Md CY2006

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanmcnt of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
'Rt,VS3); (LA LP(A3e,LL,
Well Contractor (Individual) Name
(C .()(e a C A1_0oi 0.-1‘_L,1fa(pWell Contractor Company Name -1 1 ��
STREET ADDRESS 35 I f' B(a t331C(i�lE',UC. 1-1Wy
Asfbbl1 tt ¥C aggo6 /
City or Town Stale
(cat>• a,s4 - 3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply G/
DATE DRILLED ^ 1 — O G
TIME COMPLETED kV. O o AM 0 PM 0
3. WELL LOCATION: c�
CITY: GARJOil�'J�)LLe COUNTY Mt 1...35b
' J (i Gt-3n)S
(Street Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Corse)
TOPOGRAPHIC! LAND SETTI G:
❑Slope °Valley ❑Flat n4dge °Other
(check appropriate box)
LATITUDE 3 2_`1 J.`'L(,f
LONGITUDE 7 3 v
May be in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: F3G'PS °Topographic map
flocahun of we# must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER `1 [� /�I
R1-
OWNER'S NAME Y"lQ `JR�'W Az�o �o _AV 1r
STREET ADDRESS 51 ba c-toltS UZI V E
fl`GL lk n3lA GA 3 (R 3 g
City or Town State Zip Code
< ). a-1 -1— sc b 4-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Id
505'
c. WATER LEVEL Below Top of Casing: p D FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. /j (f
e. YIELD(gpm): 6 METHOD OF TEST (Z1G-A1 (2—
Submit the original to the Division of Water Quality within 30 days. Attn: Info
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 51
Inform
100 HEREBY CERWY THAT MIS WELL WAS CONSTRUCTED N ACCORDANCE WIN
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER �/1
SIGNATURE OF�D WELL CO� -/ DA7E
L.Lllsp 1iAs4j J
PRINTED NAME OF PERSON CONstc fivE1 LL
Mgt.,
8.
FEB 07 2006
Form GW-1
Rev. 7/05
I. DISINFECTION: Type
g. WATER ZONES (depth)
From ( b O To 1 L J From To
From 33t1, To Sal From To
Fran To From To
Amount 1 a OZ
6. CASING: p Thickness/
From Dlhl DNJ FI. l@y?)eler 5 &i M er
From To Ft.
FD� U
ToSX
From To Ft.
7. GROUT: ,,11 Depth
From 4- To at
From To
From To
FI.
Ft.
Ft.
Material 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 FI.
10. DRILLING LOG
Frome
T9 6'
Ibt'
1 lei sto/
Sao'- 3a1'
Sal' 5D5/
11. REMARKS:
Size Material
Fgrmation Description
G 2,4 r V-r L�:4 - '3 CD err,.
C RAN/TCam,
!-Q1s t - a C3?m
GO-Ar1ITS,
L
fV
J
0
cs
13 06
a
Asheville Regional Office
Aquifer Protection

NoneCaroline • w?erfrrard al Er,ronment end Natural Reaotreee • Derision of Water Oueey • Groundwater Seodon
1431 Mall Service Corder. Pali*, N.C. 2750/•163S•PIIda (ale) 723.3221
WELL CONSTRUCTION RECORD weLLcorn-mot* (7e-A-, Li 4k
WELL CONTRACTOR CERTIFICATION tl1 211 3
STATE WELL CONSTRUCTION PERM1Te:
t. WELL USE (Cheek ApplWebn Sea): Resldantlel{'J ►lurk al❑ Mon ng ❑
Redowry ❑ Heal Pump Water Injection er 0 Ior, Uolel 0 Agricultural
❑ Other ❑ fl0tller, Usl We:
2. Newest tlCATt�Q`
)S w ska II ylhe kaftan below)
/ Coo y:
h' Z!3
sus Na end tier ben, Csnn.ty, or Sulpheaun end Lei Ne.)
3. OWNER Snu fhe,e4/i uiY1G S
Address ( ' 14 j f Aor 7/L
(Street et Neon Nol
City et Teen Stale Zip Cede
4. DATE DRILLED 3-Z7-os-
5. TOTAL DEPTH 1 (a,C
E. CUTTINGS COLLECTED YES ❑ NOEr
7. DOES WELL REPLACE EXISTING WELL? YES [] NOer
8. STATIC WATER LEVEL *Now Top of Casing: FT.
Nee "es 1 Above Top el Carp)
9. TOP OF CASINO IS_ / FT. Above Land Surface'
'Top at enhp ferminand alter brow lend aurraee !squires a wahines In eeeor.
dense with TEA NCAC 2C .a11e
10. WIELD (gpm): 4i METHOD OF TEST /(2i)
11. WATER ZONES (depth)*
Cl
12. CHLORINATION: Type Amount
13. CASING:
From
F ram
From
14. EIROUT:
From
From
15. SCREEN:
Depth Demme
To FI
To FI
7o F1
Wet Thleknass
err WWNFL MWdr
!/
Depth Material Method
To 'a-U Ft < QM ef✓ r
To FI
Depth Dlameler Slot Size Maledal
From To _ F1 _ In. In
From To Ft In In
From To FI In. In
16. SAND/GRAVEL PACK:
Depth Size Msledai
From To Ft
From To Ft
17. REMARKS:
/l'l,adlsoc�
DRILLING LOG
From To
/- 25
2Xn
ly/—ZY/
Zve-365- e-rR�4,u,f
DEPTH
Forrnetbn peepyup,
i•e
�-9�,v•f-er
_C,eer/rtL
I1 addNonol space Is needed use back of knn
LOCATION SKETCH
(Show direction and dinette from al Weal two Stets
Roads, or other nap reference paints)
1130 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS RECORD HAS PEEN PROVIDED TO THE WELL OWNER.
:-
0
FOR OFFICE USE ONLY
Cues Na
4.21
�On ,Q 4c ied
/5faro R
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Iubrre odSklr b WNW el Wile o altty. 0Iavorrraaj3 ccarlItArL30.daya
own V*V. leas
Asheviiie fer`jon a+ C'`!f;.=,
1

North Carolina . Department of ErMrerrns t and Natural Resource* - Ofvlslon of Wider Pueaty - OrormdwSamba
1631I Mali Sarvka Cantor - Rehash, N.O.276116.1436-Phan* (915) 7E3--1721
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
C(e,4R 1J44e/L
WELL CONTRACTOR CERTIFICATION M: Z 11 `?
STATE WELL CONSTRUCTION PERMITS:
1. WELL U9E (Cheek Appllcebta Sea): Residential 0 Municipal ❑ Industrial C3 Agricultural 0 Monitoring 0
Recovery 0 Hest Pump Water Ingsotbn ❑ Misr It Mar, Usl Use:
2. WELL LOCATION: (Show 'Itch o) the location below) 1
lamest Town: MY)r4R i f�/ Can,: MA d/SQ4
f{(✓ykJ 2/ 3
(Rose dame end Number*. et d�a and Lai No.) ORILUNG LOG DEPTH
3. OWNER feti-/i O Ae�`j�5
Add
(Rob To
Fa rwden
AO, leot s,3� l^/0Q Om.
nm-g s lzif7aa (Emma" c.. '" 2 3 7S� � � 2 — ! 9 o G.PAn, i f
Oty sr TowsIw yp Cede G4 ea
4. DATE DRILLED : -06
S. TOTAL DEPTH 2-
S. CUTTINGS COLLECTED YES Q NOar
7. DOES WELL REPLACE EXISTING WELL? YES NOe
6. STATIC WATER LEVEL. Below Top o1 Casting: FT.
One •.• E Abase Top d Carp)
9. TOP OF CASINO IS / FT. Above Land Surface'
*Top of casing 1ermlnoted aver below lend soften requital a va.lsua en sever.
dances wls 154 NCAC 2C .61111
10. YIELD (ppm): _ METHOD OF TEST R
11. WATER ZONES (deplh)-
12. C:HLORINATION: Type Amount If additional span W nosed us* beck of loan
13. CASING:
war tNesnn LOCATION SKETCH
From Depth h FI Demeter er Wet* eR. P1.4210111 G (Show direction and distance Iron el West two Sista
Ronda, or other map serene. pants)
From To Ft
From To Ft
t4, GROUT:
Depth Material Method
e.
From / To 2 0 Ff C e/h .k.-{'
From To FI
15. SCREEN:
Depth Diameter Slot SI26 Material
From To Ft In In
From __ To _ FI In In
From To _ FI. _ In. M
16. SAND/GRAVEL PACK:
Depth Site Malarial
From To Ft m A,c3 ){wy
From To Ft //
17. REMARKS:
)'" r
Z/3
w4_/et
set cJe c,e. $/476uJ
4.'4 J 'C
1 'DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BE PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ' �f
owd N*:
Send No.
NATURE OF PERRON CONSTRUCTING THE WELL DATE
Submit original N OMslon of Wets Duey. 0round/Met Seem within 30 days
W.1 REV. 12M
In .CERV u:D
Asheville Regional Cffice
Atloiter PIc4ecfion

North Carolina • Department of ErM,orwnsnt and Neon! Resources • W nylon of WMSt Query . Groundwater
1030 Malt Servks Censor • RYelph, N.C. 27e14•1030-Phan (eta) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
C/eA/Qw.4 /e.e
WELL CONTRACTOR CERTIFICATION 0: Z//3
STATE WELL CONSTRUCTION PERMfTIt:
1. WELL USE (Check Applicable Set Reeldentiatla Municipal
Reaov Other
,ern Ust ❑ Agricultural 0 Monito 1 []
«Y ❑ Heat Pump were. iryeclbn ❑ OIMr (] R Other, Ltst Use:
^g
2. WELL LOCA11 : (show Ayer,, 0 the location below) /
Nonni Town: A•�P !-f• ( D,,.yt. /i1Ad/SGt.�
4-,t0/9-re S Cat` //. /16�/
1 ea Name end remain, Cenmunky, or SuklGslsn end 514 No / DRILLING LOQ
3. OWNER L/P/C /-tpC Ve,9n/ //itf fo1L /71PAef Rem To
Address 6_'247 //'Jy 2s/i4 A1Ae.s/A/I 1— O
t§k«t et Norge No.) C 0— 6 0 y
AQV
/!S%v /.76-
Ore or Town 6tele
4, DATE DRILLED 3- 21-64'
5. TOTAL DEPTH
0. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES [] NOES"
S. STATIC WATER LEVEL Below Top of Casing: FT.
I. twee'.' a w AbsTap el Cali* TOP OF CASING IS / . FT. Above Land Surface'
*Top of casing Isnnins.d saer below land swflce requires e rodent, In anon
desrwu wl h 11iA NCAC 2C .011111
10. YIELD (gpm): , CO METHOD OF TEST
11. WATER ZONES (depth).
Zp Cede
12. CHLORINATION: Type Amount
13. CASING:
Wet Thklnea
From /Depth Otaryler er "DWI-
�1s4del
To Ft f'l/ L
From To Ft
From To Ft.
14. GROUT:
Depth From % . To 2. 0 Ft C A e-.-- t Method
From To F1
15. SCREEN:
Depth Diameter Slot SiLi
From To _._ Ft In ._ In
From To F1 In In
From To _ Ft. In. In
10. SAND/GRAVEL PACK:
Depth Sin Maledel
From To Ft
From To Ft
17. REMARKS:
Matedal
� DEPTH n
Y7J/4p SA /`ac/C
i'r/PAAJr¢e_
r/Peei 4 Z
6-4
If additional space b needed use back at lone
LOCATION SKETCH
(Show dine lon and dietaries Iron at Nail two Slats
Roads, or other nap retaraetee pcln s)
$ AR N AALkO "/C ilc
u)
0
O
1130 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO," HAS SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ones NOT
Sidle No.
i
NATURE OF PERSON CONSTRUCTING THE WELL , DATE
Submit odynd b DOW* d Wider , nitro—ur hotel beWn within 30 days
RECEIVED
ED
1 REV. tam
i
Ashevilie Regional Office
paTiifer) et; tect on

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. (45V240E U---E .
WELL CONTRACTOR CERTIFICATION #: 2 / / Z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town:7174t @ft 4 County:
Wcc l/, r /J ra Hck red.,
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Migrrn✓ & iS`lci (( From To
Address Wu' may' 0 _ '7S
"Street o Route No. 6 A 2 C 8
iYCt� tiI/ jW. •?A75Y .7a �3ct
City or Town State Zip Code
4. DATE DRILLED-I-a3-Q(,,
5. TOTAL DEPTH U C./S
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF
8. STATIC WATER LEVEL Below Top of Casing: J. U FT.
(Use •+' 0 Above Top of Casing) r
9. TOP OF CASING IS I FT. Above Land Surface*
'Top of casing terminated et/or below land surface requires a variance In accor-
dance with 16ANCAC 2C.0118 n Fi'.'7ni i ) 2!"v
10. YIELD (gpm)• -4 METHOD OF TEST ;PIA
11. WATER ZONES (depth) ASIIBVIIIP Rar�ipr)a1 Off1Ce
DEPTH
Formation Description
ai+./Ftct Ar/l'it .
1ACF14-2b .
12. CHLORINATION: Type
13. CASING:
T7..j.
Amount a
Wall Thickness
Depth ter or Weight/Ft. Material
From d To 7S Ft 2:r/ r PIA
From To Ft
From To Ft.
14. GROUT:
Dept)),1 Material Method
From d To =r0 Ft LDrrt v /Uf,r.e"
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft in
From To _ Ft _ in
From To _ Ft _ in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft
From To Ft
17. REMARKS:
Material
in
in
in
Material
�.�/_,1P
S»- _ 3s- 7
jstt, 9 d s
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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:
i/ dad item Mv»S //Z 3/66
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No
GW-1 REV. 12/99

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) _
WELL CONTRACTOR COMPANY NAME i'fpp IAA' !AN
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
324395
au b'�N,� CERTIFICATION t�'oQb',�q �}
kirei AN PHONE # (in t�gt3 %Olilp�
.ASSOCIATED WQ PERMIT
(if applicable)
I. WELL USE (Check Applicable Box): Residential lld' 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:1A1$ ke I 1
County'.YAQI SON
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: BN-lched I
�ylJ
Address a,� 36X. Van l''i tweet or Route No.)
CA VI(c, n�c. ai411-
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED a7(000
5. TOTAL DEPTH:_v 5
6. DOES WELL REPLACE EXISTING WELL? YES O NO 51/---
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
Topogra tciLand setting
DRidge lope ❑Valley ❑Flat
(check appropriate box)
Latitude longitude of well location
N,35 5CD. (05a W$9'30. (M
(degrees/minutes/seconds) C42a�
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
8. TOP OF CASING 1S i FT. Above Land Surface*
*Top of easing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): I.s METHOD OF TESTA/ �Lt.1id'/NIQ,F
I . WATER ZONES (depth): 9 5'
11. DISINFECTION: Type J&13(.t Amount 02,
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To '7"� Ft.
From To Ft.
From To Ft.
13. GROUT: Depth in
From To V Ft
From To_% — F
14. SCREEN: Depth Diameter Slot Size
1-rom To Ft. in. in.
From 'fo Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
I6. REMARKS:
Material ^Method
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.
RECEIVED
Asheville Regional Office
Aquifer Protection
I DO HEREBY CERTIFY THAWHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONST CT1ON ST NDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE
F PERSON CONSTRUCTING THE WELL
ATE /rJ`Q
Subm the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION CORD.
North Carolina - Department of Environment and Natural Resources - Division/of Water -Quality GramdwaterSection
WELL CONTRACTOR (INDIVIDUAL) NAME
(Priat)/�J///te'n /C R/ L,d s `i t? -CERTIFICATION # Z
WELL CONTRACTOR COMPANY NAME ``—tU( F. Lei414 .2 e// 9 PL'ivc1 /� PHONE # Pt) e4/9- _'z?0
STATE WELL CONSTRUCTION PERMI[# ASSOCIATED WQ PERMIT/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential LY� Municipa1/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery Cl Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: /
Nearest Town: f i9)i/S/1I%t// County 12,9 / 5O17
y 04K/r/ Cinnreennn R,i 7F75'?
(Sneer Naar, Numbers, Ccmmmmity, Subdivision, L« No., Zip Code)
3. OWNER: i)NO/ 44/4/e/
Address �1 cal( [y Fi^eeenni Krl
Route No")
d i9S/AT file; Z? 75-3
City or Town State Tap Code
Area coda Phone mamba
4. DATE DRILLED 3-2 - C 6
5. TOTAL DEPTH. IDs'
6. DOES WELL REPLACE EXISTING WELL? YES NO Er--
7
. STATIC WATER LEVEL Below Top of Casing:
(User ." if Above Top of Casing)
Topographic/Land setting
ORidge p ope OValley OFlat
(check appropriate box) , rat
Latitude/longitude of well Location ce
(degrees/Smiles/seconds) �
Latitude/longitude source:OGPSOTopograehicsinap
(deck box) '� �)
DEPTH DRILLING'�LOGK
From To Formation Des xipt n
8. TOP OF CASING 1S f lr'i n/ FT. Above Land Surface'
*Top of casing terminated at/or below tad surface requires a
variance in accordance with 1SA NCAC 2C .0118.
9. YIELD (gpm): 3 METHOD OF TEST // M f27
10. WATER ZONES (depth):
11. DISINFECTION: Type C'
12. CASING:
From0Depth
To 50 F
From To FL
From To Ft.
13. GROUT: Depth
From To 2- 0 F S
From To Ft
J,O('.ATION SKETCH
(� /f Amotmt / f) v Z Show direction and distance in miles from at least
Wall Thiclmess two State Roads or County Roads. Include the road
numbers and common road
jThePeterij CA%v 5' Yee/
Material
t "One/,.
ore
r W ' t/Fk
-0
.o
CD
Method
wee max
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
O
materilitX,‘�
c6or
r
st
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2G WELL
CONSTRUCTION STAI ARDS, AND THAT A COP) nF7HIS RE¢ORD HAS BEEt ROVIDED TO THE WELL OWNER
r ZZvin ��
SIGNATURE OF ERSON CONSTRUCIINWELL 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
.1

