(o
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Savice Cep- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. (3W-1 REV. 07/2001

WELL CONSTRUCTION RECORD 4 1 6 5 7
North Carolina - Depattment ofEavuonment and Natural Resources - Division of Water Quality - Groundwater Section u
WELL CONTRACTOR (INDIVIDUAL) NAME / n ,/ vo Q CERTIFICATION d 2 7 v I •
WELT. CONTRACTOR COMPANY wee w /4 he" (,Q it "PRONE a m72i 6 Y9-O flu
STATE WELL CONSTRUCTION PERMrr# ASSO C. TED WQ PERMITS
(ifapplicabie) Of applicable)
1. WELL USE (Check Applicable Box): Residential G MunicipaYPublic ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pimp Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION
Nearest Town: 3'4N-i rt bJ Catty N W E1.L
gr,txrE 10 LI - Qr #th .
(ShatNamt,Numba.L Community. Subdivision, Lot No, Zip Code)
3.OWNER-TOM ���N�`l��'7'' (degoa'm�eleemods)
Address � rvE -7n M+ ,H#aL 'Q-iStN Latitude/longitude sawce:0GPSCITopogtapbicmap
(Snort or Route No.)
MnioN NC..Z$737 n m ( DRILLING LOG
(Myer TOMB State Tap Code From To Formation Description
L_J-
Rea odalLooe somber
4. DATE DRILLED II—q-Olp
5. TOTAL DEPTH: SO 5 '
6. DOES WELL REPLACE EXISTING WELL? YES NO Er
7. STATIC WATER LEVEL Below Top of Casing I: T.
(Use "m r if Top ota's*/
& TOP OF CASING IS I S FT. Above Land Surface*
`Tap of easing terminated ter MYw bind main requites' a
variance in teto with ISA NCAC 2C .911&
9. 'YIELD (gun): 8 METHOD OF TEST-VMB-t)
10. WATER ZONES (depth):
11. DISINFECTION: Type P/J-ice Amount /ODZ
12. CASING: Waall_ThiccllmFesss
nnr.From 0 TDotub) Ft 04 !� -1
F _To Ft
From_ To Pt
13. GROUT: Depth Material
From To % . i Ft&Orin— a
From__ To Ft
14. SCREENDepth Diameter Slot Size Material
From (1 To Ft_in in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From p To Ft.
From To Ft
setting
MA. CISlopeMoan
One&appmpdatewar)
Latitude/longitude of well location
LOCATION SRETCFX
Show direction and thsance in miles from at least
two State Rests or County Roads, Include the road
numbers and a road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT
CANSTRLT 'ION STANDARDS,
WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
TCOPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
Submit the original to the Division of Water a , . , Grotmdwater Section, 1636 Matz Service Ceuta -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 072001

WELL CONSTRUCTION RECORD
North Carolina - Department of Envhonment mod Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (NDIVIDUAJ) NAME f . ,P otirrn oator # 2 7 8 y .
WELL CONTRACTOR COMPANY �e e w /¢ Per { / / 7 .war to a lift ct) 6 W/-o fl0
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
341658
1. WELL USE (Check Applicable Box): Residential W MUaiciPaUPublic Cl industrial 0 Agricultural D
Monitoring El Recovery 0 Heat Pump Water Injection 0 Other 0 If Odter, List Use
2 WELL LOCATIO :
Nearest Town: male. LON County tAc>c (JaL
Mub (-LT grab .
(Sheet Name,Nmbea. Cmmu , Subdivision, Let No., Zip Code)
3. OWNER LKo
Address 1 75 kl (teuD r Q,p
Moutfetallo.)
IA+ZtoN Wt. 26 15 -
ayorTaw Sure Zip Code
Atm�eodor rime number
4. DATE DRILLED i - JU -0 (0
5. TOTAL DEPTH: Y55
6. DOES WELL REPLACE EXISTING WELL? YES NO IW
7. STATIC WATER LEVEL Below Top of Casing
„ (User iAbove Tap afCasig)
8. TOP OF CASING IS / n PT. Above Land Surfaces
flap p of ming #as6wd tar baba Sad weBee meshes a
Tatham la nsdaneeule ISANCAC 2C Al18.
9. YIELD (gpm): Z'5 METHOD OF TEST 11 MED
10. WATER ZONES (depth): /
Topographic/Land setting
[Ridge 9Sfope Malley DFIat
(cheek append'sebea)
LatiludeAongitude of well location
(/)
Latitude/longitude source:DGPSCITopographic map
(cheek box)
PEPfn DRILLING LOG
From To - FamationDescription
I1. DISINFECTION: Type C 44
12 CASING:
Depth
From To ion
From_ To Ft
Front__ To Ft
13. OROUT: Depth Material
Fmm .O_To ZD Ftf byre. MtV
From To Ft
14. SCREEN- Depth Diameter Slot Size Material
From_To Ft in. in.
From, To Ft, ---in. in.
15. SANDIGRAVEL PACK:
Depth Size Material
From To Et.
From To Ft.
Amount Ibo2..
Wall T6idtneas
or Weight/Ft.
Jn('.ATION SICETC$
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 15ANCAC 2C, WELL
CON CTION STAND •-. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4,417
SIGNATURE OF P CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 7333221, within 30 days. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3i 6 5 9
North Carolina - Depart ofEnviromawt and Nauual Resources - Division of Water Quality - Gmamdwater Section
watt aurritAcroB (INDWWmAL) NAME / A to V csarmlcwruse it Z 7 $ Li ,
WELL CONTRACTOR COMPANY w'ee wa )rr W/ ' "PHONE S 2gglr 6Yg-o 0
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PII3MIT#
(ifapplicable)
(if applicable)
1. WELL USE (Chock Applicable Boa): Residential Gr.MmicipalPublic O Industrial Q Agciculnual ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection D Other ❑'Mika, List Use
2. WELL LOCATION�:,I��.,
14 Town: k4AR. O TT County MC v.)�J t. midge setting
t E2.A1.1Nlly Oboe appropriate b ac)
(Steen Nam, N.sCam asigcSarno,Lot No, Tap Cade) Latitude/longitude ofwell location
3. OWNER: IC,l-)•ArfZ.D
Address �t✓f EV M.j�
(Suatac RadeNo.)