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and /Natural Resourcpees//- Diyision,J/__�of Water Quality - Groundwater Section�G
WELL CONTRACTOR (INDIVIDUAL) NAME (prlat)/i//Pf1 L,✓/ k40'1b TR CERTIFICATION* 2 /O
WELL CONTRACTOR COMPANY NAME. 1k-: luE'I 1N/94ft Wtr// // FL^ Ph1PHONE/cezB In WY -WIC
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT*/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential E Mumicipal/Public 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
N��estTower ////,l/,/r/n� County vi l tv
Pr % A'#A on /< la 17i75
(Sheet Name, Nimbus, Community, Subdivision, Lot No., Zip Code)
3. OWNER (tY s/ / /24/ N
Address X*7 Rent c9Ak )a
err Roma Noe �.
//''7/4/45//7 - r Ne- 7S-3
City or Town State tip Code
Acre code - Ph as number
4. DATE DRILLED 3- / _ C5
5. TOTAL DEPTH: it 5-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 2 r" i FT.
,r (Usre if Above Top of Casing
8. TOP OF CASING IS %I FT. Above Land Surface'
`Top of easing tenanted at/or below and urine require a
varince In accordance with ISA NCAC 2C .6118.
9. YIELD (gpm): 7 METHOD OF TEST %/ it nit
10. WATER ZONES (depth):
11. DISINFECTION: Type r.Chi
12. CASING:
th
From TDo -70 Ft Yoir
From..... To Ft.
From_ To Ft.
Amount /n C 7
Wall Thic)mess
or Weight/Ft Material
SDK 2/ 7 U G
13. GROUT: Depth /,Material
From fi To 7 r) Ft C not e-
From To Ft
T dsetggr
Midge 0Slope 0Valley-Tat
(cheek appropriates box)1 U'7
Latitude/longitude of well Wattoh
Kb :J
(detgealmmusea/sxw4 6 _.
Latitude/longitude source:❑GPS og phic map
(cheek box)b 7
DEPTH p Tht LOG
From To Formati
Method
t�.t ft-ih, y
14. SCREEN: Depth Diameter Slot Size Material
Frorr To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVELPACK:
,y/ Depth Size Material
From f0To Ft
From / To Ft
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. fncladethevoad
numbers and common road names.
((
I DO HEREBY CERTIFY THAT THIS WELL WAS COSTRU
CONSTRUCI1ON $3'Aj91DARDS, AND THAT A P OF TIT!
IN ACCORDANCE WITH 15A NCAC 2C, WELL
RD HAS Bi EN PROVIDED TO THE WELL OWNER
G 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 CONSTRUCTION1tECORD
North Carolina - Department of Environment and Natural Resources - Diyam of 'Plater Quality -Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 4ge/1 C Alto (IP, Tie antimorrron # 27F ,
WELL CONTRACTOR COMPANY NAME l.0 fe fir / 84-79 PHONE # ea) 4 Wit Vki,
STATE WELL CONSTRUCTION PERMMi ASSOCIATED WQ Plaittrin
(if applicable) (if applicable)
1. WELL USE (check Applicable Box): Residential Er—MimicipallPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: i , /
Nearest TOW11:17275/4 / County /mkt'', er
202 < RA -71 7s-5
(Steed Name, Numbets, Community, Subdivision, Lot No., Tap Code)
3. OWNER: ertic_se 4e//4/4
Address Z�Z E forg /t>
orRoute No.)
flints I, /Pe' e 5- 5
City cc Town Slate Tap Code
Ares cods- The number
4. DATI3 DRILLED 2/ -0 6
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er"
7. STATIC WATER LEVEL Below Top of Casing: / FT.
, (Use ar if Above Top of Cake
8. TOP OF CASING IS / 74 4 FT. Above Land Surface*
flap of casing tee...butted Wes below land surface requires a
variance In accords, with ISA NCAC 2C Ala
9. YIELD (gpm): / METHOD OF TEST / z 23-7 edf
10. WATER. ZONES (depth):
11. DISINFECTION: Type C C IV Amount /0 0 -2
12. CASING: WallThickness
or Weight/Ft. Matenal
SO /2 V
Depth
From 1 To /30
From__ To
Prom_ To
13. GROUT: Depth
Froni f1To ze
From To
Ft plater& /-/
Ft
Ft.
F t Cirree;t1 .//e. -
Ft
;
Topopayhic/Land setting f
ORidge 0Slope OValley OFIat fl
(cheek appropriate box)
Latitude/longitude of well location —
(degrees/minutes/seconds) . ; ,
Latitude/longitude source:OGPSOTopographicitnap
(check boz)
DEPTH DRILLINGiLOW
From To Formation DesCriptita
Method
t.tiP M/E
14. SCREEN: Depth Diameter Slot Size Material
From/To Ft in. in.
From_ To Ft___in. in.
15. SAND/GRAVEL PACK:
/ Depth Size Material
From To Ft.
From —To Ft.
16. REMARKS:
LOCATION SICETCH
Show direction and distance in miles frontit least -
two State Roads or County Roads. Include the road
numbers and common mad names.
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CON
CONSTRUCTION STM4$ARDS. AND THAT A
IN ACCORD CE WITH 15A NCAC 2C, WELL
RD HA&EEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUt1NG THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 43(.
1. WELL CONTRACTOR:
Decc,cu lieCA!\n t'G.a'esS
Well Contractor (Individual) Name -
C\ NI Cie_ 5c )Qcs "!1- So
Well Contractor Company Nafne
STREET ADDRESS \ A S -1ta-7 ao C1
-Ho* 'Sit6=snCt`� 1JC-.
City or Tdm j Sae
( artily (COS- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3-/ - Cp
TIME COMPLETED 2; d AM ❑ PM E}�
3. WELL LOCATION:
CITY: At/,e '// COUNTY vial-ros'7
f /T��
ST7n: o// c'rr K
(Street Name, Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope °Valley ❑Flat ORidge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE
asi 43
Zip Code
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: ❑GPS oTopographic map
(location of web must be shown on a USGS topo map and
attached to this form Irnot using GPS)
4. WELL OWNER
OWNER'S NAME T ES He+wSCh
STREET ADDRESS \alcs C0.\dc+,l,4 'C,VQ
Can a\ec NC aQ715
City or Town State Zip Code
(eaEy aa\-a9L;3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 7 6S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO lir
c. WATER LEVEL Belau Top of Casing: ,SlS 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 accordance with 15A NCAC 2C .0118.
e. YIELD(ppm): S METHOD OF TEST
f. DISINFECTION: Type 0 .1 \S
g. WATER ZONES (depth):
From To
From To
From To
From
From_
From
Amount a 0
To
To
To
6. CASING: Thickness/
Depth Diameter Weight Maatlerial
From k-\ To 3 J Ft. (o �Y S'[1R21 �J/4Si-,-
From To Ft.
From To Ft.
7. GROUT: Depth 1 Material
From 0 To ot0 FL ee.'Mtnt
From To Ft.
From To FL
Method
8. SCREEN: Depth Diameter SDI Size Material
From To Ft. in. in.
From To Ft. in. M.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
Size
Ft.
Material
From To Ft.
From To Ft.
10. DRILLING LOG
From To
1 3/
3/ gar
Formatici Description
cries
( ran; e
11. REMARKS?
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONST I LIED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. Ann THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTR\CTOR DATE
Decc.c'c lAQo.tti Sq,A, 2.CS
PRINTED NAME OF PERSON CONSTRUCT NO 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 Depanmcnt of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N ' 4- v
1. WEL CONTRACTOR:
Fu -iu CAL(uC)_L
Well Contractor (Individual) Name
R��hetJ CAt_nLtiZt-k-c- O2tLi t , INC
Well Contractor Company Name
STREET ADDRESS 7171 r-i a ice 'YGIL 141-J7
3-C‘Kc6
Zip Code
Ne. J) t__L P C-
City or Town State
(gay( )- aS4- - 35M
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check AppYicabll Box): Residential Water Supply
DATE DRILLED 55 { a / 0 G
TIME COMPLETED 14. o a AMID PMV
3. WELL LOCATION:
CITY: /r".AP..S t4 1 LL COUNTY MAtb1S DA
CAr 4' A%C1'D .DR1vE.
(Street Name. Numbers. Community. Subdivision, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley HFLLlat El Ridge 0 Other
(check appropriate box)
LATITUDE 5_ a 1. S53
LONGITUDES 9 4 a. J-r 0
Latitude/longitude source: EKES °Topographic map
(location of wel must be shown on a USGS logo map and
attached to this form 7 not using GPS)
4. WELL OWNER I
OWNER'S NAME V'` I L..t-1p •-,3QAm L{t 7"�'
STREET ADDRESS 15 P g pal -LB tab 14t 11-1 OR..
fl S1l64tt_t_IS tic a.gio(o
City or Town Slate Zip Code
( %at )- A53 '.4 Di ?.4
Area code - Phone number
May be in degrees,
minutes. seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: • •e
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO IL
c. WATER LEVEL Below Top of Casing: 6 0 Fr.
(Use -✓ d Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. e
e. YIELD (gpm): ao METHOD OF TEST RIG' A {
327114
1. DISINFECTION: Type 14114 40 is Amount G of •
g. WATER ZONES (depth):
From 13q To IC From To
From To From To
From
To From To
6. CASING:
Thickness/
1- Depth
h53 Ft q atT/eter s t)Ki'+tt Y C+ Frompi �v�
From To Ft.
From To Ft.
7. GROUT: Depth Material �f Methods
From To a Ft. Ck/M$NT 9ouPJ )
From To Ft.
From To FI.
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
From
To Ft.
To Ft.
10. DRILLING LOG
From r To r
'L - 4
1'- 140'
O_
F rmation Description •
rJ M up-b8 t� o
GP-ANI a `�
C.12.1tot - a o t'r
t+o'_ a4-5 GetA go tTb r_ r"t,11�7
o ufr3
0 D�
JUN 06 2006
11. REMARKS:
1 DO HEREBY CERTIFY THAT DAS WELL WAS CONSTRUCTED N ACCORDANCE WEIN
ISA NCAC ?C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
n
1�,9,L1.Q,&V% @ AULAQ 5 ' M'
SIGNATURE OF CERTIFIED WELL CON CTOR DATE
gE. NA,
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 3 2 . / 1 T
WELL CONTRACTOR CERTIFICATION # a ' 4 0
1. WELL CONTRACTOR:
Revs'btn Ca1&we,11
Well Contractor (Individual) Name
Re,u,be1 CALK I)e11 Ov1 1t113 11IC.
Well Contractor Company Name
STREET ADDRESS %S 1 km) let Ce iln'r N W I
AsheJ;tie Nc airo b
City or Town State Zip Code
( sag,- 3,54 - 3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(tt applicable)
DWQ or OTHER PERMIT *(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 5/IS/0 b
TIME COMPLETED s - e 0 AM ❑ PM g
3. WELL LOCATION:
CITY: M A&$ N 1'L
COUNTY /►`abiSON
3
(Street Name. Numbers, Community, Subdinsion, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETT
❑Slope °Valley ❑Flat idge DOther
(check appropriate box)
LATITUDE _a_ 5 4g . 63 1
LONGITUDE is_ a 3 1 , 39 1
Latitude/longitude source: rieS °Topographic map
(location of well must be shown on a USGS tops map and
attached to this font I not using GPS)
4. WELL OWNER
OWNER'S NAME
May be in degees,
minutes, seconds or
in a decimal format
s+eve Mete. -If
STREET ADDRESS 1-19 t)a -Tq ra(Lit- 42-4-.sA.D
QAilJA0.(SSf11L1-q- 1 a ei 3%'109
City or Town State Zip Code
(daK» `1bK-iRs
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ,n 0 5
b. DOES WELL REPLACE EXISTING WELL? YES ° NO ti7
c. WATER LEVEL Below Top of Casing: p 0 FT.
(Use's' if Above Top� ei Casing)
/
d. TOP OF CASING IS `L FT. Above Land Surface'
*Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118. /1
e. YIELD(gpm): .3 METHOD OF TEST RtG- At Q
1. DISINFECTION: Type MTh Cie; Amount ai OZ •
g. WATER ZONES (depth):
From 2¢d To a4-3 From To
From 660 To 56 t From To
From To From To
6. CASING: Thickness/
A Depth Di eter Weight Material
From To g7 Ft. (-) G012. -1 PVC -
From To Ft.
From To Ft.
7. GROUT: qa Depth CAS
From To � ^W Ft. Mgaf
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
9. SAND/GRAVEL PACK:
Depth
From
From
From
Ft. in.
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From A To
in.
Size Material
$a Formation Description -
e?JtLBua-laaof
ea'- a4a' G z,Lat-ram
a4A'- at Sc 26-d'tc-e - a (0 PA"
a43'-560 GaJtt-r
560- S6I' cka1tce - 4. GP►n O
riblt bOS, CJG2ANrr6 -z
N LSE 2011h
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RVAliem COut.(,tA.l24 (215
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
► tet.-I,; I3ACbH
ob
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-1a
Rev. 7/05

r •
North Careens • Cpsnment al Envkorm enl end Natural Resreasa • ohWon el Water Oueety • ormerdwelsr Samlon
1N3S Mel Send= Cyder • Meth, N.C. 27N9-1ll014Thnrr pun 733 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: GAPO rwoJ f
WELL CONTRACTOR CERTIFICATION F a I
STATE WELL CONSTRUCTION FEMME.
1. WELL USE(aeaaAppleakb see nnldmiM2( WIMPS CIIndusbS 0 AgdAaM CI wafting 0
Recovery 0 Heal Pump Walla 'Madam ❑ Other B Ohm, Lbt UW
2. WELL LOCATION: (Show Munch of Rio iohalrh low) t71d(Son
Mona Towne
rn
plod Name ad tiorbory,Conommly, a S.Edrwon and tat NO
3. OWNER f am' -1-In
Addra« %'W 4490 1Cs or
Wt1�!(Tvl (It, N! 2;1r141
Omer Tam Naha We Cede
4. DATE DRILLED
5. TOTAL DEPTH
S. OUTTIHGs cou.ECTEO YES 0 NO(
7. DOES WELL REPLACE EXISTING WELT YES 0 NOO
a STATIC WATER LEVEL Below Top of Caning: FT.
tun'.' a Alan Tap et Ces/s
S. TOP OF CASING IS t FT. Arose Ltd Suttees*
'Tap et seeing t.redrrsad oder below lend eartwa ryukes uarana b eawp
donee maIIANCAC 29 AM(
10. YIELD (gm): .._a_._ METHOD of TEST I\/1 l �
11. WATER ZONES (dSpBh):
ORILLMG WO
R.eh To
DEPTH
saner i;r+-
12. CHLORINATION. Type Amount N additions! owe b needed us* tad: d bum
13. CASING:
From ' To ' ' FI 7 91
LOCATION SKETCH
vais Tidiness
at MOWS "WS (Shorn anion and SL..e . from el Iad Iwo Slabp
Roads, a other mop pots)
Fmm - To Ft.FFrom4» u
m To FL .1 J irinnC
(Ai
14. GROUT: 5`�\�{� y 4(
From� 1 T FL fl• (▪ flt lJ" 1 C
From To FL '-S �o
V
15. SCREEN: .1.
Depth Diameter Slot Slay
From To _ Ft _ In. _ In.
From To _ R. _ In In.
From To _ FL _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Eke lANlats
From To FL
From To FL
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA 'CAC IC. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HIS BEEN PROIAOEDTO THE WELL OWNER.
OP PNneoNConstMlCistl THE wal OM
Suers Word m Dbkae etWelerOrme Wounds aueee *Win 30 days
owl REV. OWN
FOR OFRCE USE ONLY
Ouse Hoc
law Nee.
JUN 0 6 2G113
N C rri
O
O Crj
Cr,
r

•
North Cambia • DepennwM al SwLmnr.A end Natural Resouees - OMdwt e1 Water Ousey • Groundwater Seaton
1660 MS 6avke Center • RSsI N.C. S7Qe•1lflP ions p1S) 733-S ll
WELL CONSTRUCTION RECORD WEu coNTRACTOR: C.1 e ary'n1-,Gel
wELL CONTRACTOR CERTE7CATWN 6: .7 I I q
STATE WELL CONSTRUCTION PERM11Tt
326820
1. WELL USE,,S k Applicable Sea) Re MurdcIpsl 0 Industrial 13ASdouMurel ❑ Monitoring 0
RAY an HeatPump WaterMooron 0 OMr El IIOber, UN Use:
2 Neal Imremarl I(StayrCI 1 of t»M:aTan man tROV1
Mead Nbtb end Mwono Visor itw et saeat and tot No.) DPIWNG LOG DEPTH
3. OWNER, e, �(. it f •fell n n Ye Fotn n6w
Address C In Qrl
Marshall NI acIs3
CryaTeen SIW 2pCede
4. DATE DRILLED 5 5-()U
5. TOTAL DEPTH IUS
6. CUTTINGS COLLECTED YES 0 Not"
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NCO
6. STATIC WATER LEVEL Show Top of Cuing: FT.
Nee•.• s men TW al Cueq)
S. TOP OF CASING IS I FT. Above Land Surface'
nod et amine MradiMd ear Mew lend maraca maw a abbe In mere
dunes wr615ANCAC20MIS r l % ^
10. YIELD(ypm): 1 METHOD OF TEST ! AL
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
From l To51 Fry, LD 4
From To FL
From To Fi.
14. GROUT:
Amount
S whatnot apace b needed rise back al lint
YAW Ttldsree
LOCATION SKETCH
awJ$a .- (Show S S...darn.:. Man at Isar two mate
Roe* or other nap reference Fabm)
From I ToTDept R C to cell t teriel Method
From To FL
1s. SCREEN:
Depth Diameter Slot Ski M$sdd
From To F1 In in.
From To Ft In • In.
From To _ FL ___ In. In.
16. SAND/GRAVEL PACK:
Depth Slur Mandel
From To FL
From To Ft.
ac.10
Mai PE
17. REMARKS:
i DO HERESY CERTIFY THAT nits WELL WAS CONSTRUCTED IN ACCORDANCE WITH /6A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
l dlo
FOR OFFICE USE ONLY
Ord Nee
Seib Pit
,TUBE OF PERSON CONSTRUCTING TIE WELL DATE
Subil oAyl.rl b oat anorWaferOJSSy Owudreew Setter. WlidR 30 days
�f
OW1 REV. 12e1
JUN 0 6 Lit.'

6
North Carolina • Department c( EmAwmNMand Newel Resources • ONYon M Misr Cury • Onsu dw•sr Simeon
1130 Mel Servlo. Center • Raleigh N.C. E7/.5.1aaahors (1N 731
WELL CONSTRUCTION RECORD wpm. CONTRACTOR: CIDd rwratx 3 2 6 8 2 3
WELL CONTRACTOR CERTIFICATION fh a I t3
STATE WELL CONSTRUCTION PERMITS:
1. WELL Si Applicable Owp Rnld.r SuI 12' Mu iolpd ❑ Industrial 0 Apdeulhnl ❑ Mo.lorblp 0
R.covory DO Vaal Pump Watt Moollon ❑ mar [] E Is Lbt U..:
2. WELL LOCH tom'^5 oR the locale. b#os)
Neared Taw
s J V f� 1 ', Con I nnill,cinn
Mead
3. OWNER rernestd Frnn%K Cesvieruct �� ea)
c.kGa a
awe/Tow —Ma;
4. DATE DRILLED _
S. TOTAL DEPTH
S. CUTTINGS COU.ECTED YES[] No133
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOEF
a STATIC WATER LEVEL BMow Tap of Carp: FT.
Nei Y•. Aber Tep el cereal
S. TOP OF CASING IS 1' FT. Above Land Surface
'rep el seem Iredn.l.d War Wee lend stem wMe. • .rrme In eerier -
dense vai HA NCAC 2C MIS
10. YIELD (gpm): METHOD OF TEST 9119
11. WATER ZONES (MOM:
a Csd.
DRILLSd(i LOG DEPTH
/-Fr.: Ti
1813 Mi to
12. CHLORINATION: Typo Amount
19. CASING:
From-.1.-----Tnet Ft. VT
Fro. To FL
Frain To FL
14. GROUT:
1 Stood specs Is needed use bee' el loon
Wsil Minn
erWeida
LA. Method
From Zito
FI. rid I7 I LE
Front To F1.
t5. SCREEN:
Depth DI m.Nr Sot Ski NSW
From To _ Ft I.. In.
To FL_ In _ In. n li
From To FL ht. In. L7
10. SAND/GRAVEL PACK:
roth Slat MAWS ()
To Ft
LOCATION SKETCH
(Show flea and d trine ban M WS two SIMe
Roads, rother imp rMrrs•pokes)il 0) . I lAx%
7cCf ;rya.
cit
mrn
From
From To Ft.
1.J
0
m
17. REMARKS:
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRICTED IN ACCORDANCE WITH ISA NW 2C. WE.L
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
oad Ne
Said ire
, _ ` I`+..f.e-stre... S/ /1 /4
.IONATURE OF PERSON 001MTRU aNO THE WELL DATE
&OM od#W Is Lemon Wader O sdy. Osadeel.r Seal wlfln 30 days
mom REV. 1WM
.RUN 06 /case

North
Combo • prMd► a..5 MSS Mason 7�+ 1 0l Wan Out*• Orou d*SW Swam
WELL. CONSTRUCTION RECORD WELL CONTRACTOR: rl -r-
WEU. CONTRACTOR cERTIRCAT1ON « a I I s
STATE WELL CONSTRUCTION PERMIT«
326828
1. WELLRuco n � WRoeldentlal arn Inlodlon O ow p Gahm, UM tInduetdolw Agricultural D I o:rw 0
Recovery CI
2. WELL LOCATION (Show ktetchd«alocation b MCaC�ia-n
NotwSToww WI Ale SVP
Spy tianwAS MmMra, Connzar.a ShaAoMcad
d Lot No.)
3. OWNER l,KUUSl irii[\
Addr.W al IS t cw 94.
Mars 1at11 a antic. 18154
awe Tea r
s. DATEDRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOES
7. DOES WELL REPLACE EXISTING Wei.? YES [] NOEZ
6. STATIC WATER LEVEL Below Top d Casing: FT.
prow II Non Tee el Cnkd
It. TOP OF CASING IS FT. Above land Suffice
°Top el esdne Wrdned ever Inks lad saw moan a vats la swore
down wan 11* NCAC2CVia
10. YIELD ((loin): METHOD OF TEST
11. WATER ZONES (depth):
•
jil�LxdO LOG
at To
Prel /912
1q0 — ,2/e
12. CHLORINATION: Typo
13. CASING:
Amount
From o« FL 4
Depnor
From_.---- To FL
From To FL
14. GROUT:
Depth
From _L__ To g_Fl.
Frain To FL
15. SCREEN:
Tadmoss
a%rlyaFt
mawfw
DEPTH
Famine
711.1- jc lirk
(asp rini to
JC reyir <
Omnt-tP_
x addWawl spew Is "add too beak of lore
LOCATION SKETCH
(Show M+�. w Swim and Sea from al Nat boo elle
ptosttG R0SLorShur map J . pan)
\ G
,.I —�
—r r*r_2
<
ro
c c0
a+ D
r
Method
From
From
From
16. SAND/GRAVEL PACK
Deplh
From To FL
Fran To FL
Dplh
To
To
To
Mono* Sal Sinai
Fl In. In.
Ft. in. In.
FL In In.
S. Marcia!
S
O\0
17. REMARKS:
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA MAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A 7 OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER
IMTUNE OF PERSON c0NS7WSIG Tli Mill DATE
WWWI diewl a CMOs. at Wow Day. Osandealar ONOINI w Wt 30 days OWI.1 REV. tYM
I
FOR OFFICE USE ONLY
Ohrd Nee
SNAS Ne.
JUN 06 2UU6
r

W MCombs • Oponn.wtd `wL _ed ad WNW Reoaim -Make or WarChef • OraadaebrSiOm
INN lie{MMwCoat • PSIS N.0.27M►1NiNirrpMTO al
32684I
WELL CONSTRUCTION RECORD wits CONTRACTOR: C 1 eant ^ rt )PC
nu. common c■111NCATION I' t3
NATE wr1001 STINE711011 PENET*
1. WELLLISE AMeeYereyeNoWit Selo Mwierlal0 llileY -D ASdeeSaral0 Mariodne0
Rap"C Had Pump Wet IjoaNwe 0 Ober p E 0Ihp UM Lbw
2. WELL L:OCA aw elskh S2 bat0on below)
N-wetrawrc sAfr a h(1rc H; bootlr, !"-kClCi 1�EXl
a.
Peat Maeaera «Yaidena SIb1
WNE1 1 Ct mct �fX1n Y-# sst`l
Addis" lain Wires* P-O
F lrul N1C,
wTawr we N►tbA
4. DATEOI:LLID-;)-l`)lD
S. TOTAL DEPTH l r()C-
d. cImNoscomaED YESQ
7. DOES WELL REPLACE EXISTING WM1 Q NOiEr
t STATIC WATER LEVEL Doke Tap al Color FT.
ON se II Non Tip of QOM
S. TOP OF CASING IS -.I---. FT. Aiwa Land !Dale__"
Mop •aAea Lena-DrdS Iwlwlea !awls men ewebs* asp,
inn valli MA NA a !L
10. YIELD METHOD OF TEST r l\ g
11. WATER ZONES pool*
D It W0
118111 To
12. CFLORNATNRI: TTpe Amount
13. CASINO:
From ` To ' 3
Fan-- To
From —
14.(ROL7T:
Ron I
a10yamr
FI.
To FL
OEPTH
4r \-
mil%► r C
�i r o.n Er
a
0
EMISS piebneededmebetdb
Ivauses IOCATldil S €ETCN
wwaturt eoDlril Psi swim ant ain loom alknot lwIlre
1)1aj1C. Reade,areMwrn raturensep_iey
N W; MISS
To c 3f FL COmnan\-
Fran To FL
1S. SCRIM
Dap* Olorwlw Slat MP
Ram To_ R
Fran To _.__ FL M. M.
Rom To _ R. In In.
1S. SANQgRAVEL PACK
Dap*
Fern To
From To FL
Method
Sba PASS
FL
i
Ln+'1to3
17. RL4LARLS:
1 DO HEMP !.cnirY THAT MIS WQJ. WAS cONOTR ICGW SL CORO IC E WRN 10A WC W. WELL
CONSTRUCTION STANDARDS,AND THAT ACOPY OFDNS MIC PIDHASSEENRIMEDTO MMD.0E/IS&
FON OFFICE LSE ONLY
Cal No
INS No.
crawa3774,
a►nuse om e.-mrt, ni. MIS
Dube Me+eeorwwrwroese&lame s - wNi1SOdap
irr4MtMI
JUN 06 2053

Nett Combo Depeo+rrtdEn.M..milend NSW Re weee-MOW dwe rady•oeuna.el.rS.sm 3 2 V 6 6 ? :
ISM r1rPeat Coral •ReleaM
yILCANWPI ONto ep710411
WELL CONSTRUCTION RECORD Wuu.CONTRACTOR: (VP 2 (rtCOi 9'"
WELLCONTRACTOf O/IIT1r1OATi0N ds 11`,
STATE WELL CONSTRUCTION PEMNik
1. WELLu1E wird.r.pr..d.nD' Me.delpd0 admits, Aylward dCI l wrerrg0
Recoverpu1.Hord Prop WaMWoolen Mar[] EOSMr.UNIMr,
2. WELL LOCAT101! ydMbw n low) �n c� r
NOM.Ttrm. 1XSr�[A�-A ass f 1 \oc�lay� i
Weed e& of lithealin /e41MNe.1
3. oaten YV\Ctl�l\51)rl 1'if rr tl)
ACaew,C7 t�x...�� — 1(�
c r.�noli.� TJ k1
aYsTww ere ZIP
4. DATEORIUED 5-`-F-
5. TOTAL DEPTH PET
S. CUTTINGSCOU.EcTEO YnD Nocr
7. DOES WEIL REPLACE Ora WW2 Yt% 0 NOtz
4. STATIC WATER LEVEL Sobs Tap d OoMF FT.
tha 'V II Meth Tee ei CAWS
P. TOP OF CASING IS 1 FT. Mtn Lad *- --
leper eab.lwelat We bike RS Sae eepbw • vaewee flew
asumma lonmAC IS pip
10. WELD (pp* I .-4 METHOD OF TEST Rnt G
11. WATER CORES Ito .
DRILLSw EI
leer
12. CHLORINATION: Typo
13. CASINO:
1
-1
c
iSt
Amount Sedited spat bneeded we beard ban
WeeTWesw
Depth atWrbeert
Fmm�To 11/4-1L' R. L l
Fran--- To FL
From To R.
14. GROUT:
From �Ts2_RC�►1 Mwwe
Fran To FL
1S. Ste!
Depth Dlrneler W el11.i Made!
Frain To R In. In.
From --- To FL, In. In.
From _To_R._ rt bL
15 SANDIGRAVEL PACK:
DpPr 1lbe SSW
From To Pt
From To FL
IrVAMMAETd1
tenet. _a-1_aborn Mssroam
1 Ra ewelhermepaeSWpobef
17. RIDAA ICIb
1DDIEREST lRMBYTNATTIpwdLWASCONSTRUCTEIIACCOMWJI SWRNTEA NOMIC. WELL
CC.STRUCTICN STANDARD&. AND THAT ACOPY OFTMP IECORDHASSSSN ROAM TOTHE WILL OWIEIL
/Azad
noway cornmlomosno r.eL OATS
atme.AdwaewadararM, ass Maki SO dolrs
66o 11r.1 reY. Wee
FON OFFICE 111E ONLY
on.rr
NOM

Nor Carobs • DepsYasrd a Embalmed and Natural fnowaas • Dlvleien el WaNr OuSy • Groundwater Salton
163E MS Service Corder • RSsIp . N.C. 27NL166bM n. (6/6) 733-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CU XL X
WELL CONTRACTOR CERTIFICATION lb S1'\
326639
STATE WELL CONSTRUCTION PERMITS:
1. WELL USItsdi AppWeble u Reeldewilatr Mw&4 J CI Industrial AprloWWM ElMonitoringCIRecovery 0 Heat Pump Wats Irdeu4on 0 Other p N Other, UM Use:
2. WELL LOCATIO (Show sketch of On Ww6on Sa) `� n
Nearest Tem tl NI1l-X.Srlalit cos Y v IC1 30n
3. OWNER 1 IEi CI:77N 1.1 Y i r
Adam IQ` u �t ►"tll nCi
tV1aiSha "ni'(. aSii 3
Ow or Tan Saba ED Cede
4. DATE DRILLED
5. TOTAL DEPTH 0
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO v
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS, 1 FT Above hand Surface*
'Top of Pang 1..--Isrodnined enter Wow lend arleas rendre a vi rase In mop
dreg ads WA NCAC 20 41111
10. YIELD (gpm): l , METHOD OF TEST R q
11. WATER ZONES (dplh)
12. CHLORINATION: Type
13. CASINO:
From 1 DTot t
Ert
Amount
Vern Tess
rWelehYFL
From To FL
From To Ft.
14. GROUT:
Ram ' T fl. CQYYI Ik-
From To FI.
15. SCREEN:
Depth Diameter Slot SIS
From To Ft
From To fl.
From To _ FL
Method
M In.
In k4
kr: _ In.
16. SAND/GRAVEL PACK: •
Depth Stu Martial
From To FL
From To
17. REMARKS:
6Salami pecsleneededusebeckdam
LOCATION SKETCH
($how dk.c6m and Swat kern at least two Mini
Roads, or other map Serena parts) a
.-c
J
a
1
Suns Sc Vick)C
NweU On
Sricyr
O
O�
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
DARE OP PERIOD OONFINUCwle THE wal DATE
Suborn .4kW a Chas, dtsar Busby. oeordaater seem Min 30 days
JUN 06 tai.!3 GYM "at niw
FOR OFFICE USE ONLY
Cued Na
Sdet Ns.

. , . -
NaatCalm •IlpratwaaEmaaamdandMOM llanana.-Olatla.lwsOrs.taaudawraaMln
INS Man Omar •Pal N.arnINI/wtatono n Mal3 2 6 6 3 7
WELL CONSTRUCTION RECORD Wnu.CONTRACTCIB DU,t Antr
Ww. canwAcroe c.mPIwATI0H r. ,a I 3
CTMTN WELL CONSTRUCTION PNREIIIU
I. WELL ueE A}ImaPa h Baia 1W12 Mtondpa 0 b-ri D
R.od.M'Uaat
HMMPaw WMwltj.aEan0 OMr[] ROEMr,UMU.e
Y. WELL L OCATIONt Phow Waldo al Radoeolan
Sow)
Na worm trt efl Tex v I I) er. cots fl'C *tNrn
Ota.. laud Nriouro. Gairriaara.awaa.aaaltoo NI4
a OWNER (-tirek Ter
Pa" \ 10 CQrQQfihnP Din
\NR-Nvervi ? tJC 1Y) bbta. -a
COW or Teas VIS aR.Dda
4. DATE Natal
5. TOTAL DEP If
s.
7.
AplalMidD M.aietae
t7RL SIO 1.00 DEPTH
Pat To
1-Ike Strc\4cr1-
(Van t
at -ID- (yrXni fee
CUTTINGS COLLECTED yes CI $OO
DOES WELL REPLACE METING WBLs YES p NOE
A. STATIC WATER LEVEL.: L. Tap al Cambia FT.
fa WV Mao Teat QOM
.. TOP OF CASING E 1 FT. Abyss land Sat Sy
4apMsat Iaraana.aa a.ar Wlpwhud_.....aiaaaman sap
i TEED Isptal: METHOD OF TEST 2m1 9
11. WATER LOVES *par
12. CHLORINATION: Typo Amowd
13. CASIHt
rn
S Salo d pan Y naiad w Waal
Talokoas LOCATtoN lIETT2R
oplh anow FL 12 w ____ aim tatoone dame how Atha aIle
From 1ao*mopnee
Fmm To R
From To R
14. GROUT:
Maladsd Method
From 1_ To C) R. nLn\C.ft
From To FL
15. CORETIt
Dela Dl.mMer SW ES MModal
From To R __ In. In.
From To R. In.. In.
From To R. Inc In.
N. SANWORAVEI PACK
DR* Mao M.I.dM
Rom To R
From To R
17. TIR4ARIUk
DOZERS CERTIFY THAT THE WILL WAS CONSTRUCTED P4ACCOIb I011 WUH ISA MPS SC. WELL.
CONSTRUCTION STANDARDS. AIDTHAT ACOPY OFTIN REOOIDRAS WW1 FROWDEDTOTNE WEU.OW1ER.
U JD_yl66
j
ooaanasaror mtooNaaucmaTNawna MIS
wawtieba Ia.ar.rra.+f.simmamw.asulnaaodon
JUN 0 6 2033 EMI NEV. Vaal
FOR OFFICE USE ONLY
ors we

I FOR OFFICE MI6 ONLY
tommoo
I
ISMW.
t
11. CASINO:
4. DATE ORLL.Et 0
0. TOTAL DEPTH I for
7. DOES WRL REPLACE 10081110 watT Nq�
a STATIC WATER LEVEL Odom Tap 1 _ '" FT
E. TOP OF CASINGW owe .nn _tad MLlor
FT. Mhos Laved Eatlter'
Mop Maatlr.lor.aarArw kMaerwt r.-.wirw.b..aw�.
dam MO1MNOACfaatn
10.r1ELD( r HERHODOFTar ali!'1
11. WATER ZORES (dog*
MiS Cater wMM M .roomdie.wr-r.11lr•t#
lea Onlan
►11.C. 717MMOlfOwr plp man
1
WELL CONSTRUCTION RECORD Wrnsc NTRACTOIR all('K x 3 2 e 6 3
CI
WILL CONTRACTOR cd,TwlATlofl * r9 t t
STATE WELL CONOIINICTpN PIMUM
1. WELL tpE Ay.ara.b mom r__ardoll r Mraile.l 13 sums El Apib*nl CI MoidloAt1 D
It t..rya11oa1PompWainMjooFanD Ode D Rahn, LMIkt
2 wBL t:OCA710It pan AM* w b la.Mwr O.low)
N-NMJflat YVV1X5 }'h11 pus mnoIst` n
F1omnorwrr ctinorem.«somas..atrlr..) ..QffiL Ia DEPTw.
I. orrNE11 Mat iml es
Add... `11\D i S> IV E I - S.S Fats °'"q'`
ce
211
frill fie.
12. CHLORINATION: Typo Amount
/.dllld apsen tw.dad stook of bar
WMMeawa 1_�GTiON EIL=TT[ai
MomI Dupit t D y «wry.tal M MS .Asatimilen.w-- Monr.tltatlne
Frorrt__----_TO Fri. ?Ilan Rork srMan mop abwwopoi% 4
From To FL
14. GROUT:
From 1 Dank To aO FL en w(I Method r -17. wiiIC St
From To FL n.
1R. SCRIM 1 rfr����
aPh 0lrrwlor S al lki MOMS`
Ran . To __ Ft h. ti
Fran __ To __ R. it.. ___ In.
From . To __ R. bt h
10. SAIIDKIRAVEL. PACK:
Dap* its. Me,'
Frorn Fran To FL
17. REMARKS To FL 6+# (71
100wen KI!RyErVTNATTI'SWDLLWAD OONImip 1110 RI Accomplice WIIH ISA NC Sc, W.Z.
OONSyRUCRONRANWIiDE AND RATAQOPYOFTMRRECORD NM EMI PROVIDED TOTHE WELL OWNER
?UMW P1.11011100111117NUORINGION WM Ism
°i"' sot My tin
Jul ti lid Liiu5

Nest Cane •Dgrnaaatkt_.. enland NadIaeowea- addend Wear ow4r•SaadwmerIan
a a ScadsCar -Ada NC.SNS►Il i p+„ITSe3R1
WELL CONSTRUCTION RECORD WELL oONIRACTORt C C Wit
WILL commas* COIMPICATICNSI cm?f1
STATE WELL CONSTRUCTION PERNITS:
1. WE.LUSE A,pSwdr er-R,ad-iaEr Mw-t l w- ---0 Apktati-sD rlontelny
,w
R,eryf ,ssr.. Pump OW Ohm,
\,Sheol l%�ii`�i %'SOS -
tare Tea ,aa *OM
TOTDEPTH .4.119
4. DATE CHILLED
s CUTTNIOSCOLLECTED mEs0 ND0'
7. DOES WELL REPLACE EXISTING WELT YES p NOD—
& STATIC WATER LEVEL Snow Top o1 Cooky FT.
a MiewTePnand
P. TOP OF CASING N). � µ. FT. Abe., Lad Rua'
'Wont seed aped eNeeadandsass rwtiee•wad aen..
4na.wllePIA RCM 211
10. YIELD WSW METHOD OF TEST Y
11. WATER ZONES (Spar
: turdwea i }r` awft leldwlx+oiarbelts 1 (i'(11 SOf
i1+ For h P-d.
pae,New nap%mow .oeewrae.rMI WI ORILLSIOLOA oe'UH
a. amen k A"1 1hI (JIl caw To war Dendena
1 rm - 31 k-t
aRc- PSSa-*
326650
r
er
12. CHLORINATION' Typo Amount Iod llomlmomrneededonbdcSI o
18. CASINO:
WSUkaaee b, aa
� �JDIJ1TEN SKETCH
Flom ` ~-1� Olinuelor .w.yML. 1+r " SWOPdl,e-end dil a, boro .theta
Rosa sres,rrorpSaes pdae)
From To FL
Fran To FL.
14. GROUT:
Rom I To 0 p, 0 role s li T MNgd t \�\y X
From To FL
SCREEN
Doplh Mont Slot Ski MOWN
From To_Ft be. M.
Front To FL In. In.
From _ To _ FL rt In.
10. SANWORAVEL PACK:
Duple Stow Mulnkl
Ram To FL
From To FL
17.1
•
1 DO HERESYCERIIFY THAT THIS WE .L WM CONSTRUCIro PACCORDS= Willi 15A NCAC ITC. WELL
CONSTRUCTICNSTANDARDS.AND THATAC OF TIW RECORD EMI FRDNDED'tomEWELL WRIER.
FOR OFFICE USE ONLY
0-It
Add We.
,16eN11,ROFPNIKINO,MN,Ip1,YM MIL ,AT,
,SA SWIM adepdwee,OSP.Sweweaer'S'erlw'}a* 30dry,
JUN 06 2d
OW/ MP a

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rceourccc. Divition of Water Quality
WELL CONTRACTOR CERTIFICATION # a (4- 0
1. WELL CONTRACTOR:
Qeu.'Oev1 Ql,Ael ae,ll
Well Contractor (Individual) Name
Rtli ben Q\COCl1 Or; \l;n i Inc..
Well Contractor Company Name
STREET ADDRESS 35I tie A) .1-.Et ees+e.r FLWy
i\shell ilt NC aggo6 I
City or Town State Zip Code
(39-g» eat 54--35I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(a applicable)
STATE WELL PERMIT#(it applicabie)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) !Residential Water Supply
DATE DRILLED 1 • I -1 G
TIME COMPLETED 'L- -CD AMD pm Eft
3. WELL LOCATION: (/\
CITY: A 'P ,,� S i`)L��' COUNTY t Y\RDI�ON
(Street Name. Numbers. Community. Svbervvon. Lot No. Parcel, Zip Code)
(TO °GRAPHIC / LAND SETTING:
lope °Valley ❑Flat DRidge CIOther
(check aipprop.iale box)
LATITUDE yT S �1= . G1 ' J
LONGITUDES .]]) 1 r i 6 3
May tc in depc<s.
minules. seconds 0
in a decimal format
Latitude/longitude source: 31 PS °Topographic map
(location of wel must be shown on a USGS fopo map end
attached to this form 1 nor usng GPS)
4. WELL OWNER r �, n R l t-
OWNER'S NAME V ^ Lt L LJ 6 �'`AiLt ✓e
STREET ADDRESS CI l aMw�, jtCtt 1CoA
1.-AA0 5 11 tiJ c- 2411 s
City or Town Stale Zip Code
( C3S a7 -8 4- 45
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO e
c. WATER LEVEL Below Top d Casing \ e 0 FT.
(Use •+ if Above Top ri Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top o( casing teTnviated aver below land surface may require
a variance n accordance with 15A NCAC 2C .0118. A,
e. YIELD (gpm): b METHOD OF TEST LG- IT (P
DS
)
j .k rt
I. DISINFECTION: Type Amount
g. WATER ZONES (depth)
From rot To rsa
Frt.,, 349 To 3 SO
From To
6. CASING:
Dept e
nm To OJ FI.
From To FI
From To Ft
7. GROUT: Depth r_
From 1 To �P
From
From
8. SCREEN
From
From
From
To
To
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
F,On
From
From
To
To
To
FI
Ft.
Ft
t
From To
From To
From To
Thickness/
eiy)8, Aty ial
Material
C.QI'✓1�T
vRMethod
Diameter Slot Size Material
Ftin. in.
Ftin. in.
Ftin. in.
FI.
FI.
Ft.
Size Material
10. DRILLING LOG
Fro / To / 5ormation Description
l4q/
I1. REMARKS:
G Q-AaJ
Grey
-3 me 0
c-Qts,J'1G5 - 3 GWfl<
re, N Kt
L -._..,
r— _ ..
roi--
fPl_
v.
N °r
U C
0 . —
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRN
ISA NCAC 2C WEII CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS
BEEN PROVIDED
WELL ELL CONTRACTOR DA E
tT_(.L &AS4)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh. NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05
TO THE WELL OWNER
_9-Qclune-Q0- "V 3
RE OF CERTIFIED

329328
RESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Di is' of Waa Quaid)
WELL CONTRACTOR CERTIFICATION # • atilt.
1. WELL CONTRACTOR: -
Q tce: Os- NNQn h Sawale cS
Well Contractor (Individual) Name -
Wen Company Norte
STREET ADDRESS `yV85 .���� 2oq
% o * vc %\\s) hie - -8't' 3
City or Town . - -Zip Code
(8 )- Ln(os-aOa. '
Area code Pharm numbs
2 WELL INFORMATION:
SITE WELL ID #(rraporeabb)
STATE WELL PERMIT#(aaoono01e)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 11'
DATE DRILLED 7 S- (o .
TIME COMPLETED it' 0 0 AM 0 PM &
3. WELL LOCATION:
CITY: /{4nfj{i`/
Dec� /7 r
{Street Name, Numbers. CommuMly
.. COUNTY Ala J+,✓Oi
01-04
Subr8WWti ibCLot No.. Parch. Zip Cone)
T9POGRAPHIC / LAND SETTING:
( bpe DVa1Iw ❑Flat 0Ridge ❑Other
(cheat app.opnate box)
LATITUDE 3 _
LONGITUDE
Latitude/longitude source: ❑ OPS D Topographic map
(location of wet mustbe shown on a VSGS tapo map and
attached to form T not using GPS)
May be m
minutes, seconds or
in a decimal font
4. WELL OWNER
OWNERS NAME e.,., a. a ..
Sltcttt ADDRESS unit 6v eeJew CCttn R6.
Pit l ev:ne ,C. flQ)02
City or Town State Op Code
(8-as y aver- tgavl
Area code- Phone numbs-
S. WELL DETAILS:
a. TOTAL DEPTH: 30i
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
c. WATER LEVEL Bdwv Top of Casing _CO Fr.
(Use •+' 99 Above Top of Casng)
d. TOP OF CASING IS FT. Above Lad Surface`
'Top of casing terminated Ivor blow lad surface may require
a ice to accorddatcewi h 15A NCAC 2C .0118.
e. YIELD (gpm): /v METHOD OF TEST R•3
f. DISINFECTION: Typ., :11S Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
8. CASING:
Thickness/
Depth Dram V4W Material,
Fnan��To U %R. 1p�`�/tQ� . i �`
From To R.
From To R.
7. GROUT: Depth r�77 Macau
From 0 To 00 Fl. (eflterlt
From To - Ft.
From To Fr.
tee
8. SCREEN: Depth Diameter Sbt Size Material
From To Ft in. it
From To FL in.. in.
From To R. bt in.
9. SAND/GRAVE- PACK:
Depth - Size
From To- Ft.
From To Ft
From To Ft
10. DR!WNG LOG
From To
i
70 3os
11. REMARKS:
Material
Formation Description
3ocr -
L
C
by
r';' 1
Vr
cj r=.,
J
I CO HEREBY CERTIFY THAT TIC WELL Y 'AS CONSTRICTED N ACCORDN CE Wrnt
15A tCAC 2C. WEIt CONSiRUCt10N 1TA WARDS. A/SITNTA COPY CF Pis
RECORD WAS BEEN PROVIDED TO Ter: h ELL OWNER.
SIGNATURE OF CERI1 'Ell CONTRACTOR DATE
PRINTEDNAME OF PERSON XiNSTRUCTING THE WEU.
•
Submit the original to the Division of Water Quality within 30 days. Atm: Information
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Fain GW-la
Rev. 7N5

.RESIDENTIAL WELL CONSTRUCTION RECOWD
North Carolina Department of Environment and Natural Resources- Division eV. ater Quality
WELL CONTRACTOR CERTIFICATION #- o[ t e
1. WELL CONTRACTOR ,
Q,Ce:etr: eczth
Wel Contractor (Individual) Name
�.11JJ4.Q • '6o a'yiQ-CS 1 Son.
Wee CJ1iLsb. r Company Nat*
STREET ADDRESS i"SB8 S .11c, AZ7 aoS
Hoar 5?r;'n I NC - a8'-%' 3
City or Twm s$ a -Zip Code
(8p$)- tp(ps—aoaa.
Area Cade- Phone number
2. WELL INFORMATION:
SITE WELL ID Afdapprirabte)
STATE WELL PERMII-Mrapvtmble)
DWQ or OTHER PERMIT S(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply ya
DATE DRRIED
TIME COMPLETED 2,-100 AM O PM fir
3. WELL LOCATION: ,�,r /
Girt /4G�" �/ - COUNTY /A IC.1/rch
&a,.' urn- f.My r-
Aster Name, Numbers, community. SubS is3on, Lot No.. Parcel. Zlp Code)
TC3POGRAPHIC / LAND SETTING:
oValley ❑Flat °Ridge ❑Ocher
(deck appropriate box)
LATITUDE 3
LONGITUDE
May ben degrees,
minutes, seconds or
in does al forme
Latitude/longitude source: GODS °Topographic map
(location of net mast be shown on a USGS topo map and
attached f0 MiS form Trot using GPS)
4. WELT.. OWNER ,. JJ II�
OWNER'S NAME 56 bl..i`R ieLi'L Pre.;dt
STREET ADDRESS %%i % ota elkeen C.cQQK *U
ASIAe -Me nit. airib03
City or Town State Zip Code
(8e18 :1`►3' (pan
Area code - Phone number
A WELL DETAILS: ' .7a. TOTAL DEPTtt J o s
b. DOES WELL REPLACE EXISTING WELL?NOV
BelYES ° NO
c. . WATER LEVEL ow Tap d Casing Y �/0 FT.
(Use^+' IT Above Top d Casing)
d. TOP OF CASING IS : . FT. Abet Land Surface'
'Top d casing terminated odor below lad sulfate may require
a variance in aloe with 15A NCAC 2C .0118.
e, YIELD (gpm): C METHOD OF TEST-R -.
329327
f, DISINFECTION: Type4.113 Amount /S
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING: Thickness/
Depth a?Ft. �'�%� From } 1 To
From To P.
From To R.
To
To
To
7. GROUT: Depth Maid
From O To 20 Ft Ctenten ..
From To - P.
From To Fl.
Method
8. SCREEN: Depth Dianeler Slot She Material
From To Ft. in. in.
From To Fl. in.. in.
From To R. in. n.
9. SAND/GRAVEL PACK:
Depth She Maul
From To' Ft.
From To Ft
From To Ft
10. DRIWNG LOG
„Zonation
tom 7 � .gocv"A. ;;
a7 3os-
11. REMARKS:
100 HEREBY CERTIFY THAT TIES WELL V'AS CONSTRLCkED NMr'rnWCC ecru
15A !CAC 2C, WELL CONSTRVCUON IMINCARDS. AATrnHAT A COPY OFTNS
RECORD HAS BEEN PROVIDED TO THIw ELL OWNER,
73-
SIGNATURE OF Cf_RTIFIED )orefi CONTRACTOR DATE
`tie Ct.Ck HteAltt 60.1.•blit5
PRINTED NAME OF PERSON X'NSTRUCT 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 GN-la
Rev. 7R 5