NMA12-101N1 NC
City or Tom Same
(_}
Area code- Phone a®ber
4. DATE DRILLED 1 -1 O -O 1p
5. TOTAL DEPTH: ;05'
6. DOES WELL REPLACE EXISTING WELL? YBS l7 NO
7. STATIC WATER LEVEL Below Top of Caster .32- ET.
win & TOP OF CASING IS 1 S� FT. Above Land Surfaces
Map easing tandaided adar bedew Iaadawfaca tgairera
animate Ica accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): -_15 METHOD O F TEST I I M E-D
10. WATER ZONES (depth):
Z8-1S2_
zp Code
( )
+C?EEC Latitude/longitude souuce:CIGPScropograpbic map
(cheek boa)
DEEM DRILLING LOG
From To j Formation
11. DISINFECTION: Type CC, Hr Amount 1002..
12. CASING: Wall Thickness
Fro ._To_i .Ft 614 riles/Ft7
From_ To Ft
Front_ To Ft.
13. GROUT: Depth2 material
FFrom rom r To 60 Ftf nt•Y jl
To Ft
14. SCREEN- Depth Diameter SlotSze Material
Fron_To Ft. —in. in.
From To Ft,,_in, in.
15. SAND/GRAVEL PACK:
Depth Size Material
Ffom_To Ft.
From To Ft
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road names.
16. REMARKS: ZUOI
I DO HEREBY CERTIFY THAT
CONSIRON ST
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
THAT A COPY OF THLS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Ado - le
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

STATE WELL cCNSCYUCfON PERMIT% ASSOCIATED WQ VERMIN
Of applicable) Of applicable)
WELL CONSTRUCTION RECORD 3 4 16 6 0
North Carolina - Department ofEuvuonmmt and Natural Resources - Division of Water Quality - Groundwater Section nu CONTRACTOR (INDIVIDUAL) NAME n p�iio cEflzcAnow Q to 2 7 O G/
Wm. cONTRACTon COMPANYSA) t4 Lr Wil/ apPRONE t & 6 Y 'reap
1. WELL USE (heck Applicable Box): Residential Erbluoicipaipublic ° Industrial ° Agricultural ❑
Monitoring ° Recovery ° Heat Pump Water Injection ° Other ° If Other, List Use
2. WELL LOCATION:
Nearest Towr-,_tAAcR..l b�_• County i�arAhleU
Z.ION -9-1 2zAb
(Street Name, Nmtbeaa. Cammm'sy. subsviooe, I.atNq 2;, Code)
3. OWNER: 6t.t. O E4
Address b(o M�CYO"
Bo 2nc / #r 1 -
/10
MAaoN N 2R1S2—
City or Taw Sure Tip Code
Ann code -Phew amber
4. DATE DRILLED 3'0IP
5. TOTAL DEPTH: S
6. DOES WELL REPLACE EXISTING WELL? YES NO S
7. STATIC WATER LEVEL Below Top of Cashel:
„ (Use'r if Above Tap afCasieg)
8. TOP OF CASING IS / 5 FT. Above Land Surface*
'Tap of miss teradaided attar below bad tartan MOMS
varbaee b<aeeordanxwith 15A NCAC 2C.011S.
9. YIELD (gpm): , D METHOD OF TEST TI)✓lEt)
10. WATER. ZONES (depth):
TopograpMc/Land setting
°Ridge °Slope °Valley °Plat
(Meek appropriate box)
Latitude/longitude of well location
t )
Latitude/longitude somee:OGPS°Topograpbic map
(cheek box)
Diwnt DRILLING LOG
From To 1 Formation
11. DISINFECTION: Type (EC Amount 1 O tort_
12. CASING: Wall Thickness
(Jp at Depth Wei -F-�' �—
Front To_ ^ fill
Fronk_ To Ft
Fromm To Ft.
13. GROUT: Topth �M �•
LO Ft
Emit__ From_/To Ft
14. SCREFId Depth Diameter
From (� To Ft in.
From To Ft,,__ia
15. SAND/GRAVEL PACK:
Sartre Material
is
in.
DgMb Size Materiel
FTo Ft.
From To Ft.
WCAngigiblini
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad aanms.
16. REMARKS
R YCERTIFY THAT
(IL l�
•
ON STANDARD
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-610.
OF PCONSTRUCTING 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

(Sander Route No.)
Mtkg.tc*4 INl(. Z3'15Z
Cary or Tenn Sme Zip Code
Awe cede- Phone number
4. DATE DRILLED 1-IS' O(.0
5. TOTAL DEPTH: (p0,5 •
6. DOES WELL REPLACE EXISTING WELL? YES [' NO 13--
7. STATIC WATER LEVEL Below Top of Casing: 92 FT.
(toe 4" if Above Top afanivg)
8. TOP OF CASING IS 1 ' FT. Above Land Surface'
'Tep et casing tartsdaaa d allot bWw landsmen requires a
variance Y ecein Witt ISANCAC 2C mlt
9. YIELD (gpm): METHOD OF TEST- Iwl J, ? .
10. WATER ZONES (depth):
11. DISINFECTION: Type O -'4 Amount 1/)
12 CASING: Wall TBidmess
DePm To %t? attar
2
From mm Ft(Q We Tr,
Fromm To Ft.
Fromm To Ft
13. ['ROUT: i TomI.D Fico1�( FIT:.aFrom (TA —To Ft
14. SCREEN: Depth Diameter Slot Sine Material
From /� To Ft in is
From To Ft in. in.
15. SAND/GRAVELPACK
1 Depth Size Material
From �To Ft.
From. /7_? To Ft
Topographic/Land setting
DRidge [Mope ['Valley Ciao
(check appropriate ba)
Latitude/longitude of well location
WELL CONSTRUCTION RECORD % 4 1 6 6 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL) NAME Jpt / /1 � DG%S'� CERTIFICATION s Z 7 8 °/ . •
WELL CONTRACTOR COMPANYxlls8-�ui a %(L/' / r-.�wnNE s IPA 6y91-0408o
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMITS
Cif applicable)
(ifapplicable)
1. WELL USE (Check Applicable Boa): Residential In micipal/Public D industrial [' Agricoltmal ['
Monitoring Recovery C Heat Pump Water injectionC Other El If Other, List Use
2. WELL LOCATION:
Nearest Towcj'. IPoirlbN ComtyMcrD01NELL.
0.1W-D)NAa. lt.P'/L. ASDtV1SlbN
(Sneer Name, Nimbus. Community, Subdivide% Ice No., Zip Code)
3. OWNER 'gare-ut try ( )
Address 1la7- mtl.1LIL TR-A1t- Latitude/longitude somce:QOPSLTTopogtaphicmap
(theca boa)
D DRILLING LOG
From To /Formation Description
LOCATON SKETCH
Show direction and distance in miles from at least
two State Roads or ComrtyRoads. Include the road
numbers and common mad names.
OW W2-V- .. PP4)6bj r v-ab
16. REMARKS:
I DO HEREBY CERTIFY
COreiTiONST
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5ANCAC 2C, WELL
AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/idz /i-l5=o k
OF PERSON CONSTRUCIING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Ceder -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 416 7 2
North Carolina - Dement of Environment and Natural Resources - DiviSion of Water Quality - Groundwater Section
CONTRA
ONNYTOD
WELL CONTRACTOR COMPANY t — e e .^ ,(J HONE �Qfzm 6 yq-origo wEu CONTRACTOR COMPANY NAISE-�
STATE WELL cONSTYUCTIONPEYMIT# ASSOCIATED WQ PERMITS
(tfapplicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential la" t l/Pthlic ❑ 'Motion] Agricultural 0
Monitoring CI Recovery a Heat Pump Water Injection CI Other CI If Other, List Use
2. WELLLOCATI
Newc5stTown: OLD Thar Calmly Mr �,wF�
(Street Nan Rumbas, Cannon. Sobdvided t a, Tap Code)
3. OWNER LAW .
Address V.,#j < pev a EIJ-Prb
(Street or Rate Pia)
CLAD ¶off 1 1y(
28-7o2.-
Caen Town Sums Tap Code
Met cede- Pine camber
4. DATE DRILLED IL- i,+-0
(P
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ° NO 0"
7. STATIC WATER LEVEL Below Top of Casing: 3 0 FT.
(Use'Y' NAbws Topdceabg)
& TOP OF CASING IS / Qj FT. Above Land Surface*
`Top eland termWhd an Slew landsman rapine a
era duce In accardaacewN! ISANCAC 2C All&
9. YIELD (gpm): 2.D METHOD OF TESTf]jf_
10. WATER ZONES (depth):
LOCATION SKETCI;
Show direction and distance in miles from at least
two State Roads or Comty Roads. Include the road
nnmbers and common road names.
tiV.1492- ii s
✓✓'3 I /��7
Topographic/Land setting
°Ridge °Slope []Valley 8Ftat
(check approptiate
Latitude/longitude of well motion
( )
Latitude/longitude somee:°CPS°Topographic map
(abeekbat)
1212111 DRILLING LOG
From To Promotion Description
11. DISINFECTION: Type r 04 Amount I 0 t�'L
12. CASING: Waf Thietness
Depth or'Weighr/Ft.
From To ?A- Ft 4 ��7 D� '
From_ To Ft
From_ To Ft.
13. GROUT- Depth Material
Fromm To_2.Ft. rOKY 1n1ETMty
Prate_ To Ft.
14. SCREE" DepthDiameter Slot Size Material
From ( To Ft —in. in.
From To Ft in. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W111315ANCAC 2C, WELL
CONSTRUCUONSTANDARDS ''i• THAT ACOPY OFTHISRECORD HAS BEEN PROVIDED TOTHE WELL OWNER
�-C ( , f2---I4-00
Tuft OF CONSTRUC'IINGT1iE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center -Baldgb, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONTRACTOR COMPANYNen� �,y r c i u iu try r suer i i a rr- .. HONE s getfintac,
STATE WELL CONSTRUCTION PERMITS ASSOCIATEDWQ PUMP
(if applicable)
WELL CONSTRUCTION RECORD ' 4 1 6 -) 3
North Carolina - Depariwent of Environment and Natural Resourcesf- Division of Water Quality - Groundwater Section
WELL tx1NTRACTOR gtenvmUAL) mama 1p ! [/�n C. Rh.9I,PS :T,l� czRTIFwton a 278Y.•
(ifapplicable)
1. WELL. USE (Check Applicable Box): Residential ErMunicipal/Public ❑ Industrial 0 Agriadnual 0
Monitoring El Recovery d Heat Pump Water Injection 0 Other 0 If Other. List Use
2. WELL LOCATIO •, N T 1`1 POLI0 N Caney MCA ,t�TM
J t
►LSO N Fw12-11A
Meet NamkNumbao Common* Sulalivisiaa, iaeNWTi4 Code)
3. OWNER: El=3Pu 1=1Ze ,
adryit or
CnyatTown Sena
Ara cods- Are umber
4. DATE DRILLED Co
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO (r
7. STATIC WATER LEVEL Below Top of CasingSr.
,, (11.. 1'' MAW". Tap afa nts)
8. TOP OF CASING IS i�) Ff. Above Land Surface*
nap Menthe terminated attar bedew Wdeurface remains a
°arbeme asmrdanee LSANCAC2CAl1L
9. YIELD (gpm): _ METHOD OF TE dP n
IQ. WATER ZONES ( ):
Z 87.5�
Tap Cade
11. DISINFECTION: Type Amount
12. CASING: WallThaneas
From � Two no Ft.:n
FuouL_To Ft
Front__ To Ft
13. GROtYF: Depth My•M
From To Ft
14. SCREEN' Depth
From To
From To
15. SAND/GRAVELPACK:
[ Depth
Fmm VDTo
From To
ciLand setting
Loge °SllTopogtao a °Valley -Olga
(c "mode box)
Latitudellongitude of well location
()
Latitude/longitde source:�SOTopograpbic map
(Meekboa)
P.EETR DRILLING LOG
From To , Formation Description
Diameter Slot Sire Material
Ft,_,in in.