329317
RESIDENTIAL WELL CONSTRVClQNRECO3D
North Carolina Department of Environment and Natural Resources- Division of V. atc Quality
WELL CONTRACTOR CERTIFICATION k .
Ott aisa
1. WELL CONTRACTOR
QATZ > QcZ h 5lo.'a'Ve.cs
Well Contractor (individual) Name
e-CS icSon.
Wen Cdhackr Company Nose
STREET ADDRESS \'\% .\t.J7 QGS
%1OAt 5ic;h4S NG - a811443
City or Town sSe -rip Code
(8a8} (a(oS- doa2_
Area code- Phone number
2. WELL WFORMATIOtt
SrrE WELL ID A(depprroebie)
STATE WELL PE MTMeitopFoMe)
OWQ or OTHER PERMIT S(d appicable)
WELL USE (Check Amicable Scot): Residential Water Supply II
DATE DRILLED G 9- G
TIME COMPLETED l 'Q O AM 0 PM
3. WE.L LOCATION:
rS
Crr11�1:./7 .. courNT/Y /AAr'(Gnh
A I"ch 6
4Sbaot Nane, Numbers. community. Subdivision, Lot No.. Parcel, Zip Cade)
T POGRAPHIC / LAND SETTING:
i Valley ❑FW ❑Ridge ❑Other
(check apprcpdah borer)
LATITUDE 3 _
LONGITUDE
Iatitade/Iongitudc source: uGPS oTopographic map
(bcation of wet must be shown on a USGS topo map and
attached to Wris bra foot usig GPS)
May be in dogma,
minutes, seconds or
in a decimal format
4. WELL 4WNER
OWNER'S NAME
STREET ADDRESS
Q/l
Town
Area code- Phone number
Tip Code
S. WELL DETAILS: •//
a. TOTAL DEPTH: oe(n
b. DOES WELL REPLACE WUSTING WELL?
//YES ❑ NO 1
e. WATER LEVEL BebeTop ct Casing /O 0 FT.
(Use •+' it Above Top of Casing)
d. TOP OF CASING IS 1 FT. Abel a Land Surface*
'Tap of casing terminated atfor below'lard surface may requite
a variance in aotadance with 15A NCAC 2C .0118.
e. YIFLtT(gpm): //2.) METHOD OF TEST ('C.,3
f, DISINFECTION: Type4. %$ Amount /3
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:Depth /
Rom 41 To
From To
From To
From To
TmicNhessl
DitrnMer Weigle
Fl. _T3 _'ti1042I
From To R.
From To Fl.
7. GROUT: Depth Maria!
From0To2o F. &siit*.
From To - F1.
From To • FT. •
Method
psi eV.
& SCREEN: Depth Dia rater Sbt Sine Material
From To R. in. in.
From To R. in.. in.
From To R. in. M.
9. SANDIGRAVR. PACK:
Depth Size Material
Rom To- Ft.
Fran To Ft.
From To Ft
10. DRILLING LOG
ac
From
To
�ll�Cr nAes74
V 2 C
11. REMARKS:
L
r
rri
--r
100 PEMEBY Ch Y-MATT IS WEL I Y AS COt6WRLCIED PI ACCORDANCE Moran
'ISA?CAC 2C, WELL CONSTRUCTION UThNOMRDS. AN)TW .TA COPY OF INS
RECORD 11AS SEEN PROVDEDTOTMZ MELL OWNER.
SIGNATURE OF CERTI WEIJ. OR DATE
'tie CC". Cx Vice l50.uJ'7te_ti
PRINTED NAME OF PERSON X'NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MIL,
1617 Masi Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7A5

329316
RESIDENTJAE WELL CONSTRUCTION RECO:AD
North Catolila Department of Environment and Natural Resources- Division of \1 ater QuaLty
WELL CONTRACTOR CERTIFICATION # OM Its
1. WELL CONTRACTOR: -
Wet Contractor (k+drvidual) Nave •
�..�\ et �JQl.wiyy-t-f s *"Son.
Well Leak Company Natet1
STREET ADDRESS VyVBS .YCteS oii4
Ho-4 5Tr;n% 7 NC - ot8'1`-13
City or Tam she -ZIP Code
t 8 %» 1n os- o&;a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ANsopa:able)
STATE WELL PERh6Tti(eseproble)
DWQ or OTHER PERMIT ti{1 ale) I /`
WELL USE (Check Applicable Box): Residential Water Supply {¢'
DATE DRILLED G -1-
Tea COMPLETED / 00 AM O PM ®r
3. WELL LOCATIOIt
CITY: [lle4 t)t/✓//4 -. CO
rs,
.(SDnC Name, Numbers. Community. Subdivision, to No.. Parcel. top Code) -
T POGRAPHIC / LAND SETTING:
dstope °Valey URN D Ridge
(check appeoptiate
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS °Topographic map
(bwtion of wet most be shown on USGS typo map and
attached to this tam tnot using GPS)
Other
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER PIMA
OWNER'S NAME Gl
STR ADDRESS E PO
WCa✓etrolie, /1 d-
eity or Town State
Area code - Phone number
Zip Cade
a
S. WELL DETAILS:
a. TOTAL DEPTIt '2O
b. DOES WHS. REPLACE EXISTING WELL? YES ° NOV
e.. WATER LEVEL Below Top of Casing So FT.
(Use'+' I Above Top of Casing)
d. TOP OF CASING IS 1 FT. Abaft Lad Surface'
'Tip at casing terrvneted aVa below lard surface may require
a variance in accadafcewith 15A NCAC 2C .0118.
e. YIELD Wpm): C METHOD OFTEST i •�
t DISINFECTION: Type_9;.‘ %S M.oa t /6
g. WATER ZONES (depth):
From To Fran To
From To From To
From To From To
6. CASING:
Thickness,
Fran k 1 TO (0 7 R. CAta 1 +
From To R.
From To F7.
7. GROUT: Depth Masai
0 To o R. CPnvan 4-
To Ft.
To R.
From
From
From
fritre4
8. SCREEN: Depth Dia rater Stilt Size Materiel
From To Ft. in. in.
From To R. rtt. if.
From To R. in. in.
9. SAND/GRAVEL PACK:
Depot - Size Material
From To- Ft
From To Ft
Fran To Ft
10. DRILLING LOG
From To
11. REMARKS:
ForrrationA ort
n
r-
-C
I00 HEREBY CEaWY THAT TM WELL Y'AS COtSlnuCTED N ACCORDANCE Welt
15A MAC 2C. WELL CONSTRUCTION tTANDA90e. µDTINTA COPY OF INS
RECORD HAS BEEN PROVIDED TO T I: w ELL OMER.
ER.
SI NATURE OF N/E(iCONiTaCTOR DATE
bete. c - H4o.Rb 563la'ye_s
PRINTED NAME OF PERSON ;ONSTRUCTING THE WEU.
Submf 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.
Fans GW-la
Rev. 7/05

RESWENTL4.L WELL CONSTRUCTION RECORD
North Carolina Department of Emrtonma,t and Natural Resources- Division of Wear pcalit)
WELL CONTRACTOR CERTIFICATION # - OM Ilia
1. WELL CONTRACTOR:-
0--Cc: c\c key Vx So.•a'Rcs
Wall Contractor (individual) Name
e...‘ t142 S 0.v.11¢.{ S *
Wen Cdd.acta Company Nance
STREET ADDRESS \y%$ 5 .Vt.A.Z oZOS
F1ok Sc c:112) NC - al3
City or Teen e -TAP Code
()- tn(oS- &Gas_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 90:mancthe)
STATE WELL PERMIT9(rsophabre)
DWQ or OTHER PERM T #(ff appLnble)
WELL USE (Cheek Applfade Box): Residential Water Supply
DATE DRILL
ED LP -
TIME COMPLETED S ; 3n AM O PM 2-'-
3. WELL LOCATION: ' / ,�I S
CITY: la Lys ��(-11 I.I commie Ilka, nfri
S t1r (r-tgQe RJ.
.(Strte Name. Numbers. Canmuary. Sub6tion, La No_ Parcel, Zip Code)
chime
f LAND SETTING:
gSlope DVSaey ❑Fial ❑Ridge ❑OSer
(cheek appropeatebox)
LATITUDE 3
LONGITUDE
Latitude/Iongitude scrum_ OOPS cTopographic map
(location of wet matte shorn one USGS tcpo map and
attached to M b tor, fnot using GPS)
i WELL OWNER /,(��')
OWNER'S NAME to L'Ci "-^ T ,QJ-G M
STRWIDORESS #ra*T
Q, ;n r7 &14 e.
City or Tors State Zip Code
May be in degrees,
m`muns,secondsor
in a decked format
•
Area code- Phone number
S WEU. DETAILS: - v-
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O
c. WATER LEVEL Edo. Top of Casing 96 FT.
(Use v' ItAbove Top d Casing)
d. TOP OF CASING TS FT. Abate Land Surface'
'Top of casing terminated at/or below lard surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST (4.•u
Nov
6. CASING:
t. DISINFECTION: Type4;,t1 \3
g. WATER ZONES (depth):
329315
Amount��
From To From To
From To From To
From To From To
7raCtalessr
Fran _TToo Ql R.Atli_ .910aI
From To Ft.
From To R.
7. GROUT: Deans Maeda
From Q To GO Ft. (enter .
From To - Ft.
From To R.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAYS-PACK:
Depth From To -
11.11 tele
Dianeter Slot Ste Mate!
Fl. in.
R. of if.
R. in. it
Fran To
From To
Size Material
Ft.
Ft.
FL
10. DR!LWNG LOG
From To Fonnaton
g
11. REMARSS:
r
k DO HEREBY CERTFYT AT TUS WEL L WAS COWFM.ClD N ACCORGMCE wme
15A ?CAC 2C. WELL CONSTRUCTION Me ANSI THAT COP+OF INS
a HAS BEEN PROVIDED TOTED, OWNER.
cY- r
TURE OF H ONTRACTOR DATE
't+Qce C.V. Et20.Ri. ;S13.Ta7a_
PRINTED NAME OF PERSON XINSTRUCT!NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MIL,
1617 Mali Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Tam GW-la
Rev. 7)t5

RESIDENTIAL WELL CONSTRUCTION RECO:ID
North Carolina Department of Environment and Natural Resources- Di':,.vu of Waor Quail)
WELL CONTRACTOR CERTIFICATION #- o[ late
320214
1.WELL CONTRACTOR:
c 1s 191Qc'th 'tc' Y^12.ts
WeR Contractor (Individual) Name
Q.\\ S.t ' 'J O.a.d ¢--CS 'S O'7.
Well Company NaiteQ
STREET ADDRESS �'\%% ..�ta7 ao9
t\o4 5 C *\ ) NC -
City or Town state -Zip Code
(8a9} (ofos- oSoa-a-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Me epprl able)
STATE WELL PERMIT#(Raopliicable)
DWO or OTHER PERMIT ME appracab1e)
WELL USE (Check Appricable Box): Residential Water Supply QJ
DATE DRILLED ? (
TIME COMPLETED 3 120 AM 0 PM [D-
3. WELL LOCATION: / // N/ /
CITY: !iv(!(LCI:4�J .. COUNTY /.l /... /d9
ZCzre 1/
{Stet Name, Numbers, Cmu nmay. ., Lot No.. Pacel, Top Ccde)'
TORAPHIC f LAND SETTING:
QBlape OValley OF 0Ridge ❑Oter
(Mack asymptote box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS ❑ Topographic map
May be in degrees,
minutes, seconds or
in a decimal format
(location of we/ must be shown on a USGS fopo map and
attached to form /not GPS41-1
4. WELL OWNER
OWNER'S NAME s. _,�_
STREET ADDRESS 8% t,Js t as Cat eW t
%1t's'a±
City 0} ar Town_ jj 6v__ d Code
Store ZR Cade
(78114.1
8a8 t tt- 950io
Area code- Phone number
S. WELL DETAILS: ,
a. TOTAL DEPTH: ' j. ,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
c. WATER LEVEL BelowTcp of Casing. e C.) FT.
(Use-+' f Above Top of Casing)
d. TOP OF CASING IS i FT. AMAe Land Surface'
'Top of casing terminated a fa below and surface may require
a variance in asc:ardatce with 15A NCAC 2C .0118.
e. YIELD (gpm? Y METHOD OF TEST R•g
f, DISJN ECT10N: k5 Amount cal,
g. WATER ZONES (depth):
Frorn To From
From To From
Frorn To From
6. CASING:
To
To
To
Thickness/
Depth From L To_ . Ft. Diann er Weight
-tea
From To R.
From To R.
7. GROUT: Depth r7 Maeral Method
From 0 To pcC3 Ff. CP Ivent- fri tee il
From To - Ft.
From To - FI.
8. SCREEN: Depth Dia Teter Slot Size Maeda!
From To Ft. n. _ in.
From To R. in. in.
From To R. in it.
9. SANDIGRAVEL PACK:
Depth - Sire Material
From To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From To Forrtalion
/ 93 »tier fir.
IL REMARKS:
--:
4-
-c
1 DO HEREBY CERTIFY THAT TOS WELL V'AS CONSTRI.Ctm INACRCalhaorr WITH
IB.A NCAC 2C, WELL CONSmUCfON ITANDAROS. AW aMTA COPt OF was
RECORD WAS BEEN PROVIDED TO Te:IA ELL COMER.
7-e-C OF CERTI ter N ' CONTRACTOR DATE
bete. .%' it1/4e0.4jy Sauk^tre_43
PRINTED NAME OF PERSON CONSTRUCTING THE WEU.
Submit the original to the Division of Water Quality within 30 days. Attu: Information Mat,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7)05

4. DATE MILLED t r
E. TOTAL DEPTH
e. cumin COLLECTED Yes NOQ-
7. DOES WELL REPLACE METING WELL? YES CI HOe'
S. STATIC WATER LEVEL Solon Tap al Caber FT.
Mee II/lwoTop cCa d
S. TOP CIF CASING W I FT. Mon lsdSad -
'Topktsly IndaOho bolo alaMwrlwsmew saloe Yrwwr-
doeSSIPA PICACl1MW !�
10. YIELD (op* ,--(") METHOD OF TINT
11. WATER ZONES J
12. C LORWATON: Typo Amount
13. CASINO:
D�Tp4
Rowe, Cosol0000
Bur(Arl (14ct- r ;
�.� ,_
ityClnt f
f oil hone mes r nosed Ins bock d Sat
TM fikilion L OCATiON SICEitH
From 1 ~1L f on /, ' t diwinaMdibasbonahmeeooSs
�""t�'1— — Rtusde or*or mop rMwsm.spit)
Rom-- To FL
From To FL
14. GROUT:
dot 1AModol
From C To p. e cyrnP--
From To FL
15. SCRIBER
— Dbmalw Slot SW
From ___To_F1 In.
From __ To _ FL
R bt.
ant _ To _ F1 Irk
15.SANEVORAVEL PACK
Doper Stow
Fl
Ram . To
Noon
CiSuo•Doperno Oar - of... o.. sdNand Ib en-CataalWar Ord" •OisweMs►Ogden
N.C.E/fa llMAsroAlf)tfl4 it
-_ WELL CONSTRUCTION RECORD wru cg wui*ctatx Wan Anti —
WELL CONTRACTOR cmnrecATCN f: -113
STATE WELL ocNSTR nnol PERWI :
1. WELLUll��osb wows En¢Roeldmislip Wadol M❑ ISSAf❑ Padlrrml❑
Roweety Hai Pump Wee Irgnolbn OWN 110114cLWUs
2. WELL LOCATp[t (Slaw Math of M be2oa bibs)
Nie ssTeweTM' 1' 'YL.t a caw f flri i 3cmfl
eallewoo,00ltiorbwoC savolly. -_-.ssadLelNap
3. OWNER 1-bnQ rm raLl--rr,Q .f
p�j�j Alr,� " "eel
as--1s3
CySTat SINS
2rar. Ri^ - 3C
FL
From To FL
17. REMARKM
LloraorIng CI
u ac Lao
Ras Ti
1 ri O
-10 -
-iC-
t 00lEREVY CMlaTIFY TWAT TM WELL WAS OORII1RUCTLO W ACCORDANCE WITH 15A NCfl WRL
COIMTRUCTIONSTANDARDS. AND MAT ACOPY OFTNSRECORD fWERNRgWEIEDTOTLEWELORIER.
FOR OFFICE moms
caret
Sad No.
OPPM
•enas rft.lfrlronkOOISTmlCl ICS116 OATS
OidRsass slam n days
SAM fa UMW

Nola Carolina•DopKlmwtolErnbawnetandNNvafRuourno-DWWottofWarrCully-Grandmas Senn
1939 Md Cents Canter- PS* N.C. 27999-NUS-P tans (91i) 733-3221
WELL. CONSTRUCTION RECORD WELLcoNTRAcrof: CU OcLX1 l
WELL CONTRACTOR CERTIFICATION 9: )\ L
STATE WELL CONSTRUCTION PEAMIm
1. WELL USE(e,hoakAppuerbSear) RisdwwalLd Munkepai❑ Industrial ❑ AgrloWWrd❑ Monitoring
Reeowty LI lint Pump Wider M..t,. ❑ Other If OI sl LSt Use:
2. WELL LOCH (iti. ` q(9n IoadIon ham)
Nana Taws tY 1-el TTt LI Cpun- 1Y \rA is(
(Roodwe. n» *abet aSiAdL iandLoNo) ORIWNGLOG
ASWN
3. t �� S 'err Yk n kt0._ V -- L -` To
Mran
�t-1- ',I A
`1` AX�X1�' i tSIDG - no
atmTmn EpCode
4. DATE DRILL -
5. TOTAL DEPTH r
S. CUrT)NGSCOU.ECTED YES 0 NdD-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOb'
6. STATIC WATER LEVEL Below Top of Casing: FT.
Woo'1AboveTopofCSO
9. TOP OF CASING IS FT. Above Land Sudan*
'Top el nebq Maind *to bsSw lend awfaeo r000lvollottoto:n now
donor edit WA NCAC2C MIS
10. YIELD (ypm): ¶Q_ METHOD OF TESTV. 9
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
DEPTH
Fenno•an
Amount 9 addlbnst spa Is needed use bads of Norm
Wa Tildawn LOCATION SKETCH
' D.pth3,4 or WMyNFc „lol l �, dt•a9on ad adorn ban M moan two Sas
Frain To J 1 Ft. a 7� tow
a oast map rMstwa pots)
From----_- To FL
From To Ft.
14. GROUT:
From L ToT _n C JJ'I' Q y }t inh Materiel Metlad
From To FL
15. SCREEN:
Depth Di mekr Slot Ski
Ram To FI In. In.
From To FL In In.
Ram To R. In: In.
16. SAND/GRAVEL PACK
Depth
From To FL
From To Ft.
17. REMARKS:
MOMS
0
,l' rr-- :---I
_ -c7
Siti''' - a<
Ilt:.- ‘I cr.r. o
Slat Maeda —
►l a 3
t 00 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA //CAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT ACOPY OOF_INS RECORD SEEN DEDTOTHE WELL OWNER.
FOR OFFICE USE ONLY 01J y �� 7i 5t Q 4
Oa Mc SONATEAnE OF PEASONCONStWOCiac 1NE WELL DATE
Submit o.Midb obbane Wile OnNSp. Srond.NSaSa•on wain 30 days
OWt IEY. 12EN
SeS No.

Norm Carolina • Omar d Enwr.nant rd Natural Rears - 0wwon ol Water Ornaty • Groundwater S.maon
103C Mae Service Center- RM SSh, N.C. 27as-103S•Ptrorte NH) 733-3 21
WELL CONSTRUCTION RECORD WELL CONTRACTOR: COtii ark r x
WELL CONTRACTOR CERTWICATIONa:
STATE WELLC0NSTRUCTI0N PERMT71:
1. WELL USE (ce.nnp ee.w. Pep ReeldeneweJ Muie)pol 0 IndsMs 0 Agriculture! 0 Monitoring 0
Recovery ❑ Heel Popp Wales Inleelbn ❑ Other [] If Other, Ust Use:
Z. WELL
stTaw KAIGhowithelo-h of I V l(}..1-5 n III county. Y V�n'QISOf
louden bin)
tiniest Taw (
Iliad NomeA^rr?d ran Car.rray, or awaet.twr and Loots) ORIWNG LOG DEPTH
3. OWNER 601 fliscj FrTs Fairer
Address Loci Ilia i 1 -
c(ISSe1►riom I r t'.1 :Aalo-1 1 I
air rTeen awe Bit Code
4. DATE DRILLIU)SD
5. TOTAL DEPTH L0,
11
6. CUTTpiGS COLLECTED YES Q NO(3-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOG'.
& STATIC WATER LEVEL Below Top of Cuing: FT.
(Ua nAbwe Top et Cant
a. TOP OF CASING IS 1 FT. Above Lend Saba'
'Top et maw bmrrbotrrd War below lend sore rag otraea ear In e.ar•
roe was ISA /CAC 2C,Ot/a
ant) — Lit.pr
10. YIELD (ppm): METHOD OF TEST
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount
13. CASING:
11 Depth
Front --To 11- P \D
Fron• To
From To
14. GROUT:
From
From To Ft
15. SCREEN:
Depth Diameter Sbl Ski
Ram To Ft In In.
From _ To _ Ft _ In
From . To _ FL_ In. In.
16. SAND/GRAVEL PACK:
Depth Size Malerw
S.ddelontl apiece b needed me beck of brat
Wr Mrs LOCATION SKETCH
FL, Obit rvhkle%z *e,,;�.,,. ($how drrybn end don kern ad least hero Sr
l"S_I_`rLLT1L Il._]LL].G71 (C. �e,rdrrmap eaNe.roePotrdq
Ft.
Method
Materiel
From To
Front To
17. REMARKS:
Ft C
aid
�� �
►rj
unti
--i
1 DO HERESY CERTIFY THAT VMS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTKINSTANDARDS. AND THAT ACOPY JTIM RECORD BEEN DEDTOME WELLOWNER. FOR OFFICE USE ONLY Al . <"� 5-- 2614
Cued Ha
San.
SOMA OF PERSON CONSTRUCTNG THE WELL. DATE
DAWN SOW b owes sifter Duey. orrrdarer Slam whin 30 days
GYM REV. 127e
1

Addrsu 23g1 msch
Wi QQV nck—ASco
4. DATE DRILLED l�-o_sVV
5. TOTAL DEPTH
6. CUTTINGScoLLECTW YES 0 NO®-
7. DOES WELL REPLACE EXISTING WELT YES 0 NO9
6. STATIC WATER LEVEL Below Top of Casing: FT.
` lure Y'a AbeamTep erCuing)
I. TOP OF CASING IS ` FT. Above Land Surface
'Top e< enkp lerarkated she bares lend serfage rsgsku a valence b aaeer•
dawe S ISA NCAC 2C Ale
10. YIELD Wpm). .9 METHOD OF TEST
11. WATER ZONES (depth):
r
North Cudba - Depaanr. of Environment and Naked Resources - Division of WNa " .'•+ z-i
163E NM See Center - Rakish N.C. 27610-lasacn, (e16) 733a?21 - GroundwaterSaran
Senate
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 0 OCUr\.t .r
WEU.CONTRACTOR CERTIFICATION 6: Ca I 1
STATE WELL CONSTRUCTION PERMITO:
4 0
1. WELLUSEL applicable maReddened Munk:Mal0 Industrial
Recovery ► aat Pump Water Irgeotorl 0 Otter p B Otter, tbt the
2. WELL LOCHTI (Shaw sketch of M ioa ion bibw)
Nearest Toe j�T 1C'l f� H I I County- IIriLS(en
Agricultural 0 Monitoring 0
(Road Nana Nan. Conanaar, or auk brim one Lot No.) DRILLING LOG DEPTH
3. OWNER hen HU irv2J) Fan Te Faaaa n
V1 'MCC t tZq
CNp sr Tam Nete
2i Cede
12. CHLORINATION: Type
13. CASING:
Front -- Ft.
Fmm To FL
From To FL
14. GROUT:
From
Amount t eddltb al epee* b needed use beds of form
Materiel T Ft 0ICA— Method
From To FL
15. SCREEN;
Depot Diameter Slot Mai Nadal
From To _ Ft In. _ In.
From _ To FL kt. kt.
From ___ To FL In. In.
16. SAND/GRAVEL PACK
Depth Si Makwhl
From To Ft.
From To FL
17. REMARKS:
LOCATION SKETCH
ddron and detente from at bast two Stan
or other map Maraae pokde)
a
r rs
nit_i
Jtilk‘
EAvt
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORWINCE WITH ISA NCAC 2C. WE!.
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORT BEEN OVIOED TO THE WELL OWNER.
FOR OFFICE USE ONLY pp
arse Nix
Sold Ns.
5-2.2-°*2
aemuwuRE OF PERSON CO5SmuCra*O THE WELL DATE
Submit originate Olrldeadefter Oat% Ore veer sooten align 30 days
oW.1 REv. farm