Ft __in in.
She Material
Pt
F1.
LOCATION SXETCB
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common mad mains.
• 1 (4/33
N 35 e -73z
u (D (32J' b4 4'1)
S6AY— F1aL edsco TO
Zto N 12-0Pv)) —ft,
WlLSON tFpnwj
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE A TTE 15ANCAC 2C, WELL
CONSTRUCTION ST i e a. i THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
°a�Ikr�aNs1R /Z l5 OCo
GNATUREOFP UCIINGTHE 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 3 416 7 4
North Carolina- Dot of Environment and Nalmal Rmaaces - Division of Water Quality - Groundwater Section
w,taa, coNrnscron (INID1v1DUAr.) NAME / n G _PA Odps 3 outstemanore to 2 7 B y . .
WELL CONTRACTOR COMPANYNa�.� w �e e LA) tit Per WO/ /'T.��raoNa s gang"�oygo
STATE WELL CONSIaucaIONPERMITS ASSOCIATED WQ PERMITS
(ifapplieable) (ifapplicable)
1. WELL USE (Check Applicable Boa): Residentinl 0 Munuipallpublic 0 Industrial 0 Agricohuml 0
Monitoring 13 Recovery 0 Heat Pump Water Injection Other 0 IfOther, ListUse
2. WELL LOCATE) :: 1
Nearest T :.__L L QT 77 Cmmtywalk/E>LL)
hi FT(Sized NsaN mbta. Cannes ty, Sobdivime. Cat Na, Zip Cods)
3. OWNER: 1�i%
Address 01 t�/YL y nisei
laPo
(Seen orRoe )
OLD F*-r, Nil 2-8itc2.
Cray orTown Stye TapCbde
(Rze). '719— tY11f
Meacode-Plnoe saber
4. DATE DRILLED /Z// Pi/b to
5. TOTAL DEPTH 51-) n
6. DOES WELL REPLACE EXISTING WELL? YES O NO Er
7. STATIC WATER LEVEL Below Top of Castor
(Use• t ifAboveTop aWCbSg)
8. TOP OF CASING IS � R FT. Above Land Surface*
'Top of wing tentivated attar blow bad nine requires ,
verbena Is dneJC'SlSwxcA _
9. YIELD METHODOD OF OF TE M i✓a
10. WATER ZONES (depth):
LOCATION SICEra;
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
mambas and common road names.
TopograpMcaatnd setting
Midge 13Slope Malley a
(tat>!box)
Iatiwde/longiuide of well lion
( )
Latitude/longitude sometOGPSO opogtapbic map
&beck boa)
DRIIS.(NG LOG
From To Fonnation Description
11. DISINFECTION: Type [(.i-+ Amount 1 0 OZ_
12. CASING: Wall Thickness
Depth
�. �w
From To �bl Ill
FromL_To Ft,
Front__ To Ft
13. GROUT: Depth Material
stoat To f7 Ft CnA)Lt26
From._To FL
14. SCREEN: Depth Diameter Slot Sze Material
Front_(1,To Ft,____jn. in.
From To Ft�__in. in.
15. SANWGRAVELPACK:
Depth Sim Materiel
To Ft.
Fro
From
To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT TBIS WELL WAS CONSTRUCTED TN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_4,e/4_2�� iz. AA*
'^mr OF P TRUCTING THE WELL DA
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

0/0640ke- lirS1- �e762.
City or Town Sole Tap Code
( )- (05l1-965°)
Area code- Mae number
4. DATE MILLED j'lleAei 4- 06
5. TOTAL DEPTH: 202 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top ofCasing: FT.
tt)s_ "t" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surfaces
'Top of cuing terminated actor below land surface rewires a
variance is accordance with I5A NCAC 2C .0118.
9. YIELD(gpm): 9D METHOD OFTEST 4tIZ'
t 0. WATER ZONES (depth): .2O irk bt2 ''ZAt
I!. DISINFECTION: Type 610fie/it Amoud S O"L
1? CASING:
(St f `lamtm_ily, Col Ha_ Zip Code)
3. OWNER:6°CCOsi(/t�(,u,r`''t rtiYA Soh'
Address 533 ICrNDON r effi-cpfl
IStr-.a ar Route No.)
(Street
Depth
From O To 8C.) Ft.
From To brut? FL.
From 2P'To f 62 Fr
13. GROUT: Depth
from
34rl i63
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resouttes�- Division of Water Qua
NV ELL CONTRACTOR (INDIVIDUAL) NAME (prim) �"rTfI 5 (is--lc.G
%Y ELt. CON -TRACTOR COMPANY NAME SVST(G& (/%Ct4 ei/la4U4'
STATE. WELL CONSTRUCTION PERMIT# ASSOCIATED WQ P£RAIITp
(ifapliable) (if applicable) _..
1. WELL USE (Check Applicable Box): ReSuluRial 1�MtmicipaVPubtic 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ I f Other, List Use
2. WELL LOCATION:
Nearest Town: LD AM-
S )7 CQFot/32q�(t�eyy
Name Numbest C Svstmaamnd�
Di
County f A oe
Wall Thickness
atcriai
Method
To Ft.
From O To 90 Ft pe l
14. SCREEN: Depth Diameter Slot Size M crial
From To FL in. in.
From To FL in. in.
1S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft_
16. REMARKS:
Material
iiry - urv0miwa,i:r Sat3un
CERTIFICATION-
#
24
,f
PHONE t ( M2d -4$vP
Topographic/Lalld setting
❑Ridge ❑Slope p valley ❑Flat
Icbec1 agaopnatc boa,
Latitude/longitude of well location
OeeZ Cal ,tIAN VI 36°39 t 34(&
(degrees/minued )
Latitudc/longitude soumc: PS❑Topographic map
(check box)
DRILLING LOG
Fomration Description
DEPTH
From • To
`)C-- /20 /Ana-e-
f lit" ) 2 c
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
nund,.aa and common road names. O
C1
1.6Ptediel c
1 DO HEREBRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wifil I5A NCAC 2C WELLCONSTRUtt
STANDARDS, AND THAT A CCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a-t7
NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section. t636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], witbin 30 days GW-1 REV. 07/2001

FL
FL
Ft.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
WELL CONSTRUCTION RECORD
323761
North Carolina - Department of Enviromnent and Natural Resources
/- Division of Water Quality - Groundwater Section
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) gAvigi Tug TLr Cif [� ' l CERTIFICATION if 2/.S
WELL CONTRACTOR COMPANY NAME Sa .5 *Pit it - we�- D .f i IX ;Ai PHONE S (BO -72 y—ysv/B
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# /
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential (7 Municipal/Pubiic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection D Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: or o t ij- County
/yJ—DactWc ,
�/ 73 in ink, ceeclt: /u
(Sint Name Numbers. Comm ay, Subdivision. tot No- Zip Code)
3. OWNER:
/J c' L S e' -L. e inr yf t
Address . I173 MG.cIC.c7 5 ev as k
(Street or Route No.)
"nit fort A/C Z Q76 2
err or Town Sere Zip Code
( )- nil-- 773o
Area code- Plume number
4. DATE DRILLED Antic /% 06
5. TOTAL DEPTH: /6 S
6. DOES WELL REPLACE EXISTING WELL? YES D NO lY /O- .4/0
7. STATIC WATER LEVEL Below Top of Casing: /C FT.
(the "sue if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terwitated at/or below land surface requires a
variance in accordance with 15A NCAC ZC .0118.
9. YIELD (gpm): 7 o METHOD OF TEST A / /Z.
b0. WATER ZONES (depth): ZOt ! Oai be, /4fO
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longilude of well location_
,3SN ° do. 7a3 ,682 e o335W
(degrees/mimddsecaak)
Latitude/longitude sourcc:DGPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
11. DISINFECTION: Type CLOt NC Amount g bZ
12. CASING: Wall Thickriea,
or Weight/Ft. Material
Depth
From To
From 0 To 7L
From 7t. To %S/
13. GROUT: Depth
From To FL
Diameter
le ID,C
/ 9 R C./4/1/
atonal Method
From O ToL_ Ft. 'f'r,# t / Ably211
14. SCREEN: Depth Diameter Slot Size Material
From To FL in. in.
in.
16. REMARKS:
d- /0
rs- /ZO
/'L. e-1 00
$A-A4, f'...Foc*rat) Attie
t-
k
LOCATION SKETCH _ -
Show direction and distance in miles from at tasl
two State Roads or County Roads. Include tltp?oad
numbers and common road names.
ri r4�
r' 7—
t DO HEREBY CERTIFY THAT THI YELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, THAT A COPY OF 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 Mall Service Center -Raleigh, NC
27699-1636 Plume No. [phone], within 30 days. G W-I REV. 07/2001

32176©
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Qualty - Groundwimar Section
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) 6r4 L9 S0Sit GE CERTIFICATION ii Z 1 SO
Ns ELL CONTRACTOR COMPANY NAME SUS41.CS WC CC Dritii ! PHONE 9 425 nt'- Y599
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT*
(if a. thimble) (if dpplicable)
1. WELL USE (Check Applicable Boa): Residential LT Mtmicipal/Public 0 Industrial 0 Aericu1tutal 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: ell D Fort County MSOoLoea-
not. ec<rmr,_ Fc2to 4...ei.1e
(Street Name- Numbers, Commtmity. Subdivision. Lot ZipLot Ha_ Code)
3. OWNER: lkt.�IN .I-Na✓OVC
Address 1447Pb ey.F-,rFss X5ess.d ert.
(Sweet Or Rome Plea p4LPP (net.Ct 31.110
/o
Ciy or Town State Zip Code
tslfj) qys- 9s01
Area rode- Plume number
4. DATE DRILLED S— 22- 0 (n
5. TOTAL DEPTH: SD
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL Below Top of Casing_ /$O FT.
Dist '+-ifAboneTrpof
3. TOF OF CASING IS I FT- Above Land Surface*
'Top of ¢sine terminated at/or below Ind surface reatdaes a
variance is accordance with ISA NCAC 2C .01111.
9. YIELD(gpm): (p METHOD OF TEST .9%a
10. WATER ZONES (depth): 17 M t9 Said
11. DISINFECTION: TypeCCO.[j/Jc
1? CASING:
Amount 8td2-
Wall Thickness
Depth Diameter is Weight/FL Matalai
From To Ft
horn 0 To &f Ft #0,a
From 6 4 To I/ Ft. ./8Q aj __
Material Method
13. GROUT: Depth
tram To FL
From 0 To .7 .5.-
] 4. SCREEN: Depth
From To Ft. in in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
16. REMARKS:
FL ,0e /
Diarheter Slot Size aterial
Topogra hic(Land setting
ORidge IRclope Walley OFlat
(Check appropriate twx)
Latitudelioneitude of well location
35- 35: zbyU ,082./STng7
(dcgees/mimrtNseconds)
Latitude/longitude sourcc:OGPSOTopographic map
(check box(
DEPTH DRILLING LOG
From To Formation Description
O - G2
42- 5- s Crert-({e
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the rand
numbers and common road names_
1 DO HEREBY CERTIFY THAT WELL 11HAT THIS WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONSTyjQ RDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
E 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. G W-1 REV- 07/2001

Topographic/Land setting
❑Ridge OSlope QClley OFlut
tetorcA& arm.q._e.