Noah Crofbs • Dprtment of Fanned and Nicene Reso roes - Didion o1 war Only - Groundnut Saatlon
1636 Hsi Sinks COS? - RUM N.C. 2NreslflPtmns (1119) 733a221
WELL. CONSTRUCTION RECORD Wcu.coNTRAcron• C) n VL& -r
Will CONTRACTOR CERTIFICATION St c3 t
STATE WELL CONSTRUCTION PERSST6:
1. WELL usE (awwa<APFnabb Seek RsalderrOat E( MurAetpal ❑ 111dweial ❑ ApdmS ral 0 Monnwrp ❑
Recovery 0 Heat Pump Warr h4ectIon 0 other ❑ rt Other, Ust Use:
2 WELL
, A t 1 ( ' s 'I 1'"L(oea6en CI1C6 30i J
3. OWN OkAWren I Cf-'fly, or ach
Address
W e«vef-i %n(
ayrTows SMs Zip Cot
4. DATE DRILLED � -cIto
5. TOTAL DEPTH
6. CUrINGSOOLLECTED YES NO®-
7. DOES WELL REPLACE OUSTING WELL? YES 0 NOf2"
8. STATIC WATER LEVEL Below Top of Casing FT.
fuer **When hen Top of f
S. TOP OF CASING IS_1_ FT. Above Land Surface*
Ip el cans drrdrrabd ant brew tend inns n., M. s radon b uesar•
dunes west ISA NCAC2C Atli
10. YIELD (ppm): . METHOD OF TEST e7-1 Ice
11. WATER ZONES (depth):
•
12. CHLORINATION: Type Amount
13. CASING:
D.pth
From 1 To lam' R.
Fran To FL
From To FL
14. GROUT:
Dpth MatsrMt Method
From ) To ice` FI. e C nicrit,
From To FL
15. SCREEN:
Depth Diameter Slot Site Material
From To Ft , In. _ In.
From _ To Ft., In. _ In.
Fran _ To FL in: _ In.
16. SAND/GRAVEL PACK:
Depth SW Malarial
From To FL
From To FL
17. REMARKS:
ORIU.NG LOG DEPTH
From To
_koa.
IcA. - 1 5--1
iS--q- )iD
1tuv-i S
Oewkean.
r
6 ddWara peed Is nosed cud beck of bin
LOCATION SKETCH
&wagdneeon and dries Prom at Ina two Stab
Rods,aawn imp Sarre* points)
4-46
apy, .
*it =yn
r, . 7
ry
rri
I DO HERESY CERTIFY THAT TIES WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD 11*s BEEN PROVIDED TO THE WEU. OWER.
FOR OFFICE USE ONLY
okra rra
Sun Ns.
0/lAn --9-04
eptMTUHE OF PERSON cONSTRUC1N611E WELL DATE
Santa solubW b Olrbba at War Out GravaraecSudan wain 30 days
6WI REV. 1VIt

North Carolina • Daperbrnt al F.rwtorarree and Nowt Raoouraar-d•lalan of Water Ouiy • Otaunt wNr Seddon .c v;
103E MN 8aMcs Came, - RNly4 N.C. 2700-1030-Plon. p/t) 733 21
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CUP P in A l
WELL CONTRACTOR CERTE=ICATION 1 113
STATE WELL CONSTRUCTION PERMITS.
1. WELL usE t teekA„1ki[a a«.SO* Rosidene ' MIRdch r p Indu.ew 0 Ayriadktrw 0 Montbrtq 0
Recovery ❑ Hs& Pump Wear woolen p Other p n Oster, List Use:
2. WELL tocivrocitMaus Town. ,N Lt . —*Fi r n. we.r.n (j(�(1(it
vial)
Caw* iIkI
rand Nand . tree,. •.. ar and Na) • RILING LOG DEPTH
3. OWNER A st - . Oa r iS1 1 a Lit
S ant• J S �Ia r — Li
f7ly atTarry _ you (� - )�-%l`l
4. DATE DRILLED...) 1 l.� j/
S. TOTAL DEPTH I In
6. cul nmas COLLECTED YES 0 No127-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOJ
8. STATIC WATER LEVELWOWTop of Casey FT.
WI I I Phan Top WOO*
II. TOP OF CASING IS L FAT. Ahem Lend Surface'
dar'Tap Mfa .. Sat beq4aa below ru• nebula In awe
10. YIELD (yam): ) METHOD OF TEST ) 9
11. WATER ZONES (dspihr
(40 - l LQS
12. CHLORINATION: Type
13. CASING:
ROM—L—T1 "T1 FL
From To FL
From To FL
14. GROUT:
Amount a addling peso b nodded uae beak al Ion/
wmTrdans LOCATION SKETCH
rwa a (Slow drr.7on grid dawn ken M bat two SUM
Roads, or other snap boa paha)
Ram �_ To a� R C�.I 7 L -� ma's
From To FL
15. SCREEN:
Dopes Darner Slot Site Materiel
Rom _To P1 In _h
From To FL M In.
Rom To _ FL In.
16. SAND/GRAVEL PACK:
Depth Site Mabrlai
Ran To FL
Rom To Ft
17. REMARKS:
c� D-
;�
3 �
I DO HERESY CERTIFY THAT THIS WELL WAS CCMISTRUCTED IN ACCORDANCE WRH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPxjt// F THISRECCiD HAS SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ��
curd Na
Meant
OF PERSON canonic THE W Hr. DATE
Sutra adatet a oiridan er War Way. OwandaM . sei w*t 30 days
oW-I REV. UM
1

th
Deportment
No, Met Ceram - of Environment and Nand Rama - Da en a War CuYy - OnudwaSeamISM r Seam
Ratak N.C.2769MS76P ors (91Y) 7f3-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: el C( run
WELL CONTRACTOR CERTIFICATION f7: I V.
STATE WELL CONSTRUCTION PERMITS:
1.
WELL USEaaar seeneeblesash R.Ndene Mfl%,aI ❑ Industry ❑
Recovery u Fat Pump War Weston ❑ Other p Wirer, flee Use
WELL LOCATION: (Show sketch of the baton bibw)
we.e. Toes ll 1 IC'; Co„
AodoulMnw ❑ Monawrw ❑
(load - endNuataa,
3. OWNER & a f CorcLer,
Address
PIS
Cheer Town ets
rt. DATE GRILLED (`1 —D ('
S. TOTAL DEPTH 1 tit^ c-
6. CUTflNGSCOU.ECTED YES 0 NOtr
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQI
& STATIC WATER LEVEL Below Top of Caber FT.
(Um •.• I Men rep et CawS. TOP OF CASING IS FT. Above Lend Surface*
'Top of easing terakated War below bond anus ngaka a va enee In near -
doves war ISA NCAC 2C Atli
10. YIELD (Rpm): I METHOD OF TEST Rd
11. WATER ZONES (depth):
DRELUNG LOG
l7 6 For T.
gap (32r' -701
ayCede 7C 1 70�i
70. — )DOS"
•
Subaisbn end let
12. CHLORINATION: Type Amount
13. CASING:
Depth 2
From o 9 FL
From To FL
From To Ft.
14. GROUT:
DEPTH
Ferman' Desenplort
11-4 ct_ci
C3,ra n t Fe
( )' ('
(31-- nite
t Slat span b needed use beck of an
Yra Tleetrwas LOCATION SKETCH
et Wrenn •, sty. . Mallond dlet.oe boom et lent Iwo Ma Robe, or other nap narrow pokes)
From 1_ T isJU__ I S Y -11 F Me
thod
From To Ft
15. SCREEN:
Depth Dian* Slot Skb Maledel
From To Fl In rI.
From To _ FL _,_ In.'
From _ To _ FL In; _ kt
16. SAND/GRAVEL PACK
Depth
From To
From To Ft.
17. REMARKS:
FI-
Sin Ma era
Lel
-7r Ala
0
� Cr+
o _
Crt
r
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.FOR OFFICE USE ONLY < fir&n !O —���
owed pre
saki No.
TUBE OF PERSON CONSTRUCTING THE WEIL DATE
Sae ski* Mace Kan Oak. oa.deSam NNett30days
Ow-1 REV. 12AR

Moth Owning • Depwrrtent of Etwra.nwa and Hound hewwese - DIAdon of Ww OuSty • Groundwater Salon
1636 Mal Smits Center- Raetda N.C.275 l-1a6Phons MS) 733-322/
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C 4 crt-ructisler
WELL CONTRACTOR CERTIFICATION l: c-Q\
STATE WELL CONSTRUCTION PERMIT!:
1. WELL USE Idea AFplfal / Rksdunls MudellaM ❑ Suer. ❑ Agricultural ❑ Manhunt, ❑
Recovery ❑ Heal Punp Water k IN' ❑ OBIr 0 I Otter, Lbt Use:
2. WELLNeareetWCATcrarcMtw f ccin , 4::«'nc ,iSD(\
3. AddressowNER ` wed L rn �s isMim^R and _ _ DRIWNG LOG
clyarTam r C I*Cy'J
4. DATE DRILLED -C -�
.12
5. TOTAL DEPTH �
6. curnNGSCOLLECTW YES 0 NOja--'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOt'
8. STATIC WATER LEVEL Below Top al Cuing: FT.
Moe •.• I Above Ted Casty)
/. TOP OF CASING 18� FT. Above Land Surface*
Rep of near. toraineted Woe bdew bed steam n..r.e . mans In .now
dine. with ISA NCAC 20 A1/6 n
10. YIELD (ppm): METHOD OF TEST 1r1
11. WATER ZONES (depth):
r‘l-d\S-
12. CHLORINATION: Type Amount
13. CASING:
WO Term
From \ irk° FL1 T7t i arrvt4ee11
Fmm To FL
From —
14. GROUT:
From
From To Ft
is. SCREEN:
To FL
Tot O n es 14"dei \t Metliod
Depth Diameter Sal Stria Metaled
From To Ft In. _ ki.
From To FL In. In.
Rom To FL_ In: In.
16. SAND/GRAVEL PACK:
Dept Stu MAWR
From To FL
From To Ft.
17. REMARKS:
DEPTH
1t
u
N C^'
I tailored spew b needed use boa of lei � `'
tt
--r
LOCATION SKETCH --c
(6hww anion and damp rem at 1st two SISi 1 eltr\n .
Rode, or ether nip Saes pore)
t DO HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH /6A NCAC SC. WELL
CONSTRUCTION STANDARDS. AND THAT A OF THIS REOOR444HAS E PROVIDED TO THE WELL OM ER.
FOR OFFICE USE ONLY r T 1 ' 5 /
Cued Mx
ssdd No
64.
el0)MTUNE OF PERIOD CONSTW JCINO T1i WELL DATE
Sutra wirrreite Di.Mw, of WSNOury Oreurdeww Swam Win 30 days
OW-1 REV. 13te

4. WELL OWNER
OWNER'S NAME
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envuonmcnl and Natural Pr wnrrl r . Div Hon of \Vatcr Quality
\VE_LL CONTRACTOR CERTIFICATION a a t
1. WELL CONTRACTOR:
ReaCalk;>aGt
Wen Contractor (Indrviduall Name
aF2AX,eh C.ck (Lej.1 Or{ t ;tag 1 I nC
Well Contractor Company Name- ' j
STREET ADDRESS % J 1 (,e.w celrL
tt Lr Y(41
(sheuc a\ggc b
City or Town State Zip Code
(gaC» S4--355'►
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID r(it applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT r(I1 applicable/ /
WELL USE (Check App cable ,€iox) Residential Water Supplytj
DATE DRILLED €3 / 0 6
TIME COMPLETED 3 - 3 0 AMO PIAI/
3. WELL LOCATION:
CITY: ICUS t+LL.c- COUNTY rinAol.S2)
M u p 9 M WNAs A 2D FhLL-CYai k0
aNumbersCam nM. . Suba..HonLa No.. Parcel Zip
Code)
Nam, .
TO GRAPHIC / LAND SETTING:
Slope DValley ❑Flat ❑Ridge °Other
(check appropriate box)
LATITUDE 3 5, _ 5 (a 595
LONGITUDE& a 3 o ac,t�Sci
S
Latitude/longitude source: .6s °Topographic map
(bcafion of wel must be shown on a USGS lope map and
attached to this form I not using GPS)
Kg 41 CALF
STREET A DRESS a,b C 2 CP.Z13K �-L(c to
LAW>A � .v-tu E agl �S"t
City or Town State Zip Code
Slay be in degrees
minutes. second, or
in a decimal format
( sat F G5%-)a6-3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? 'YES 0 NO RI
c. WATER LEVEL Below Top d Casing FT.
(Use it Above Typ d Casing)
d. TOP OF CASING IS 1 FT Above Land Surface'
'Top d casing terminated Wv Delon lard surface may require
a variance in accordance with 15A NCAC PC .0118.
e. YIELD (gpm):
S
METHOD OF TEST Lb —A (R_'
/ DISINFECTION: Type
g. WAT ER� ZONES Id•pili
Fran (q3 TD1a
From To
horn To
6. CASING
Depth OJa ter e, t�]h�l
From To J FI 6 W cSlJ7C.y-�
Rom
From
F r om
Amount
n O r 'sr
F Inn To Ft
From To Ft
7. GROUT!,1
From_1
From
Material
Ft UMW'
To Ft
From To Ft
To
To
To
Thickness/
Depth T
To a-0
Method
taBT.)P.ZA
8. SCREEN: Depth Diameter Slot Size
From To Ft. in in.
From To FI in in.
From To
9. SAND'GRAVEL PACK:
Depth
From To
From To
From__ To
10. DRILLING LOG
From
TO
.,
a5r - 1a3�
tar% . a4 ;
tad-'- Q65
11. RENI.ARES:
Ft
FI
Ft
Ft.
in in.
Material
Size Material
Ftsrmatio Descriptisn
alz�s yr c
G
A
C
CT)
0, r_
N
I OO MEREIW CF R Tin THAT THIS wEll WAS CONSTRUCTED al ACCORDANCE WTI
ISA Neat 2r W F l t CONSTRICTION STANDARDS AND THAT A COPY OF,THIS
RECORD MAC RC FN PROJVED TO THE WELL OWNER
s d o'
SIGNATUR,_ OFSFRTIFIED WELL CONTRf1CTOR
�1 1�t_c6 �5 AS
PRINTED NAME OF PERSON CO STRUCTING THE WELL
TE
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-ta
Rev 7/05
0

2 7 799
WELL CONSTRUCTION RECORD
Nbtth CatoIlhti - DEjiatttEtlt bf Eh91tStiltaiht and d Natural kesoiirces - Division of Water Quality - Groundwater Section
WRLL thStlialli* i3lltltE i$tlAL) HAW �l t^ - KAil es- 32---. 4/ C % -- CERTIFICATION P
WELL CONTRACTOR COMPANY NAME icfw /9/t't LC ell / 1I
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ
Of applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential E M®icipal/Public 0 Industrial ❑ Agricultural ❑ n
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ other 0 If Other, List Use (D 2)
1-0 a�z m
2. WELL LOCATION: /
NmrestTon: t i7'Jgcl,nN
3//R 0R n s 2re fd 7t7f3
(Sestet NataS Mambas, Community, Subdivision, tut No., Tip Code)
3. OWNER:
dd 0S�L fi/ r ;� its
� // err Rome No.)
/17/7t4% /41 G.2,-?7-3
City or Town Stale Zip Code
Alta code- Phone somber
4. DATE DRILLED y'/ $
5. TOTAL DEPTH: 2 4'5
6. DOES WELL REPLACE EXISTING WFI 1 7 YES 0 NO E'
7. STATIC WATER. LEVEL Below Top of Casintc yg Fr.
(Use *4-- if Above Top of Casing)
8. TOP OF CASING IS / YJ / FT. Above Land Surface*
'Top of slug termiltftad attar blew land surface requires ■
mitiance In aeeerdaae, was ISA NCAC 2C AI IL
9. 'YIELD (gpm): le METHOD OF TEST / i m 21Z7
10. WATER. ZONES (depth):
1 I. DISINFECTION: Type i' et /7 Amount //9 e27
IL CASING: WallThidmess
oe ` Depth
From To Ft_
Fromm To Ft.
From_ To Ft
13. GROUT: Depth Material M
From_ To Z.(7 Ft. CnnG/'e/et to ntvy
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From pi To Ft_in. is
From To Ft_in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From 1 To Ft.
From To Ft.
16. REMARKS: t24At5L/e/I
,...'
Topof c/Land setting;
❑Ridge OSlope ❑Valley
(check appopnat box) i i
Latitude/longitude of well location
v)
co
co
(atpeerhaiarmlemods)
Latitude/longitude source:❑GPS❑Topo
(Mork box)
DEPTH DRILLING LOG
From To Formation Description
JOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road o
numbers and common road names.crie
\ 2
I 1
Rf-213
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
TECHd ST A COPY OF. t RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
.et liC/R-0‘
SIGNATURE OF PN CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mall Service Center - Raleigh, NC

to R2777
� � ti
WELL CONSTRUCTION RECORD
Norio eatoiitst - Di tiff brF.tivito fluent iitid Nit t}aal Resources = Division of Wafer Quality - Groundwater Section
WELL tbptt blaRDtvmv a) It t, t /f/il/fn-// __ En -a - RAM e5.. �+e CERTIFICATION flan V�C+
WELL CONTRACTOR COMPANY NAME 51 ,t.YP7A,t'4a 5(Y5/ IN el/ 7 %L/N�PRONE s 22.I y%- 5'&)
STATE WELL CONSTRUCTION FERMITB ASSOCIATED WQ PERMiri
(if applicable) (if applicable)
D
1. WELL USE (Check Applicable Box): Residential unicipa1/Public 0 Industrial 0 Agricultural W. T
Remy 0 Ry 0 Heat Pump Water Injection LiOther 0 If Other, List Use '_ _. et
T7 C3
2. WELL LOCATION: / / J/ Topo d setting; ` i
Nearest Town: mi9fl l 17 rff�l/S w ❑Ridge Galley ( .
$L l if RPu t°re ler ( t?.1,/ //2ie -n7r3 (rti«t wwopr++lt ) o,
(Sweet Name, Numbers, Cammwiry, Subdivision, Lot No., Tip cote) Latitude/longitude of well locenF
3. OWNER Flit -s, ly
Address (c / `� e^ d Latitude/longitude ado utc:0 S0Topogaithic map
PVe'P
(�araonrcNoJ (check ) ____ _„_
/li9t5b ef 7 t 757 PEPTR DRILLING LOG
City or Town Zip Code From To Formation Description
Arn code- Phone number
4. DATE DRILLED q—/L/'d6
5. TOTAL DEPTH: 7 915
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO R-
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
p (Use"`' if Above Top of Casing)
8. TOP OF CASING IS /,D f/ FT. Above Land Surface*
*Top of easing terminated at or below bud surface requires a
variance to accordance with ISA NCAC 2C A118. /
9. YIELD (gpm): '? METHOD OF TEST /i / re`c
10. WATER. ZONES (depth):
11. DISINFECTION: Type re, h/
12. CASING:
Depth
From 91 T 70 Ft /11
From— To Ft.
From To Ft.
Amount / /2 o 7
Wall Thickness
or Weight/Ft Material
CPP-7/
13. GROUT: Depth Material
F To 2n Ft Cerne—refe
From To Ft
14. SCREEN: Depth Diameter
Front_ To Ft,____in.
From To Ft in.
15. SAND/GRAVEL PACK
From�
Depth
To Ft. Size Material
From To FL
M
sue
Slot Size Material
in.
in.
16. REMARKS:
c
(..r))
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common roed,pames.
I DO ra' a • Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ON STANDARDS, T A OF a / ' e a RD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSO CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC

WELL CONSTRUCTION RECORD
Nardi Catania - Dbp$tt i ht hf Hhpf nti bilit ifi8 Na
WILL tfitt'ttt&Ctb * pltDtianUAL) MAIt
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT.
(if applicable)
R Mitres
wIj
a 1UU
vision of Water Quality - Groundwater Section
well
;_�1�_.._... --_-- CERTIFICATION 027 L/
7' well 7 f. N9 /i PRONE I l f, YI 40
ASSOCIATED WQ PERMIT./
(if applicable)
1. WELL USE (Check Applicable Box): Residential lttnicipal/Public ❑ Industrial ❑ Agtical
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WEd 1 LOCATION:
Nearest Town: M / County /,ithiCa
12,`92. U s / c0 73 it iskri 3
(Street Name. Numm. bSobdivisim, id Na, Tip Code)
3. OWNER (%Ai/f 6fi9 t
Address /2 Y9, 7 IA S /�lyw Z
ln tgrsh, " YU( 2? 75` 3
City or Town Stan: Zip Code
Area code- Phone number
4. DATE DRILLED �i- of
5. TOTAL DEPTH: / h S'
6. DOES WELL REPLACE EXISTING WELL? YES El NO E
7. STATIC WATER LEVEL Below Top of Casing: v9 FT.
,- // (Use 4�' if Above Top of Casing)
8. TOP OF CASING IS / D FT. Above Land Surface'
*Tap of meths terminated idler below had aarfaue requires *
vasimee In aeeordace wnh ISA NCAC 2C Ala/
9. YIELD (gpm): / ? METHOD OF TEST /. iY1fi6
10. WATER ZONES (depth):
Or
11. DISINFECTION: Type
12. CASING: nniibTo7O Ft /' /y
From_ To Ft
From To Ft.
Fro
13. GROUT Depth
r C /i Ammmt //2 07
Wan Midwest
or eight/Ft _1
From To ?_ a /acre re
From To
Ft
o
ti
Topog�phic/Land
❑Ridge ealope ❑Valley?
(check apPmprumcbo )i:
Latitude/longitude of well issa4on
Fi 0 L.l
(depeahninazs7Wrnuds) i .:
Latitude/longitude source:OGPS❑Topo apbic map
(dick box)
pRws— _.—
Formation Description
DEPTH
From To
i�
rn
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.
ward
we/ sh-jc
14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft _______in. in.
From. To Ft in. is
15. SAND/GRAVEL PACK:
Depth Size Material
From 0. To Ft.
From_ JTo Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL W CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
COON STANDARDS , i' THAT , COPY OF THIS RECORD HAS BEEN PROVIDED TO WELL
LL OWNER
Z.7'�Ei
DATE
SIGNATURE OF PEXSON CONSTRUCTING THE WELL
rn
0
a
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rrvnncv - Division of Water Quality
WELL CONTRACTOR CERTIFICATION a a t 4
1. WELL CONTRACTOR:
�eu' 244 Qo16—wtk
Well Contractor (Individual) Name
Re kbenn 1CLCA be; k;n5l Inc.
Well Contractor Company Narnee
STREET ADDRESS JI jv1e.LL% t Ce S'+E.jr HMI
%shev\tle NC agg0G
City or Town State Zip Code
f )- 1,54-35g1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mil applicsble)
STATE WELL PERMIT#(! applicable)
DWQ or OTHER PERMIT 0(d applicable)
WELL USE (Check Applicable a): Residential Water Supply
DATE DRILLED • a. 0
TIME COMPLETED �. - o AMC) PME/
3. WELL LOCATION:
CITY: AFC 1-11�l_
COUNTY ' rr'Aol OOa
Pao t-)€ cekr,p O A P
(Street Name. Numbers. Cammunrty, Sub.nvon, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / tp/µp SETTING:
OSiope OVatky @'Flat ['Ridge °Other
(check appropriate boa)
LATITUDE 3
LONGITUDE
Latitude/longitude source: DGPS OTopographic map
(Iocahbn of we/ must be shown on a USGS fopo map end
attached to this form t not usig GPS)
4. WELL OWNER es
OWNER'S NAME -Y�� L ate--;
May to in dopers.
minutes. seconds or
in a decimal formal
STREET ADDRESS 9-
o JB� S6G3
GAszIDN1A *IC 0.41053
City or Town State Zip Code
( 8i - -ty 4
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 5 /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 8/
c. WATER LEVEL Below Top d Casing 0 FT.
(Use -a' if Above Top d Casing)
1
d. TOP OF CASING 1S FT. Above Land Surface'
'Top d casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): I METHOD OF TEST RIG —A t (L
(1 L121
) \)
1 lj `6 e2.
f. DISINFECTION: Type 'Ic't7N (.ba Amount
g. WATER ZONES (depth
From t 4- To 83
From To
From To
From
From
Frorn
To
To
To
6. CASING: Thickness/
FromkDepth Dia peter Wm h,L Maje,riai
To 30 Ft. C9 Ig s4 ' + 9N C-
From To Ft
From To FI.
7. GROUT:,f Depth Material Method
Firm 1 To Ft Csrlytl3-fat ft.)Q.13 D
Frorn To Ft.
From To Ft.
8, SCREEN
From
From
From
Depth Diameter Slot Size
To Ft. in. in.
To Ft. in. in.
To FIin. in
9. SAND/GRAVEL PACK:
Depth
From To
From • To
From To
10. DRILLING LOG
From a To
as
FI.
FI.
Ft.
Size Material
re J
0 0
a �
Formation Description N
o f66� g Jvro�pJ
a5'-- $4) (n (LA+J C�
' r t 6 en,
e65/ - ao`�
11. REN1AitK5:
OgA1333H
(-)
I CFO NEREay CERWY THAT MRS WELL WAS CONSTRUCTED N ACCORDANCE WITH
I5A NCAC )C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HA5 PEEN PROVIDED TO THE WELL OWNER
IZRAAbeAn. bejlelkAje-Sle 6/diiit CC)
SIGNATURE OFj,.ERTIFIED WELL CONTRACTOR DATE
1 1-I BJ A514
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 clays. Attn: Information Mgt.,
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Form GW1a
Rev. 7/05
c
-C

City or Town State
(gad} 9.54--35S')
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID apt applicable)
RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carnlma Ucpanmcnt of En. Ronment and Natural Rc.nnrece. Donlon of Water Qualily
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
RtJabejn �alciux �t
Weil Contractor (Individual} Name
(feu bet. Ca \d. eU1 Or-1 I; leg { 10c.
Well Contractor Company Name
l ' f
STREET ADDRESS J I I,�"eu. ^-t CeSrer (Vcuy
fkskevc Ue r3C 2,\V 6
zip Code
STATE WELL PERMITS(n appbcablel
DWQ or OTHER PERMIT eh( aoplieablel
WELL USE (Check Applicable El at Residential Water Supply LTf
DATE DRILLED VI 4-/ 0 L
TIME COMPLETED 10 - ' ' AM a,/ PM p
3. WELL LOCATION:
CITY
()VLSr4A1L
COUNTY (M-A
ti>3 J -s6 6t. A)
mm (Street Name. Numbers. Cemunny, 5uoo .on Loi No Parcel. 21p Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVaney QFlat ORdge OOthex
(check appropriate bog)
LATITUDE 3 5_ 4-9.950
LONGITUDES oZ 40. bid3
L. tituddiongitude source: ❑GPS OTopographic map
(bcatbn of wet must be shown on a USGS (opo map end
attached to this form ( not usrv7 GPS)
May he in degree;
minutes. seconds of
in a decimal format
4. WELL OWNER ii\
OWNER'S NAME ..JANnTLC- S/T'(�P
STREET ADDRESS gS I� v I A N% be -I lek
City or Town Slate
( s'a'yy} aR% "0 aaq
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ZIP Code
b. DOES WELL REPLACE EXISTING WELL? YES CT NOV(
4-45'
c. WATER LEVEL Below Top or Casing
(Use'+' a Above Top of Casing)
s
FT.
d. TOP OF CASING IS F7 Aoove Land Surface
*Top of casalg ternanated :vet below fond surface may require
a vrlance in accordance wdh45A NCAC 2C 0118/(
e. YIELD(gpmp METHOD OF TEST Q-46-A/Le
at4-D
r OISINrECTION: Type
g WA ER ZONES (deplhy
From 11 Tony
Finn To
From To
6. CASING:
+ Depthz
From a To
From To
From To
Ft
Ft.
Ft
From
From
From
Amount
Diameter
331287
To
To
To
Thickness/
Weig1/: n. Material
7. GROUT:DepthMaterial
rron 1 To aria FtcfyynCNT
From To F1
Ftln To Ft
Method
ucite b
8. SCREEN: Depth Diameter Slot Size Material
Frorn To Ft in. in.
From To
From To
9. SAND/GRAVEL PACK:
Depth
Fr OM To
rrtm To
Firm To
Ft in in.
Ft in in.
Ft
Size Material
Ft
10. DRILLING LOG
Fromro� To
/
-1 `
11. REMARKS:
Ft
Fprmalion Descriptio
(1--Gust-01.5
C CAN tC-Le A GPr•.
tS Q-A r51`tF3
Crg
I M Nf PEP'. C FRTT Y THAT THIS wrt t WAS CONSmUCIFD N ACCORDANCE W1M
ISA srA( )( µf l I. CONSTRUCTION S1ANDAROS AND THAT A COPY Or THIS
RECORD r,AC fir PRovorr, TO TNF WELLOWPIFR
�t DA
SIGNATURE �OF CERTIFIED WELL CONTRACT OA E
114L3q aJPS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center - Raleigh. NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION if a I `-o
1. WELL CONTRACTOR:
(feu- ben Q rsi &w e. I I
Well Contractor (Individual) Name
�eu'Pein Caldwell O ri l l isng \ AC .
Well Contractor Company Name"e ew 1_€ i o ( I
STREET ADDRESS SS) ' tester k4
(kShev;tie nlc aslob
City or Tam State Zip Code
( gad } a54 - 5571
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 'tarapplicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT PO( applicable)
WELL USE (Check Appli le Bo ): Residential Water Supply (i
DATE DRILLED S O ( /
TIME COMPLETED I) tic a AM j" PM
3. WELL S
LOCATION: V.L.00ATION: c�
CITY: ARSN A COUNTY MAN ,ANI O 13
R66 e'G 6a.Aac-f( (limb
(Sheet Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LA SETTING:
❑Slope [Valley ebt ❑Ridge [Other
(check appropriate boa)
LATITUDE 3 5
LONGITUDE g a 41.3
I
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(kcation of wet must be shown on a USGS tope map and
attached to This form /not usirg GPS)
4. WELL OWNER 11 �t S
OWNER'S NAME •••j" )*Lt.)13 `7 ,/
STREET ADDRESS r7'�lap t )I G rU jiA.ac i4 RiO
MARSNALL NC.
City or Tam State
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH'
3a5
Zip Code
b. DOES WELL REPLACE EXISTING WELL'? YES let NO I
c. WATER LEVEL Below Top d Casing: b FT.
(Use-+- it Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
-Top of casing terminated aver below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): tO METHOD OF TEST R)G-aL2-
331286
t. DISINFECTION: Type nTN el D ro Amount A 0 Z -
g. WATER ZONES (depth
From a 30 To a.rD From To
From To From To
From To From To
6. CASING:.t Thickness/
From 1 DToth9ol Ft. i� eler Weight
SDRZ' Re'
From To Ft. j'Y�l..
From To Ft.
7. GROUT: Depth Material Method
From 1 To �D Ft. GBmBrIT Qot'gEb.
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FI. in. in.
From To FI. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
Fran To Ft.
10. DRILLING LOG
Fro / To r Formation Description
- 21 0VegesuRD tl
%V-a3o• & arrE,
.3o'— a4o' C e.eS — ID GrtY3
a.4o'- 365' GOa'—'—ram
I1. REMARKS:
C,. r, C
r FT
a
I00 HEREBY CERTIFY THAT THL5 WELL WAS CONSTRUCTED N ACCORDANCE Wm1
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THATA COPY OF TWS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�2Q,,AQ,e,,,, Cy� G LA,eke g ,/ob
SIGNATURE F CERTIFIED WELL CONTRACTOR
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 566.
Form GW-la
Rev. 7/05

..,,r.B 1�SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departm}nt of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / 3t0
1. WELL
�.CONTRACTOR:
1 Contractor Individual) Name
E(4 S6IV hl 1E11 add rump LLC.
Well ontractor CompanyName
GG ��-/
STREET ADDRESS 37..3/ ,Fw LEteEs-1EQ litv7 .
City or Town / State Zip Code
(8-8)- 252-• 849(,0._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/kit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable7Box): Residential Water Supply Q
,f
DATE DRILLED - /7 - 4:"C.
TIME COMPLETED 2 - G�' AM ID PM-
3. WELL LOCATION:
CITY:
/////c-5 %// COUNTY/1Z-//ro.,
Onto(✓..� £�
(Sheet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOO9OGRAPHIC / LAND SETTING:
Bit -lope [Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 r ,re , 71/47'
LONGITUDE it e- 36. Ify'
Latitude/longitude source: mdS ❑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 \"r M p LJ..r s bu. r
STREET ADDRESS JO
YYlorc,h r h c -�8753
City a Town State Zip Cale
May be in degrees,
minutes, seconds or
in a decimal format
1;4( )- 2089-506 Co
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3c7/ -
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO p/
c. WATER LEVEL Below Top of Casing: 4 ° F?
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of rasing terminated at/or below land surface may require
a variance in accordance/rdwith 15A NCAC 2C .0118.
e. YIELD (gpm): 7 METHOD OFTESTA)e/:thin 9
01 n 4 6
f. DISINFECTION: Type ('er--. Amount /C/A5j
g. WATER ZONES (depth):
From 00 To From To
From ZVU To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 2.7 Ft. 6. /e/ it'gti
From To FL
From To Ft
7. GROUT: Depth Material Method
From f2 To 240 Ft. Concrete. j ` ourThij
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
/Y eicr
/t-23 S'ie</
11. REMARKS:
I DO HEREBY CERTIFY THAT TNIS WELL WAS CONSTRUCTED N ACCORDANCE WRN
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
� �itfp "ic, '•g4- 7-17-04
SIGNATURE OF EERTIFIIED�WELL CONTRACTOR DATE
PIA-N /1. bi /VeS
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /.0
1.^WLE(LL CONTRACTOR: '/
.-Bin M bf iv ES
I Contractor Individual) Name
Etcf0SON} hl?lla/ydTatty j1r,
Well ontractor Company Name /
STREET ADDRESS 5J731 Lew LE! EsJEQ may.
LE-o s-1Ft /Y c ,;V 7zig
City or Town / State Zip Code
(24 )- 52- 8g91>z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(I( applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply I,2
DATE DRILLED % -/6- o
TIME COMPLETED AM ❑ PM 0
3. WELL LOCATION:
CITY: A7 511 // COUNTY tecrc-,
Cr,/ r Ed ,.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat geflidge ❑Other
(check appropriate box)
LATITUDE 3 I. f/r
LONGITUDE r Z 3r, rz/
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DGf'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
SIDRESS
City or Town
State Zip Code
(Tess)- a52-0099
Area code - Phone number
5. WELL DETAILS: -1
a. TOTAL DEPTH: v`c/..r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q'
c. WATER LEVEL Below Top of Casing: UJ FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS I _ FT. Above Land Surface'
'Top of casing terminated agor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD m : (gp ) I0 METHOD OF TEST�'p//Jj/- r j
cv pn� Lf�i
t v o V V
f. DISINFECTION: Type r^ZY..y
g. WATER ZONES (depth):
From PO To From
From 4/0 To From
From To From
6. CASING:
Amount 72,4 fi
Depth Diameter
From 0 To 24/ Ft.i, ///
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
COiP2/
7. GROUT: Depth
Depth Material Method
From ,0 To , 0 Ft. COACrcf f;N r;
From To Ft. -J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. . in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D= is
Z✓- Zvr-
11. REMARKS:
in.
in.
in.
Material
Material
Formation Description
r/y
cA
-0
t
0
0�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W nH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
irst � -zv LLf-41- /-4- 06
SIGNATURE OF �C.EERTIFIED WELL CONTRACTOR DATE
Dik/tl !1, /L Ne5
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 # 3 / 410
1. WELL CONTRACTOR: /
Z/:9-/11 fj. GUiA'ES
I Contractor ((Individual) Name
fi eNs b ell add /ump
Well ontractor Company Name / A
STREET ADDRESS 3731 Aw LE16Es/ac IILIJ7.
itffs Et /vie • aY7 , /
City or Town / State Zip Code
(8 ?3 )- A58y91.,2_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/NI applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply La
DATE DRILLED 2-1 - t.7G
TIME COMPLETED .1..2<" AM PM(3
3. WELL LOCATION:
CITY: "7 /7// COUNTY /114/-x.n
tr7fe Pc
(Street Name. Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI
9 Slope ❑Valley [(Flat idge ❑Other
(check appropriate box)
LATITUDE 3 r C/}: 4-o3
LONGITUDE b e,,. lr, /71'v
Latitude/longitude source: 1GPS ID Topographic map
(location of well must be shown on a USGS topo map and
attached to this tom) if not using GPS)
6. WELL OWNER /1/(
OWNER'S NAME P/- (TO qs/o
STREET ADDRESS r5 13a/en (fine due
City or Town State Zip Code
(-09?st
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
May be in degrees,
minutes, seconds or
in a decimal formal
Tar
b. DOES WELL REPLACE EXISTING WELL/ YES ❑ NO
c. WATER LEVEL Belau Top of Casing: C0 rr
(Use -+" d Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
. *Top of casing terminated at/or tielvw land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): is4 METHOD OF TEST
f. DISINFECTION: Ty per&.,.. Amount __ /cS.
g. WATER ZONES (depth):
From .4.49 To From To
From 2-Y/O To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To /Id Ft. b-//SS' TD.✓1/ f'✓c-
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material Method
From Iv To No Ft. CONCrefe ?ja%,/thy j
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
/L7- /IX S4//
11. REMARKS:
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
_2
SIGNATURE OF �CERTIFIED WELL CONTRACTOR DATE
v/A-Al /J. IJNeS
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / TO
c:
oL). (324
1. WELL CONTRACTOR- �� % i+Ai / i /YES
W 1 Contractor Individuall) Name
lEff (!Sens /AJ !!and inp LW,
Well ontractor Company Name
/ 3T731,M w LEre Q JE//
!.4t
E/ tfS jft iV C' • :�r4
City or Town / State Zip Code
(2;8 i- 35�'.. S�{9lz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STREET ADDRESS
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 3
DATE DRILLED 2 - /V - �o
TIME COMPLETED CI, s/i AM 2 PM ❑
3. WELL LOCATION:
CITY: /k, ,60/ COUNTY/Are:yin
M / Ate-, .4;
(Street Name. Numbers. Community. Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ID Slope ❑Valley ['FlatE5Rldge DOther
(check appropriate box)
LATITUDE 3 r !/f 4t/6
LONGITUDE J' 2 Ji. 6.77"
May be in degrees,
minutes, seconds or
in a decimal format
latitude/longitude source: gepS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form J not using GPS)
4. WELL OWNER /l c
OWNER'S NAME l C!Ge
✓en r 0 Son 2Gldid5
EET ADDRESS ,J 0. Inv )43(0
IJJQuip .XU; I I. KC .8_78 7
Q -� �� State Zip Code
L-Q26_)- .331- A/a39
Area code - Phone number
City or Town
5. WELL DETAILS:
a. TOTAL DEPTH: -3*-7-3--
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 2/
c. WATER LEVEL Below Top of Casing: 441 Fr.
(Use "+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface*
'Top of casing terminated at/or Below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): 2 .4 METHOD OF TEST )ajierlf'R4
f. DISINFECTION: TypeC*-...e
g. WATER ZONES (depth):
From Y/o To From
From -t2,6 To From
From To From
6. CASING:
From 0
From
From
Depth
To 7i-
To
To
Amount 2xAi
Diameter
Ft. (e'er
-
Ft.
Ft.
7. GROUT: Depth
From p To No Ft.
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
S.V-✓?/ R4
Material Method
Co r to 1)10 ji t; 4
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
Size
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0-'3 (/y
77-7r J//
Material
7Y-sLr
. REMARKS:
t
CP
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
kiA-it Nes
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / �t)
1. WELL CONTRACTOR:
-4- r 4-rJ �t (.(J' i /fr ES
W II Contractor Individual) Name --�
fEetalltoAS l0IFll and
n[)T1p lir,
Well jontractor CompanyName
/�C % ) ill
STREET ADDRESS :4731 ///..lit IE)CFJE(2 htl•
-) t s J f- /r.C.
City or Town / State
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tot applicable)
STATE WELL PERMIT#(1i applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED .T e-O G
TIME COMPLETED ..."42 .s''t AM r-PM D
3. WELL LOCATION:
CITY: /hoy M// COUNTY Mcc/ds.
(Street Name, Numbers, Community. Subdiasion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p SIope DValley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 S
LONGITUDE r L ,7/, /Ia
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: C rPS ❑Topographic map
(location of well must be shown on a USGS lopo map and
attached to this form A not using GPS)
4. WELL OWNER
1/
OWNER'S NAME O� kO ▪ S,Scr/
STREET DDRESS 1 Q / 'ra
//S /./%/ b' C g75V
City or Town State Zip Code
(R25?, &89-aay25
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:.J
b. DOES WELL REPLACE EXISTING WELL/ YES NO la
c. WATER LEVEL Below Top of Casing: /Ct 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): Za METHOD OF TEST
f. DISINFECTION: Type`/+,iir. Amount
g. WATER ZONES (depth):
From <'70 To From To
From /iC7 To From To
From To From To
6. CASING: Thickness/
A Depth Diameter Weight Material
From Ci To S// Ft. t./t.,- Ca ee' r—'C
From To Ft.
From To Ft.
7. GROUT:Depth Material Method
n
From /� To SD Ft. Concrete ?IJL(fiil r2
From To Ft. .J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
Size
To Ft.
From To Ft.
From To Ft.
Material
Material
10. DRILLING LOG
From To Formation Description
O- Js ('/cy
24-0'
Ui 3'z> G.ti.
11. REMARKS:
3 4
m It
_ r £Uu3 t g c
.J ,:r
Mf;
100 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.
�?iil.. �• s4./ [- 7-2-04
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
2/A-, /), tU, NG'S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / T
1. WELL CONTRACTOR: /" /
/Z.4A-il) L(/ / /v ES
W� II Contractor Individual) Name
NS /.< fw ll add 7 ithip
Well ontractor CompanyName l� J j/
STREET ADDRESS 3 3/ /ay LE/ L7E{Z
le ske- M, c' . a87YP
City or Town / State Zip Code
(SN8 )- Las&-• Sy9t2-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tot applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply I
DATE DRILLED 3 -r- OF / �+
TIME COMPLETED w- Id p" AM PM (r
3. WELL LOCATION:
CITY:///mac l ici/ COUNTY enter>5Y2
(X/t N'sa .lam
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC�/ LAND SETTING:
[TSlope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r CA. e s'7/
LONGITUDE r Z 72, 35'o
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EtePS ❑Topographic map
(iocation of well must be shown on a USGS topo map and
attached to this form If not using GPS)
4. WELL OWNER ',r
OWNER'S NAMElI/i'r[A€ !l.[ 0 /
STR^E/l2 cJrid
ADDRESS (P7l•Lf-J to wood
ttvskcell IYC a,8753
City or Town Stale Zip Code
(”8 } (� 44 - 3 5 30
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 22. r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO rr
c. WATER LEVEL Below Top of Casing: ZO 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
•
t. 1 J 0 -2
1. DISINFECTION: Type gibe•-w Amount /2Aii
g. WATER ZONES (depth):
From yr% To From To
From / 70 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Maaterial
From /J To cY Ft. 4,/1 $04/1/ {'dL
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 10 To NO Ft, Concrctc
From To Ft.
From To Ft.
Method
�loitriro�
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
A-2ti Skid if
vie 22r 6•M.2e �r1 IS
y
So Y
11. REMARKS:
SE° E ,i
1106
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
'ISA /CAC 2C. WELL CONSTRUCTION STANDARDS AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
QG
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE 1
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WFLL CONTRACTOR:
obh/ail
r
W II Contractorrj( drd al) Nam?
Ek' olis WE II &wd (*chip, �..LC•
Well conntractor Company Name
STREET ADDRESS (Jl f.
s
LEmeskg asi
City or Town / State Zip Code
(vs )- a58-&f9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(i! applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED : 3!7 AM 0 PM E<'
3. WELL LOCATION:
CITY: "VI hi
COUNTY frW/i5dw
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETt
f] Slope ON/alley ❑Flat idge OOther
(check appropriale box)
LATITUDES/ 3 3 2 (p r
LONGITUDE / r V. b,7�7/
Latitude/longitude source: L3t,rS ❑Topographic map
(location of wee must be shown on a USGS logo map and
attached to this form if not using GPS)
4. WELL OWNER / L('
OWNER'S NAME /Pyle SGi/ie's i,-
STREET ADDRESS 3/9 & Sq,,p�. age Rd
(Its 447/ 7YC Fl?.S �{
C or Town State Zip Code
(Sa 53 )- 77g. 7.As
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
dos
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: /et FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS j . FT. Above Land Surfaces
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 6 METHOD OF TEST_',rJ
f. DISINFECTION: Type CGII Alsel c Amount / d..7
g. WATER ZONES (depth):
From
From
From
/f/
To /fr`f
To
To
6. CASING:
Depth
Frarn_,4_ To ma
From To
From To
From To
From To
From To
Thickness/
Diameter Weight Material
Ft. k, 2 i ;/6r/At1' Acs,eafexi
Ft.
Ft.
7. GROAT: Depth Material/
From 0 To �ifl Ft. CDtable
From To Ft.
From To • Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To FL - 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.
ID. DRILLING LOG
From To
0 7S
75 — 4S
qs —100
/D L=otos
11. REMARKS:
Size
Material
Formation Description
C/tr v
Sanalitie ti C
Ave
170,1/2' /it
A
8
t
o
I DO HEREBY CERTIFY THAT T115 WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO Tyg WELL OWNER.
OF CERTIFIED
CONTRACTOR / DATE
(t J, lo%fs
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
PO
1. W CONTRACTOR:
/W, rr
W II Go act vid ial) Nam S
to 1LSo,t Aft 1l fiord imp. LLC•
Well ntractor Company
yyJN2ame J(/'y / r
STREET ADDRESS Ie�/ /It
LEicfes-teg ( c. as Ab8
Zip Code
City or Town / State
g 4 >• 2ss-$(19&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
CITY: /AO,rS
3/j$6
:/1p
AM El PM21
AN( COUNTY AlaOI(SON
(Street Name, Numbers. Community, Subdiesion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI
❑ Slope ❑Valley ❑ Flat edge ❑ Other
(check appropriate box)
LATITUDE N 3$ AG 1 Pb
LONGITUDEVD$L. /titYr).
Latitude/longitude source: gc;r:S ID Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this tom) if not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME .M U ( 1-c .s fl
BEET ADDRESS R
nardSiu;O4
City or Town State
)- 146-0,75(0
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c. WATER LEVEL Below Top of Casing: TO FT.
(Use `+- if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top d wing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST��r
Zip Code
6,65(
6. CASING:
20A .9
J ei b DP`338
f. DISINFECTION: Type (r4 6/'IA/ r Amount
g. WATER ZONES (depth):
From /6 if To / 7L1 From To
From To From To
From To From To
Thickness/
Depth Diameter Weight Material
From 0 To3q- Ft.(p,%.S 1/6/AF PreS-0AN/
From To Ft.
From To Ft.
7. GROUT: 0 Depth /1 ,Material
From To to FL &ICrtIe
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To FL in.
From To Ft. in.
From To Ft.
reoz-
Method
Material
in.
in.
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 20 No
SanprTiirNG
33 — 37 KarFC
ln' keS aisetWei
11. REMARKS:
pi
t
2308
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W ml
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THS
RECORD HAS BE PROVIDED TO THE WELL OWNER
SIGNATU CERTIFIED CONTRACTOR DATE
Of IJ
PRI ED NAME F PERSON CONSTRUCTING THE WELL
{
rt
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. WELL CONTRACTOR: /' /
�/L(.44.1l fr. LZ i Ai ES
1 Contractor Individual) Name
Ergoconls b 1ell a.✓d ump PLC.
Wellyontractor Company Name/ ����{{1
x
STREET ADDRESS 3T73/ Au) LE/A1.,S/ECL &I.
LE/• k--SJEe- le • al7ijg
City or Town / State Zip Code
(SCR )- :7152-- sg912_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Or applicable)
STATE WELL PERMIT#(N applicable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply 1-
DATE DRILLED r- /L • V& /
TIME COMPLETED // D . DO AM PM ❑
3. WELL LOCATION:
CITY: Mc- (<// COUNTY ill/se.,
Af-clecie .j} -11�./ Oaf.;
(Street Name. Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat E3*Fidge ❑Other
(check appropriate box)
LATITUDE 3 _i S/. f
LONGITUDE S- L 4/r, G4v1
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: I:CPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER v
OWNER'S NAME ....TM/ 4,,(fy,
/t! 4 L✓/OS$4 0�
STR T ADDRESS //0 5 S
ity or Tam Stale
} bo
rea code - Phone number
to51Q- YS7
5. WELL DETAILS:
a. TOTAL DEPTH: ro r
36a4c
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing: 47(.7 Fr.
(Use'+• if Above Top of Casing)
d. TOP OF CASING 15
FT. Above Land Surface'
'Top of casing terminated ator belay land surface may require
a variance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm): 2 %a-
METHOD OF TEST
f. DISINFECTION: Type (74.2•Cve Amount /5 Ad,
g. WATER ZONES (depth):
From 200
To From To
From To From To
From 420 To
6. CASING:
From To
Thickness/
Depth Diameter Weight Material
From 0 To 4.7/ Ft. C /2r r.e e2/ Jzt, L
From To Ft
From To Ft
7. GROUT:n
From /)
From
From
8. SCREEN:
From
From
From
Depth Material Method
To a0 Ft. COACrr^_1C %Dl,f/i!v Li
To Ft / JJ
To Ft.
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Size Material
Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
o- 7'
36 - S/i
Sor
11. REMARKS:
Formation Description
fA y
aft
/-. !e(I
-13
O•
SE+ ;; 20U6
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCT/ON STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF
f �v/ARN
r-/1.-Qt,
EERTIFIIED�WELL CONTRACTOR DATE
Ne5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
a
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR: /,
�/Zi 4f-A1 L(J i /V ES
lEWell Contractor Individual) Name --�
44trs6ANz /.c fell add amp /,.,�C.
Well ontractor Company Name
STREET ADDRESS 373/ ,Mto LEte /EQ llttq.
/rICSke. •
City or Town / State Zip Code
(5-- sI912-
Area code- Phone number
?. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#ol applicable)
/YA
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Er
DATE DRILLED - y' Ow
TIME COMPLETED
3. WELL LOCATION:
CITY: /"/c-tCs, 1/
J YOQ
AM PM Er.'
COUNTY . 7ct>!.ion
f/vT .z/j
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ope ❑Valley ❑Flat oRidge ❑Other
(check appropriate box)
LATITUDE 3 C U' zA/ '
LONGITUDE 1- Z 37 72L'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2r6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to This form 1 not using GPS)
4. WELL OWNER ((
//'�
OWNER'S NAME gel? AN7't
STREET ADDRESS /bl (1 eke /y Dr,
05l. S;11n/7s 7.nd &A. 3/6,.
City or Town State Zip Code
( S� $)- AS /710a / 9/.2-39f-/76o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 21DJ'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO II
c. WATER LEVEL Below Top of Casing: sv
(Use if Above Top of Casing)
FT.
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 30 METHOD OF TESThjyjtJir rty' r4
1. DISINFECTION: Type C/or.nC Amount // /cf5
g. WATER ZONES (depth):
From 3 r To From To
From //O To From To
From/$O To From To
6. CASING:
e, Depth Diameter
From Cf To 4"Z Ft. b, Kr'
From To Ft.
From To FL
7. GROUT: Depth
From To 20
From To From To
Ft.
8. SCREEN: Depth
From To
From To
From To
Material Method
Ft, CO/1C/4e. pfJAef!/rq
Ft.
Thickness/
Weight Material
'Pi1Ze
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
77-1/2.
4/z-2p1 Gt . e
11. REMARKS:
N
1
J
r7
ON
i=1
3
t 4 213116
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF TINS- -
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIEDrWELL CONTRACTOR DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 4
1.LL CONTRACTOR:
Z�"
ei;ill) fit Lille At ES
Vail Contractor (Individual) Name
' t
WeR9ll Sc.Ns �p ny Name ✓� tcm��
Well ontractor Coma / rr-C�1 ��ff+r�� �lI//
S�T/R'EET ADDRESS v?�/3) Au) Lb/SSStEtc IItuy,
Z i'[Gs jeA+ J i C' • a874 ti
City or Town / State Zip Code
(S. R )- 35&-- g419t
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):`Residential Water Supply Er -
DATE
4
DRILLED - 5- 06
TIME COMPLETED /f lot
3. WELL LOCATION:
CITY: /L%t. i 1.. f / COUNTY /•<tlron
L• Idle R..c 1?-c£tYvG
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat eRidge ❑Other
(check appropriate box)
LATITUDE 3 44''YZ r—r
LONGITUDE r 2- S/r' /rr'
AM EY PM 0
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: je6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER �// ,�,n/�� ��
OWNER'S NAME )-/Z44- 0450--Y
p
STREET ADDRESS /f p ?5 / L s Wk .
�( Ias(h� `f1/2 /.
it �� 3�
L"ity or Town State Zip Code
($ )- -7 q - 9-5- 2 755
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: Ace FT.
(Use "+- if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated aUor Sow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type (fir• v
Amount 2ir+e- S1
g. WATER ZONES (depth):
From /Ze To From To
From (b/v0 To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To r) Ft. G.e'?"c /9-c
From To Ft.
From To Ft.
7. GROUT: Depth
/�
From t To NO
From To
From To
Material , Method
Ft. ConCretc. ?%0L01/114
Ft. JJ
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 C/
r4r�
n- 7-
r7-tor
11. REMARKS:
Formation Description
m
i' [F rrt1
f.UJJ
J
DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND' NAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
rt 47- a� G- r-oc
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
D1AA-Al J), hi Ate
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7105
11,