Latitude/longitude of well location
2c°3y, (De9 as 082"Mt 6N3
S. OWNER: ee12•
(dcy..�fitinuies/saonds)
L - titudeAongitude sourcc:OGPSOTopographic map
n ltlsck box)
ascgn DRILLING LOG
\ \titiat 1� Ntta NO)
G
City or Town
329756
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturai Resources �-7'-Division at Water Quality - Gairoundwe Section
\1' ELL CONTRACTOR (INDIVIDUAL) NAME (print)'R"IZL.f J'l15r11�/n4, �}.- (yam
%YELL. CONTRACTOR COMPANY NAME �� /E L,UeJ /LPHONE ! j a"AJ24' 543
STATE WELL CONSTRUCTION PERMITY ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential c Municipat/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Beat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: y ,(� ,, �(f �'
Nearest Town: (rh, ez» t County / Y t `-N'xC^Q
50 0 49"er,e Lie 6Ld
(Street Naas. Numbers. Community. Subdivision. Lot No_ Zip Code)
Address
✓y,M
(`bt )- -i 4 - G/7o
Area code- Phone number
4. DATE DRILLED 5in/ (0
5. TOTAL DEPTH: / 25
6. DOES WFJ r REPLACE EXISTING WELL? YES 0 NO 0-7
7. STATIC WATER LEVEL Below Top a Casing: D FT.
(L se "+-" if Abort Tap of Casing)
S. TOP OF CASING IS FT. Above Land Surface'
'Top of cosine terminated anor below land surface reunites a
variance in accordance with ISA NCAC 2C Atli
9. YIELD (gpm): 3 D METHOD OF TEST
in. WATER ZONES (depth): 7j U . I/) 11A e ) 00'
I L DISINFECTION: Type C L.CYL 1%e
1? CASING:
Dep±
From 0 To S L- FL
Amount
!Volt Thiclouss
or Weieht/FC Material
pre.
From $?- To 72- Ft. (P VO PVC
From 72 To l)L/ Fi.
I3. GROUT: Depth
i-rom To Ft. n
From (0 To (0O Ft. tyfe 1/2 Y'(%iJ'l 'i
m
14. SCREEN: Depth Diameter Slot Slot Size Material
From To FL in. in.
From To FL in. in.
iS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft_
i 6. REMARKS:
CERTIFICATION A 21 S (J
Zip Cade Formation Description
DEPTH
From To
p-/0 Di arc
I o- �o S�twd 6✓t,Fu e
(flu - /2 C yA,vw;1-o
LOCATION SKETCH
Show direction and distance in miles from at leas(
two State Roads or County Roads. Include the road
nutrdx.rs and comnron road names.
0
�3 A
N
cm
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WF7 L
CONSTRUCTION Spt DARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1 i
' S(GNA�tJRE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,.
27699-1636 Phone No. [phone], within 30 days.
DATE
theater Section, 1636 Mail Service Center -Raleigh, NC
GW-I REV. 072001

WELL CONSTRUCTION RECORD
North Carolina - Department of Enviroitor:tit and Natural Resources- Division of Water Quality - :,roundw tar Sot n00
(rrin-4f fQs is
VEIL CONTRACTOR (INDIVIDUAL) NAME (print)
\YELL CONTRACTOR COMPANY NAME
STATE %%TLL CONNSTRUCTIO? PERMIT# ASSOCIATED WO PERMFFA
(if aapticable
329755
CERTIFICATION a22/
TUSII';c5 (,-%etc j ,-:t i
(if applicable)
PHONE X (LC-1i&»L 7S(4`
I . WELL USE (Check Applicable Box): Residential LY Municipal/Public 0 Industrial LJ Aericuitutai u
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 II -Other, List Use
2. WELL LOCATION:�, TopographiclLand setting
Town: Count
Nearest To ALB -G I -Co t Ili f7'etat -1 gRidge DSlope ❑Valley DFlat
Latitude/longitude of well location //
3So'Ji%t O/n9/IJ UD4 /i,(degrees/minutes/seconds)(degrees/minutes/seconds)sonds)
Latitude/longitude sourcc:IlOPSDTopographic map
F�S(check box)
, 3/ e11 , 4, tees, e
DEPTH
Zip Code From To
f S- 11(.�- ran
Area code- Phone number
4. DATE DRILLED 5 -/5"- 04 0 - ivo D e1 Srj&Jc
5. TOTAL DEPTH: yess U
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Qt.'''. /00- 1,. 05`
7. STATIC WATER LEVEL Below Top of Casing: / FT.
(we ifAboveToo ofCasing)
S. TOP OF CASING IS / FT. Above Land Surface'
'Top of matte terminated attar bIew toad surface rcanit6 a
variance in accordance with I5A NCACIC -0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): J5-1/0M by
II. DISINFECTION:Type Clo%ir(/1 Amount g dL
12. CASING: WanT.hislmess
Depth Diameter or Weight/FL Material
From 0 To FL
From 0 To //0 Ft. t D nL°
From no To it FL
13. GROUT: Depth
From To Ft.
From 0 To 2 5" FL 'host
14. SCREEN: Depth Diameter Slot Size Material
From To FL in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
DRILLING LOG
Formation Description
(Strcet Name. Numbers. ComJmon unity. Subdivision Lot No, Zipe) Cod
OWNER: de%i-e-077/6
Address La r / 3 i $C/ At//c1,4 1Cetke
tSitea or Roue Ito.)
fevf We J%76
AIW
Material Method
16. REMARKS:
C/r79/✓, f- e tOi t
po �At
LOCATION SKETCH ��
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and collet road names.
/r
c_. C
c-.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
CONSTRUCTION STANDARDS, N ThAT A CoPy o mis 1tECORJ) HAS BEEN PROVIDED TO THE WELL OWNER
\
GNt p'E]CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-322!, within 30 days. GW-i REV_ 07/2001

WELL CONSTRUCTION RECORD v 3 H! i 5 8
Section
-
North Carolina - Department of Environment and Natural Resources - Division of Water n' relay - irriiurwwaav a.:wn
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (7R t-1 ru<f/L'� CERTIFICATION e/$0 �j
i ?DONE Y f'�912/,,t re/cf.
'.V ELL CONTRACTOR COMPANY NAME 5054-1 el (fiat n f C 7 /C/
STATE WELL. CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS
(ifapplicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential t Municipal/Public 0 Industrial D Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: 11
(Strnv -
U6: AbNcarest Town:W"orr;M$ okAsib.Il jCounty
Nana Numbers.Co mnny. Subdivision. Lnt Nil Zip Cat
3. OWNER: C✓04J1/ £t6.
Address ; z. !Nor we f/J F V4Ls
IStre^.t or Roue No.)