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / •c10
r, et , g
t Ci • 4 l :
1. WELL CONTRACTOR:
Bfz!>f-/J IndiIL / i'A ES
,yol Contractor Individual) Name
hilcoAb ble/I a/IC/Pa»p; kl-C,
Welll ontractor CompanyName
STREET ADDRESSyj /J/ //•E((} L
I' &TS]E4t /Y, C• 0787`f
City or Tarn / State Zip Cale
S,-3Rr2;352-•8�f91�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT (if applicable)
WELL USE (Check Applicable Box): Residential Water Supply f7
DATE DRILLED - -' et,
TIME COMPLETED 2 :49c9 AM PMp/
3. WELL LOCATION:
CITY: /h1444c e/ COUNTY /4/c0/,`5O.
(Street Name, Numbers, Community. SubdiMsion, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SET/TANG:
❑Slope [Valley ❑Flat [Ridge ❑Other
(check appropriate box)
LATITUDE 3 7- Si. sJ •
LONGITUDE :2 9-r- 41r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: GrdPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 9 not using GPS)
4. WELL OWNER
OWNER'S NAME fiend) 8
STREET ADDRESS /705/1 ah-shig/iy
1Bio,Ks (SA. ?O.2as
City or Town State Zip Code
(ga % ). fa 419 y87(,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Tr71
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing: I0 Fr.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/ortelow land surface may require
a variance in accordance with 15A NCAC 2C .001118. ,f-/1
e. YIELD (gpm): Y METHOD OF TEST!)PA(th dy-/A4
f. DISINFECTION: Type C/a: ,..r, Amount 7.1 Ad)
g. WATER ZONES (depth):
From 'Pit) To From To
From yP% To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight terial
From 0 To it Ft. l /2 C SUi77 tn.
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From f� To G%` o Ft. Concrck ?Mr;ryq
From To Ft. -J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
From To Ft.
10. DRILLING LOG
From To
6. 2,1
2 V- zP
2S roc
11. REMARKS:
Formation Description
City
rfAc /%
0
rn
I DO HEREBY CERTIFY THATTHIS 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 CERTIFIED WELL CONTRACTOR DATE
Pinto/ n, (, iv es
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
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:
'Bk.( N ZU, AT Es
VYEII Contractor Individual) Name
IE Cott h Je/l a/yc Rinp iic
Well ontractor Company Name
STREET ADDRESS44/3( jw LEl/1EQ /lady.
Leiees e. 0787Yg City or Town / State Zip Code
(22)3 )- . 5 2-'
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT/SW applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 2-
DATE DRILLED 4- /= - 0 6
TIME COMPLETED AC): e"'" AM❑ PM❑
WELL LOCATION:
CITY: 5 ,// COUNTY _4WV Ao
de to/4lD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley DFlat L fOdge ❑Other
(cbedc appropriale box)
LATITUDE 3 Sr- fl 4994.
LONGITUDE t L yr, f2Z'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source:. 'iaPS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form /not using GPS)
4. WELL OWNER
OWNER'S NAME {C/1.44/ fiioae-/ Cio s1q
STREET ADDRESS j/a' S a�rkha/A, rat
7ronres &A . 3oa6s-
City or Town Stale Zip Code
(Las )-4q9-la7&
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: r0 l-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [.
c. WATER LEVEL Below Top of Casing: / O o FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. 2
e. YIELD (gpm): METHOD OF TEST A)gj /i 15-!!I Q
r-
e; S i a cb 0
f. DISINFECTION: Type, / n.0 Amount l9'4j5
g. WATER ZONES (depth):
FromJV To From
From re/2? To From
From To From
6. CASING:
To
To
To
Thickness/
Depth Diameter Weight Material
From D To ?r Ft. G /er S Lt/ ovC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
/�
From (� To ,NO FL CO/IC r^t e ))/pjff%/rA
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. - in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Material
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
0-Jo C/c
Jo -Jr -54•//
.7r- ror-
rr
�i-I� 2205
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE wml
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF �EERTIFIED WELL CONTRACTOR DATE
P/A-W /1. /.J Ives "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Form GW4a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
1. WELL CONTRACTOR: �' /
-Btz/I.4-N 1'I . GU t /v ES
;ell Contractor (Individual) Name EMILCOnts II Len awc/ Rinp
Wellgontractor Company Name /
STREET ADDRESS 3731 Jill} LE/p ns--lEj/y.
iffskt /I r a /7d�n
City or Town / State Zip Code
(SCR a58-' S49Gz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ilapplicable)
STATE WELL PERMIT/Kit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check
Applicable Box): Residential Water Supply
DATE DRILLED Z/- 06
TIME COMPLETED dice .1// AM 0 PM
3. WELL LOCATION:
CITY:
/ 'L-7/c// COUNTY /7s-6-4-7
A 170folry ettetd
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:TI/
❑Slope ❑Valley DFlat D'rxldge DOther
(check appropriate box)
LATITUDE 3 f" i/f• 3 rrr
LONGITUDE r L ill. T41
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: RePS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME
STREET ADDRESS 017 mot/ C".2. 2/r.Ve
.76/5 /Ina/ /✓C a275 3
City or Town Slate Zip Code
c%t2 )-(o33.boa.1
Area code - Phone number
5. WELL DETAILS: /,
a. TOTAL DEPTH: YL .1""
b. DOES WELL REPLACE EXISTING WELL?JYES ❑ NO yy
c. WATER LEVEL Below Top of Casing: / d FT.
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated agor'below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD
(9Pm): ✓ METHOD OF TEST ' 1 -
Lt J Z 4 (5i l
f. DISINFECTION: Type C/wy..r
Amount 2/ Yc4
g. WATER ZONES (depth):
From 2" To From To
From CfrB To From To
From To From To
6. CASING:
O
From
From
From To Ft.
Depth Diameter
To 7/ Ft.L./tr
To Ft.
Thickness/
Weight Material
San/ /tut
7. GROUT: Depth Depth Material Method
From 0 To ao Ft. Co/1L^rC1C mur;pi4
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
)7- 26,
ZL -.7/
7/- 44 s
11. REMARKS:
Formation Description
C4j
5-4-f/
a
-<
'0
SEP _ ZCib
0
UT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Z11z7 07 L 2/ LAG
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Dia/J !lr �Ai/ves
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 310
1. WELL CONTRACTOR: p.
LAI ES
1 Contractor Individual) Name
l�U colt %IEII and f amp,PLC
Well ontraclor Company Name
STREET ADDRESS UI /J/ //xtO L
/ -lit-glee- N (' • a 7q
City or Town / State Zip Code
(S;R )- as& 84191e_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply L7
DATE DRILLED 3- Z,T - O6
TIME COMPLETED // : 30 AM 2"-PM ❑
3. WELL LOCATION: p
CITY: {��„�hP/�P COUNTY /Ic"rc-,
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
lope 0 Valley El Flat El Ridge 0 Other
(check appropriate box)
LATITUDE 3 S' «:41)r
LONGITUDE fr Z 1$ 6677
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: D.,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
I STREET ADDRESS tb
YY, rl 3 Lf0 7
City or Town State Zip Code
5 le L}Lit'I
Area a code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
4g
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO pf
c. WATER LEVEL Below Top of Casing: %OP FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface
'Top of casing terminated alior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): / / METHODOFTEST
f r1 .,1 r
J :J k . c)
f. DISINFECTION: Type ('/.r....r
g. WATER ZONES (depth):
From /C " To
From 32o To
From To
6. CASING:
From
From
From
From
From
From
Amount /it Af r
Depth Diameter
D To Zr Ft. 4/74-
To Ft
To Ft
To
To
To
Thickness/
Weight Material
SotzL/ c
7. GROUT:n Depth Material Method
From [� To p`?D Ft. CO/It".fiJfC ?curio,
curio,
From To Ft. .l
From To Ft.
B. SCREEN: Depth
From To
From To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
e- 70
70- 7r
. .4/C'i
11. REMARKS:
Material
Formation Description
C.4y
(l)
rn
-o
v
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wr1H
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIIEDrWELL CONTRACTOR DATE
niaN G(J, Nes
RINTED NAME OF PERSON CONSTRUCTING THE WELL
a
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON 11 / TO
1. WELL CONTRACTOR: all
Bizi>f-N LU, I ES
vol Contractor Individual) Name
}E /C.04s OEii anti 1"ump /.in
Well ontractor Company Name
STREET ADDRESS 10 I
l.�% tfske. N (' . 07870
City or Town / Stale
( R)-;52-- 849te_
Area code- Phone number
2. WELL INFORMATION: p
SITE WELL ID #(if applicable) f ./ 7 & - S - 3 i 66
STATE WELL PERMIT#(If applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 3 - Zf - et /
TIME COMPLETED ./ •� D AM i PM ❑
3. WELL LOCATION:
CITY: Ai-net/ifV 7/{
lad, Ck-s
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT G:
❑Slope ❑Valley ❑Flat idge ❑Other
(check appropriate box)
LATITUDE 3 r C/Y, ,r5-0
LONGITUDE P" L 7.7. C7Sid
COUNTY A7Q1�--.
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Deg ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER //•�
OWNER'S NAME l5(,4-j
STREET
Polm
City or Town
ESS
State
(. &) )_1E06-1456
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH: G Or
uj.11k
c
34.67
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO E
c. WATER LEVEL Below Top of Casing: /)-0 FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated at/or Below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
�7 e. YIELD (gpm): / METHOD OF TEST IA(1)i, ity 9
o r)
0 Q Y r 6 0
f. DISINFECTION: Type(4.v
Amount 2r /rb
g. WATER ZONES (depth):
From 'So To From To
To From To
To From To
From 4/1-7—
From S-C•+
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To Or Ft. i ,./q✓L
From To Ft.
From To Ft.
7. GROUT:/} Depth Material Method
From
ry To NO Ft. CO/ICrcfc taiigiN4
From To Ft. J -J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
in.
in.
in.
Material
10. DRILLING LOG
From To Formation Description
- .7 ritzy
23 — zr it, 5- sr,,
11. REMARKS:
m
SEP `i c 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND 114AT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2r-cc
SIGNATURE OF �jERTIFIIEDWELL CONTRACTOR DATE
PtAN 2 itl/Vf_5 "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 440
1. WELL CONTRACTOR: ,
a1e1N �f L(/'A'ES
I Contractor Individual) Name
tEr Cams I.! JeiJ aid TItrl)
Well ontractor Company Name
ST,RREET ADDRESS 373/Mw LE/LG{{1EC lfG1U.
Zeife&et Y(7 • a81ff City or Town / State Zip Code
(228 )- .;%; 5 ? -- 8 qf9 /2_
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT/kit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED Y - /f % Oto
TIME COMPLETED 3 . 047 AM ❑ PM ty
3. WELL LOCATION:
CITY: siA// COUNTY /67cr/„es,
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat 2Ridge ❑Other
(check appropriate box)
LATITUDE 3 r fir/%• p c/o
LONGITUDE 7 .i L.O. /5/J
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: I3ps °Topographic map
(/ocat/on of well must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER
OWNER'S NAME D fV • & C F{ e r
STREET ADDRESS 4535 —6I(1_4.S4-rPr).,. (aA/a N
T(ukColliJ,0e FI, 3(99y
City or Town State Zip Code
L 1)- (c(ea- t<(64(Q
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ;'Or /
b. DOES WELL REPLACE EXISTING WELL? YES El NO [j
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): METHOD OF TESTA'p1111s14;
ri
4
f. DISINFECTION: Type C4-:n, Amount
g. WATER ZONES (depth):
From
From
From
To From To
To From To
To From To
6. CASING:
From
From
From
Thickness/
Depth Diameter Weight Material
0To //4- Ft. 6.,/zr JO,('t, P✓C
To Ft.
To Ft.
7. GROUT: Depth Material Method
From /� To aD Ft. Co/lcfrit ej,(rjrypr
From To Ft. J J
From To Ft.
8. SCREEN:
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
O- /°7 C/c1
/c7 //L fie //
/ / 2 - ?or
11. REMARKS:
Formation Description
'
O
f
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER_
kik 7( r/ •o it it --a
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Th , AI
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
r
a