MAx{°N r1NpC- 87.52
( Fy Town Stain WfS-j/ D7 �caa�
€&
Area code- Phone number
4. DATE DRILLED S/iis/ 01
5. TOTAL DEPTH: 7rp'a
6. DOES WELL REPLACE EXISTING WELL? YES INC 0
7. STATIC WATER LEVEL Below Top of Casing: IS FT.
(t is "+- if Above Twat -Casing)
8. TOP OF CASING IS / FT. Above Land Surface
'Tap of casing terminated attor heMw band sartate retains a
variance is accordance with ISA NCAC 2C At18.
9. YIELD (gpm):.?O METHOD OF TEST a IX
10_ WATER ZONES (depth): .2O VFW e /30
I I. DISINFECTION: Type !! Lo/2VAw' Amount 8 p2
12_ CASING: Thidmc
Depth .J'qar Wcigbr/Fr. Maudal
From 0 To I.
_, kOVG
From 60 To _
From $0 To A Z
13. GROUT: Depth
FL_ _a_ pile
(q.4LU
Matvial
From To Ft.
From 0 To 2 S Ft i.j'yy� p.e /
14. SCREEN. Depth DiamOer Slot Size Ma
From To Ft in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
IG. REMARKS:
Topographic./Land setting
°Ridge °Slope QV -alley °Flat
(check approprratc Mal
35atudeAougitude of well location
y;.53-wont Q/.070 W
(d-win-,A. items/seconds)
Latituddlongitude sourcc:t♦IGPS°Topographic map
(check box.)
DRILLING LOG
Formation Fleveription
DEPTH
From To
D - Too 4)121-
cao- 'iS hh(XPei)
7r (b5" reed )4e) Sr
• ytwe a/z%
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
whdret, and common road names.
kiaiks
f""
,4Ca5
u
ktood
6. PASS
ZZi. 2.2 f.
t` )
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS. ANTHAT COPY OF 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 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (9t9) 733-32221, within 30 days. - GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of -Water Quality - Groirrd-w:tar S
%vELL CONTRACTOR (INDIVIDUAL) NAME (print)
\\'ELL CONTRACTOR COMPANY NAME
329759
t/ \�% G CERTIFICATION A Ca)
—� �-( /� p
ytjsf G /yie� 'gl
ad (t'�HONE x (}T2E)_n v-lj,rvE
STATE WELL CONSTRUCTION PERMITi \CWr)f7ATED WQ PERMIT.
(if applicable) (if applicable) ...
1. WELL USE (Check Applicable Box): Residential 01 M(micipaltPublic 0 Industrial L] Agricultural D
Monitoring ❑ Recovery 0 Heat Pump Water injection ❑ Other 0 110ther, List Use
2. WELL LOCAT : •
Nearest Town: Mai OP-/
020 USl kg /2.(
County
(Srrcet Naar Numbers. community. Subdivision_tot No.. Zip Code)
(c. 3. OWNER: e,r . tsr'a/e-
Address 70 Si] SY) C j 12-Q
(Smut et Rears tun.)
4jyr4/ 4�I 1J C- 2€2sZ-
Latitudellongitude source:
City or Town Saco Zlp Code
(828)- it 52-410 e
Ana rode- Phone number
1. DATE DRILLED-5//8/0 6
5. TOTAL DEPTH: /4 5
6. DOES WELL REPLACE EXISTING WELL? YES ? NO QY'.
7. STATIC WATER LEVEL Below Top of Casing: / n FT.
Ilse a+" if Above Top ofcvmvgl
3. TOP OF CASING IS ( FT. Above Land Surface'
'Top of casing terminated aUor below Ind surface requires a
variance is accordance with 15A NCAC 2C Atli
9. YIELD (gpm): (PO MkTHOD OF TEST /4 //L
ID. WATER ZONES (depth): , O Vote-t Q / ZO
IL DISINFECTION:Type] IOC. A-'C Amount 0%
I? CASING: Wall Thickness
From t)
From 7r%
Depth
To r? Ft.
To-firFt
From q To Q9 FL
13. GROUT: Depth
From To Et.
Fr^ . C9 To 70 Ft. die /
Diameter or Weight/Ft.
it/u 90
_
Material
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.
16. REMARKS:
O
DEPTH
From To
Topoglaphic/Lan afting
°Ridge °Slope C alley DFlat
(cha1 uppropnate tux)
Latitude/longitude of well location
(dggeeshninates! )
SUTopographic map
&heck box)
DRILLING LOG
Formation Description
1 rP ,5 7-2
gym ra Seale- ahtc
too - /3o etc-44c
/ 30- /Lir 6/24t-4vi1-e
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common toad names.
ALE —
L r
;—: -
C
lil. d
Gzj-226
is t.[lss»cS'S
1 DO HEREBY CERTIFY THA THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCRC 2C WELL
CONSTRUCTION STAND Li i , AND THAT A COPY FTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG DfATUR 3F 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
u

WELL CONSTRUCTION RECORD
32S757
North Carolina - Department of Enviromnent and Natural/�RcsouuttesJ- Division of Water `Quality - Grounsivater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (I,,�./!i�!' +) vie/�-'!rr CERTIFICATION it Z/�
rt'ELL CONTRACTOR COMPANY NAME _7 V7r1 e.F C✓LXe a r fail PHONE R (&g) 72 Se- 4 r .g
STATE WELL CONSTRUCTION PERMIT* ASSOCIXTED WQ PERMIT#
(if y cable) (if applicable)
I . WELL USE (Check Applicable Box): Residential E' MunicipaVPublic 0 Industrial D Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 t IOther, List Use
2. WELL LOCATION:
Nearest Town: t L b for/
.4O1- //7
(Street Nave_ Numbers. Community. Subdivision. Lot Net.. Zip Code)
3. OWNER: Yr k Hum/iec.
Address /1r./o /,(Jf'f'h. iC5 jar
(Street at Route Re.)
.j\910&1r NC
tyor
Town `Q)- LItoo-Is �
Area code- Phooe number,
4. DATE DRILLED S` ZS O G
5. TOTAL DEPTH: /o m S'
6. DOES WELL REPLACE EXISTING WFI 17 YES 0 NO Er.
7. STATIC WATER LEVEL Below Top of Casing: G 0 FT.
ltbm "t-- if Abate Top of caing)
8. TOP OF CASING IS / FT_ Above Land Surface!
?op of casing terminated aUor below land sulfate moires a
variance is accordance with ISA NCAC 2C out r1
9. YIELD (gpm): 2 METHOD OF TESTA/2,5+��
10_ WATER ZONES (depth): /ej m. P S e6'
/ gPli pAmotent
Wall Thickness
Depth Diameter or Weight/FL Material
From To Ft
From m To6— FL
From (p% To /0 9 FL
13. GROUT: Depth Material
From To FL t n
From 0 To 2 Z FL r2 / rye P6m,'
14. SCREEN: Depth Diameter Slat Size Material
From To FL in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
11. DISINFECTION: Type
12 CASING:
County /n -1Avea-
'037
rip Cock
tie
/88
16. REMARKS:
l DO HEREBY CERTIFY
CONSTRUCTION STAND
L
Submit the original to the Division of Water Quality, Groundwater Section. 1636 Mail Service Crater -Raleigh, NC
27699-1636 Phone No. (919) 733-37-1I, within 30 days. GW-1 REV. 07/2001
Method
ographic/Land setting
'dopge ❑Slope ❑Valley ❑Flat
Nista. appropriate Donis
Latitude/longitude of well location
$S° 3S• of 3 /✓ o E 2 e y SGo t.✓
(dcsms'nainutesluconds)
Latitude/longitude sourcc:❑GPS❑Topographic trap
(rued boat
DEPTH DRILLING LOG
From ' To Fommtion Description
m _ C o ,D r /Lf
ba- G etc- 9✓1.Nw >/-e
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.
•/s Ls I l !7
C_
c
r--
THIS WELL WAS CONSTRUCTED IN , - •RDANCE WITH ISA NCAC 2C WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTING THE WELL DATE
C�
elm)

WELL CONSTRUCTION RECORD'
1. WELL USE (Check Applicable Box): Residential 0' Municipal/Public ❑ Industrial O Agricnlbaal O
Monitoring O Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIO
Near ,To f rThrd Cotmty /2) C41 t> -7(
(Street Name, Nowlin
%%Commmity. Subdividao. No. rip Code)
3. OWNER
Address
(O n- l SlV"'1'3A 1 �°�e
Atn code- Thom aambct
4. DATE DRILLED
5. TOTAL DEPTH:�� c� /
6. DOES WELL RE. EXISTING WELL? YES 0 NO E�
7. STATIC WATER LEVEL Below Top of Casing: 9 (9 FT.
(Uu "+- if Mon Top of Cuing)
8. TOP OF CASING IS / AbFT. Above Land Surface'
'Top closing classed near below land stem requires a
Mum In accordance with 15A NCAC 2C .0118. ``
9. YIELD (gpm): /C METHOD OF TEST C�/Yi 0sr
10. WATER ZONES (depth):
T�pogi bi /Land setting
!]Midge QSlope OValley DFlat
( ba)
Latitude/langitnde of well location
(degrx+/mimndiecmds)
Latitude/longitude source:OGPSQTopogtaphic map
(Meek box)
DEPTFI DRILLING LOG
From To Formation Description
J c
11. DISINFECTION: Type c2i -c/c Amount __UAL_
12. CASING: Wall Mica=
Dreier or Weight/Ft Matetial
Fro To l., Ft
FromTo Ft.
From_ To Ft.
13. GROUT: Depth Material /% Method
From To�7 Ft. e" rr r -7From To Ft.
14. SCREEN: Depth Diameter Slot Sin Morena!
Front_ To Ft is is
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Sim 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.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HnS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Stction, 1636 Mail Service Center - Raleigh, NC
714441-I536 Phone Ye. '919) '3:-3221. within 39 days. G w '. 77i:001

1. WELL USE (Check Applicable Box): Readentis' eT MtmuapaVAtblc 0 Industrial 0 Agricultural O C::,;
Monitoring ❑ Recovery 0 Heat Pimp water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION�// y�Cj/ /
Nearest Tows llG�i i County 4/ / d2✓v( l
gay. /ro5S/�j
(Siren Name. Number Cemmtmiry, Subdivision, Lot No.. TT Code)
3. OWNER: t3<. /,,-7i„ f1
Address gO),c (1ko'sS
� /eos S
City or Tenon Sues _Tap Cado
(8)�- 9 c, G r if,.3 .3
Ain coal Phone amber 4. DATE DRILLED 57 _C 6
5. TOTAL DEPTH: eQ '
5. DOES WELL .REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing FT.
(Use "+ it Above Top of Casing)
3. TOP OF CASING IS f FT. Above Land Surface*
*Top of cuing wrze nied arfor below land Then regains a
melon 1e accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / X METHQD pF TEST r?f i7 /
10. WATER ZONES (depth): 9-)
11. DISINFECTION: Type. �� Amonntr / Ih
12. CASING:
f
From /�rp To. r Ft.
From_ To Ft
From_ To Ft
13. GROUT: Depth Method
From To 95 Ft Main" —
From To Ft
TopoggpimulLioad setting
°Ridge Malley °Flat
(check appcoPrista box)
Latitude/longitude of well location
(dspaQ/mmou/se oods)
Latitude/longitude soma.OGPSOT opographic map
(check bat)
DEna DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
Wall TLitdmm two State Roads or County Roads. Include the road
Manger or weight/Ft M as lumbers and common mad names.
OtreC C tress
" i
14. SCREEN: Depth Diameter Slot Size Material
From To Ft
Frond To Ft in.
15. SAND/GRAVEL PACK
Depth Sim Material
From To Ft
From To Ft
in.
in.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITIi ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HnS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
176a0.1634?Mee No. '9191 -7i:221 within 30 days. 0_._00i
----. vw-� �v. u,l..VVt