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON
1. WELL CONTRACTOR: �"
/ i �/z/i: f-Al Z(./y ES
t. II Contractor if,
Name
EA'jir• CG Ns I.( It /I ua d rump) /LC,
Well ontraclor Company Name
STREET ADDRESS r4 ,�W 3/LELSJE(L if/,Uy,
jr-ltts/k- Al( • a8lyg
City or Town / State Zip Code
(S. R )- 5 2 -• S 49 /2_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(i( applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL. USE (Check Applicable Box): Residential Water Supply IL
DATE DRILLED 7-7-Oc-
TIME COMPLETED /°. JO AM[xj PM❑
3. WELL LOCATION:
CITY: nr 11.,// COUNTYen`d(.'r�o
J.,/
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:TI
['Slope DValley ()FlatDtidge ❑Other
(check appropriate box)
LATITUDE 3 I J'/, r2�'
LONGITUDE Y L Vf. tc//
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Er6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME re
STR ET ADDRESS
.5to ohs
City or Town Stale
(gag )- &4q-076,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
to
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (3
c. WATER LEVEL Below Top of Casing: Z v O FT
(Use "+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2 / L METHOD OF TESTA)p%1JI, dy- f j
R n •' f. c ci :r 3 V
f. DISINFECTION: Type (4._
g. WATER ZONES (depth):
From Z4r7 To From
From 2" To From
Amount Z
From To From
6. CASING:
Depth Diameter
From D To 2L Ft. L/zt
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
"-ace/ ./ .-
7. GROUT:Depth Material
n
From (� To 20 Ft. Concrete.
From To Ft.
From To Ft.
Method
�ti?ifr71rj
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From - To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Material
Formation Description
1 Z Sit. //
Z2. -
11. REMARKS:
r rj
J
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
X vr:_ 7-7-0t,
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
JS➢fAN n, LU. Ales
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-1a
Rev, 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON k 3 / 410
1. WELL CONTRACTOR:
-BZ/4-N /( fY ES
Veil Contractor IndivWual) Name
j"Eryfi h IEII aivc Pump uc.
Well ontractor CompanyName
STREET ADDRESS G} L
/'(EsJEA N('" a87gg
City or Town / State
(SCR )-;52- gg96._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply 13
DATE DRILLED 7-4:2 - 04-
TIMECOMPLETED 3:JJ AM PME1
3. WELL LOCATION:
CITY: Plc , t4/
COUNTY /7cc/- coo
l de.„c/ ow"-,..,J
(Sheet Name. Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SE SING:
['Slope ❑Valley ❑Flat dRWge ❑Other
(check appropriate box)
LATITUDE 3 i 1-2. 034
LONGITUDE r 2.- 'Vs , 902 '
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: S 0 Topographic map
(location of wei must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER � /1
OWNER'S NAME / /LEI! N/ Broad ! & t. iv
STREET ADDRESS J4S�j AZ/au ell j
?PC )As C:S; 3a-2aS
City or Town State Zip Code
(ga 9 )-,49- L1gz6
Area code - hone number
5. WELL DETAILS:
a. TOTAL DEPTH: 4)--‘ f
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO It
c. WATER LEVEL Below Top of Casing: /Do FT,
(Use if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): V METHOD OF TEST,?1)iltj,-Q
J
tic
91
f. DISINFECTION: Type C 4,--K Amount /r s45)
g. WATER ZONES (depth):
From /Go To From To
From 94® To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight
From 0 To Ji Ft. cC ier ,$.ayr/
From To Ft.
From To Ft.
Material
arc.
7. GROUT: Depth Material Method
From a To a FL Co/IL^rckk ?bl!/'i/Yli
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
D - LG C/cy
Zt -d/ JLt/
)I — rtr- 4-ry K
11. REMARKS:
N
—o
t '
I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF 711I5
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
T;A-AI ifir hf,,;ves '
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
20-�
u :3 i.C5 9•2
1. WELLUCONTRACTOR:JJ P 4
l61�1J' !' 1 r
W I Contractor ( djvid al) Nam
rgeo#s kTEI1
t(&'d
Well ntractor Company Name
STREET ADDRESSt7,�
LresMg ACC-38711g
City or Town f State Zip Code
>- 5s 4f9 z
S
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
%mpg LLC
STATE WELL PERMIT/kit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Pe
DATE DRILLED 7//0 k
TIME COMPLETED ,i fo0 AMe" PMID
3. WELL LOCATION: CITY: I1142/r5 A,r/(
COUNTY /iQd�71/4/
(Street Name. Numbers. Community, Subdivision. Lot No., Parcel, Zip Code)
TOldPHIC / LAND SETTING:
ope °Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE /Ya5`,y-1,4614r
LONGITUDE(OO$A, '
Latitude/longitude source: S
May be in degrees,
minutes, seconds or
in a decimal format
❑Topographic map
(/ocat,on of wer must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STRRgET ADDRESSq_Sy54
J!ktK /J.Jl .✓C gz5v1
City or Town State Zip Code
( 8AR- 779.7ass<
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
his.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: .50
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): / /.. METHOD OF TESTI/til ,' 'girl
FT.
f. DISINFECTION: Type Ch(Otja/e Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
From 0
Thickness/
Depth Diameter Weight Material
To 3 Ft. 6, 2s- 2/6,/,t Swot
t
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material
I
From To ,Q Ft. %Dlrceejr-
From To Ft.
From To Ft.
8. SCREEN: Depth
From To
rMeethoodd
- J
Diameter Slot Size Material
FL -- 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
at
2 4 — 33 srd,/V Xea/c
.33 "5Y iPcc%
38 45 G'-,a c 'it
11. REMARKS:
t/)
m
u•
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL
SIGNATURE 6F CE42i1FIED CONTRACTOR ATE
-2ahtir 10, DES
PRINTED NAMEjDF 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 fa .3 / 7�
3 q r f1
0 C, V Q C.
1. WELL CONTRACTOR: �"
-B/C. N �} . & h ES
/kr Als ii tell a/YC u>-/p
Well ontractor Company Name / 1 �,(���`/
STREET ADDRESS rf/3t ,4 jl) LEICES/ErC llwy.
I Contractor Individual) Name
City or Town / State Zip Code
(8.>3 )- a 5 2-- 849 &.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/Nit applicable)
DWQ or OTHER PERMIT #(if applicable)/
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED / 7- —
TIME COMPLETED /1., AM LX PM D
3. WELL LOCATION:
CITY:
tI// COUNTY/!rrli..,
/
C- IOC
(Street Name, Numbers, Community, Subdi ision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat atRidge ❑Other
(check appropriate box)
LATITUDE 3 r Oft J)y'
LONGITUDE t 2. 44 t?j'
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: 136S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER '7� Lam,
OWNERS NAME alsoe r OLtIle/r`
STR5T ADDRESS {S a_, cct
�rzflef [!f 70645-
City or Town State Zip Code
(gas 1- let? -gg74/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 4 $r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 1 00 FT
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): V() METHOD OFTESTA)01tllr15_Rq
t. DISINFECTION: Type re---.e Amount Z/- ..f
g. WATER ZONES (depth):
From f e-- To From To
From G 7r To From To
From To From To
6. CASING:
r7
Depth
From To 7G
From To
From To
Thickness/
Diameter Weight Material
Ft. C./r„1- sv:Ara, -t-c-
Ft.
Ft.
7. GROUT:Depth Material Method
From /9n To NO FL & rctc ?to athrj
From To Ft.
From To Ft.
8. SCREEN: Depth
From To Ft. ' in. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
in.
in.
Diameter Slot Size Material
Size Material
10. DRILLING LOG
From To Formation Description
D-7i P/Ay
7/'SScH
7r5 - L -r
11. REMARKS:
rrl
.O c'
O
0+
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OFRTIF�IIED��WELL CONTRACTOR DATE
P/A4A, )< L(Jr Nes
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /
1. WELL CONTRACTOR: /' /
&,,4-/l f. [i!i/yES
I Contractor if.
Name
E(4UseAb h fell a/4 imp PLC,
Well ontractor / Company Name From To From To
STREET ADDRESS 573 ,Ytw(,( LE% cJEjc fiwy.
City or Town / State Zip Code
8$>4;158--g le_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
4 n (t 7J v r h
f. DISINFECTION: Type Co Amount 8 AI)
g. WATER ZONES (depth):
From f o To
From To
From
From
To
To
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(it applicable) /
WELL USE (Check Applicable Box): Residential Water Supply I
DATE DRILLED 7- 2O-0y
TIME COMPLETED /2 70 AM ❑ PM Er
3. WELL LOCATION:
CITY: Il } // COUNTY /Ace?0 .
.•C,K
(Street Nettle, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat 1:41.dge ❑Other
(check appropriate box)
LATITUDE 3 .7— c 74/LI
LONGITUDE r L 77. /re
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: QC -PS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form 9 not using GPS)
4. WELL OWNER
OWNER'S NAME
SIRE T ADDRESS
.-rS/LW/ NC 7S3
City or Town ' State Zip Code
2 •/
L$nJ- 10 s 9- aVsr»
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
2°r
b. DOES WELL REPLACE EXISTING WELL?/ YES Etc. WATER LEVEL Below Top of Casing: (ea
(Use "4- 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): 7° METHOD OF TEST
N0 Q/
FT.
6. CASING: Thickness/
n Depth Diameter Weight Material
From To JT° Ft. G.i7i Jan --C
From To Ft.
From To Ft.
7. GROUT:Depth Material Method
n
From (� To a Ft. Co/Crete. ?touf%nra
From To Ft. J
From To • Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From • To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0- Sit,' C�tY
e/-- ro .Sw'i
ro 2or or_ k
11. REMARKS:
Cn
m
0
O'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7 D-a
SIGNATURE OF CERTIFIEDWELLCONTRACTOR DATE
r;i /1. /U, Nes
RINTED NAME OF PERSON CONSTRUCTING THE WELL
0
'yr
r
a
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / 70
1. WELL CONTRACTOR:
, /LJ N FS
y.SI Contractor Individual) Name
r f L
Weeq�caNs �pc yell a�d uhlp
ell3ontracta Company r
STREET�ADDRESS 3y3/ Au) LE is JE'2 //.
/'(.eskt /1r C" • aY %Yg
City or Town / State Zip Code
S
(2 )- a5 &-• g Lic �
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(A applicable)
WELL USE (Check Applicable Box): Residential Water Supply C 2./
DATE DRILLED "2' 21--OC
TIME COMPLETED 5- : IJ
3. WELL LOCATION:
CITY: /11 t {c.//
AM Ld PM ❑
COUNTY /f/w/sw-r
G>ssyw, la
(Street Name, Numbers, Community, Subdi4sion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat pfidge ❑Other
(check appropriate box)
LATITUDE 3 J f /, }ri
LONGITUDE r 2- c/ . r 3 r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EMS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME /Cryr_ar Brp etdCrt t>
STREET ADDRESS /4 S U. -skei t/ rCri
'Ziovlrs sea 65
City or Town State Zip Code
(XaX )- 64-6/. /i'B76
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: %OJT
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 200 FT
(Use `+" tf Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
*Top of casing terminated at/or.below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TESTAibillls/i/j
4.1 n n
o3i 1' Ui?
f. DISINFECTION: Type C6,'.-t-
Amount 7'7 ,.4,
g. WATER ZONES (depth):
From sro To From
To
Fran c L r To From To
From To From To
6. CASING:
Depth Diameter
From 0 To 2L Ft L,n.r
From To Ft.
From To Ft.
Thickness/
Weight Material
7. GROUT:Depth Material Method
n
From (? To a Ft. CON: rC " Oi.f iai
From To Ft. ] -1
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. - in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Ft.
To Ft.
To Ft.
Size
Material
10. DRILLING LOG
From To Formation Description
/T
/7- 22. 5-4!!
22 — i CYO
SE' _ 2:3
11. REMARKS:
0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Pt4-N IJ, Ares "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
B/z.';f N ' . L({ i /y ES
(
w.ol Contractor `Individual) Name
r
.E�CIUSON.5 /J Jell aid RMp) /-LC.
Well9ontractor Company Name /
STREET ADDRESS 3/3/ ,EID L
JAItes Ef IC a879P
City or Town / Slate Zip Code
SCR > a58-• St/9&-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED /L 'CP AM ID/PM ❑
3. WELL LOCATION:
CITY: /7 _ (.// COUNTY /f"6an
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat Ce4lidge ❑Other
(cheek appropriate box)
LATITUDE 3 r rt. on,
LONGITUDE Z ar SL)
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2ic,PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 7 not using GPS)
4. WELL OWNER OWNER'S NAME fee/ICA /Q did(pasSi kik
STREET ADDRESS �4,} 5t, &74.4 WA" y}0e1
43/0 4/J3 A - 304165
City or own State Zip Code
(&a)- if49-fl7a,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing: t-J0 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
f. DISINFECTION: Type 0144,.'at
g. WATER�//ZONES (depth):
From Y/D To
From .%ZD To
From To
6. CASING:
From
From
From
': 0 3
Amount )T .."-Sr
Depth Diameter
From b To U+i Ft. C /L/
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth Material Method
From o To NO Ft. ConcrCtc. p69LffT ril
From To Ft. JJ
From To - Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
1I. REMARKS:
UJc
rn
-u 2
1 s
J
O
on
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm1
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF �EERTIFIIEDWELL CONTRACTOR DATE
PPPRINTED NAME OF PERSON CONSTRUCTING THE WELL
a
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 Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 3 / 7�
!3 !1 '
yeti 1 ii
1. WELL CONTRACTOR: ,� /
BfZI. f-it1 L(J / A ES
1 Contractor Individual) Name
. c4/itenls h IEII atrd�urrp lit.
Well ontractor Company Name t
STREET ADDRESS J w L
i'fe--ska /YC as'7gg
City or Town / State Zip Code
RZ3 > 5 8 L191e.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicablejBox): Residential Water Supply 3 w
DATE DRILLED I((p G/ l Q
TIME COMPLETED {//. oo AM ffrPM
3. WELL LOCATION:
CITY: /770.-/ia/ COUNTYaw.:4rv.,
7
(Street Name, Numbers, Community. Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat pRidge ❑Other
(check appropriate box)
LATITUDE 3 Jr U(. j9/Y'
LONGITUDE 1L X tit./
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2.CPS ❑Topographic map
(location of weN must be shown on a USGS topo map and
attached to this form N not using GPS)
4. WELL OWNER
OWNERS NAME AMC, � r,',t ,/ er
)�E STET ADDRESS COJO ws14eit ile y�
T/1owjersaov;l/a. � Y879 /
City or Tam State Zip Code
( Sag 6T 7- s"t7�
Area code - Phone number
5. WELL DETAILS: i
a. TOTAL DEPTH: L O r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er
c. WATER LEVEL Below Top of Casing:
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS ' FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / '/L METHOD OF TESTbglilArgel
L DISINFECTION: Type
Amount
g. WATER ZONES (depth):
From ,r0 To From To
Frcm SYee To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To c!r Ft. G. e'er SO.etr l'✓c_
From
From
To Ft.
om To Ft.
7. GROUT:Depth Material Method
n
From (� To ao Ft. COAC rCk. i101.1/1”
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From • To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
D- q/o
Formation Description
C
4/os6rH
Cer- f,or
Sir
11. REMARKS:
19(
9
4
t-
1 W HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
u-ai
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
/ J, NHS
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699,1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment andNatural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 40
1. WELL CONTRACTOR: /
II Contractor Individual) Name
Eejt/ ceNs /i 1E11 add?wnp
Well ontractor Company Name
STREET ADDRESS
% [5SJE,- /iY . eRB 7Ef g
City or Town / State Zip Code
(2 2 )- a5&-• 849L
Area code- Phone number
7.. WELL INFORMATION:
SITE WELL ID #(i1 applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply V
DATE DRILLED it' l"� Cne
TIME COMPLETED " %v" AMpj PM❑
3. WELL LOCATION:
CITY: /f'h-5 /c// COUNTY / tee''0n
�•o�. ,
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT G:
❑Slope DValley ❑Flat idge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: cad s ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this loon if not using GPS)
4. WELL OWNER ///
OWNER'S NAME CrL bh Nj
STREET ADDRESS 07/Q aQ,
ry or.rrr / Town �C �.gte ? 53
e
IA 2 - a$- 470 a -
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: elor
b, DOES WELL REPLACE EXISTING WELL?
YES ❑ NO IV
c. WATER LEVEL Below Top of Casing: 470 FT.
(Use'+" if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): G o METHOD OF TEST
f. DISINFECTION: Type r!.- .,t Amount Ic7 fa>
g. WATER ZONES (depth):
From Jfo To From To
From .7t0 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight M erial
From 0 To rit Ft (,hl Sant in -
From To Ft.
From To Ft.
7. GROUT:Depth
From 19 To NO Ft.
From To Ft.
From To - Ft.
Material
Colic rctc
Method
?OttfiiY4
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
5 �- at)? �•.�k
11. REMARKS:
rn
m
1 rn
0
cr
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.
-ill/ ;. /t. �/re✓
SIGNATURE OF CrERTIFIED WELL CONTRACTOR DATE
P/44-W . L J, iS
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. WELL CONTRACTOR:
.t' 1 3
Br,i. /li N. At. /V ES
I Contractor Individual) Name
fEec�uSGN; ti 1E11 am/ amp fin
Well ontractor Company Name jjrr"'
STREET ADDRESS r./.73I ,4 w LEl cEsJEIZ ltUt/
(' • a875/g
City or Town / State Zip Code
(C )- ;035-• 8y9le-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT/Rif applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL. USE (CheckApplicableBox): Residential Water Supply [7f
DATE DRILLED 8/ / 06,
TIME COMPLETED //; Jo AM g" PM ❑
3. WELL LOCATION: ,,/JJ
CITY: JY/ar5 /d; // COUNTY lea j-S6/t
(Street Name, Numbers, Community. Subdidsion, Lot No.. Parcel, Zip Code)
TQPOGRAPHIC / LAND SETTING:
Slope °Valley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3 i .5;2•0(c IQ
LONGITUDE .30
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS °Topographic map
(location of well must be shown on a USGS tope map and
attached to this form C not using GPS)
4. WELL OWNER
OWNER'S NAME JLL en1/2 e.
• STREET ADDRESS
52/
City or Town State Zip Code
(g g)- legq-Q183
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
P1l51
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NOCB
c. WATER LEVEL Below Top of Casing: 1L FT,
(Use '4" if Above Top of Casing)
d. TOP OF CASING IS / . FT. Above Land Surface'
'Top of casing terminated auor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): L 0 METHOD OF TESTAiljj/:i d1" r 4
f. DISINFECTION: Type C'/orru. Amount d "crL
g. WATER ZONES (depth):
From 1 0 To litir From To
From /JA% To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 6 Tc4Yp Ft. S.-at fan.i A, c..
From To Ft.
From To Ft.
7. GROUT: Depth
Material Method
/� �ti From f� To a0 Ft. crerjG '%jjpj,)fjryq
From To Ft. J J
From To • Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D -
-rt
sG -
11. REMARKS:
Formation Description
0
N t'-4
ra-t --
J
O
DO HEREBY CERTIFY THAT 11115 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.
-04
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
P/AN T), LUr Ne5
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 # 3 / g-0
1. WELL CONTRACTOR: bill
�fz(>f-N b r v ES
,� 1 Contractor Individual) Name
kerzsNs Lt Jell aric/?w,1p uiz.
Well ontractor CompanyName
r
STREET ADDRESS tl1 /J/1J/•. L) L
L /tt-sj,Ea h (7 • a873,2
City or Town / State Zip Code
2-RR )- € 58-- gg9(Q
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE W ELL PERMIT/MI applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED o —29.- Oi.
TIME COMPLETED 3. Op AM ❑ PM V
3. WELL LOCATION:
CITY: /'h, 1/// COUNTY ftc-/sari
(Street Name. Numbers, Community, Subdinsion, Lot No., Parent, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 J 40:742
LONGITUDE er ZV
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: rl 6PS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form i/ not using GPS)
4. WELL OWNER
OWNER'S NAME/ s /'C-ti d .44,
STRT ADDRESS
J`�/a(e�✓ C o7$7o?/
City or Town State Zip Code
(__)- (Q9l- 599
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S OC
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 / FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): /0 METHOD OF TESTAIpj h Q9-Rq
er tj
f. DISINFECTION: Type C'4-•
Amount
g. WATER ZONES (depth):
From 340 To From
From 'Vrr To From
From To From
6. CASING:
Depth Diameter
From E To Zv Ft. G_izr
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
JJn 2/ ✓G
7. GROUT: Depth Material Method
From ,0 To aO Ft. Concrck �d1u/i/y4
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
Frorn To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
a-
/f- zd S4,i
16/ ror
in.
in.
in.
Material
Material
Formation Description
SGF
11. REMARKS:
S
.n
rn
nn-
LLUG
T7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�.A°r4- ert2✓-vc
SIGNATURE OF ERTIFIIED�WELL CONTRACTOR DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —. Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. WELL CONTRACTOR: �"
-BtL 1u Z iATES
V1 Contractor Individual) Name �
E SON; btell anfc � tnp/ !1C,
Well r ontractor CompanyName
'% LEI
1f��� rr�,
ST,R_.EET ADDRESS r�/�/ YEW LE f(L -e 11��.
efs jfft ,$y . ae?"792 /
City or Town / State Zip Code
(Safi )- 52-• 8N91e
Area code Phone number
WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [V
DATE DRILLED f/7 - a&
TIME COMPLETED i d D AM D PM DV
3. WELL LOCATION:
CITY: / c(.16x // COUNTY /7ceilsr
.`enL4 44C./ CilTL..-r
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANK SET/TING:
❑Slope ❑Valley ❑Flat Cl<idge ❑Other
(check appropriate box)
LATITUDE 3 r fz. 07j
LONGITUDE lir 2 Vr 7r4/
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 126PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
STRZET ADDRESS
City or Town State Zip Code
Li - teyq-Lf876'
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: Orr
isinAfi
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [y
c. WATER LEVEL Below Top of Casing: / Z 49 rr.
(Use -+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / Z METHOD OF TEST
f. DISINFECTION: Type eta -Jr.,.
R 9
6
Amount /(O AS,
g. WATER ZONES (depth):
From / 769 To From To
Fran :220 To From To
From To From To
6. CASING:
From
From
From
O Depth
To ,7/ Ft.
To Ft.
To Ft.
7. GROUT: Depth Depth
From Fo To 20 Ft.
From To Ft.
From To Ft.
Diameter
L/ram
Thickness/
Weight Material
t2-C
Material
Cone retc
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
Method
?Ant hi
in.
in.
in.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
D 1� CAy
2 -- J/ S4tr/
3/- </Or C--_.Ic
11. REMARKS:
Cr)
J
liji'hasirza;s
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WW1
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ole
SIGNATURE OF IERTIFIED WELL CONTRACTOR DATE
Pi4ui n. Ate
RINTED NAME OF PERSON CONSTRUCTING THE WELL
`Atb,tii the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
;617 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:
-Blt/:fA) LC/y-/1 ES
yfrII Contractor Individual) Name
E�qo sent % 1p/1 an,cl limp /lC.
ontractor CompanyName
STREET ADDRESS r,173/LE/ LE IESC EJt„ y•
/Pt3�E� IC • ai74 1
City or Town / Stale Zip Code
(228 )- 5 &-- 8q9 La.
Area code- Phone number
1. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(fl applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED r AV' °Co /
TIME COMPLETED 2 .1.= a' AM ❑ PM a
3. WELL LOCATION:
CITY: /'%vs 4//
,a,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope [Valley DFlat 17fiidge ❑Other
(check appropriate box)
LATITUDE 3 r ,rl•
COUNTY/ lcdya n
LONGITUDE r L 4i/7 db <
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: jdPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to This form l not using GPS)
4. WELL OWNER (//� ,/
OWNERS NAME Cif/Lo /-Oi/y
STREET ADDRESS / Q n p r' 3'
en al! /7C �27S'
City or Town State Zip Cale
(V)R )-649-0633
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2Or
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 10 FT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS j FT. Above Land Surface'
'Top of casing terminated aVor Delon land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): aO METHOD OF TEST
61<r
� V Y
f. DISINFECTION: Type `hi. - Amount Q' ,4Cj
g. WATER ZONES (depth):
From /CO To From To
From ./%D To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From Q To Ft. G-/7r .S j7/ L2-L
From To Ft
From To Ft
7. GROUT:» Depth Material
Method
From F� To a Ft. CO/ICfcdc "])jp/,1/103
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in, in.
9. SAND/GRAVEL PACK:
Depth Size Material
ROM TO Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
tr% -Je
chi
Formation Description
-3F 5'4 //
11. REMARKS:
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W rmt
15A NCAC 2C, WELL CONSTRUCmON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ZS L/a Jam-/ - O(.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DiA-N / b.. Nes "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
I itI7 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
3 2
0
C
ta
Form GW-1a
Rev. 7705

e. YIELD (gem):
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 41-0
r•1'1r;9
1. WELL CONTRACTOR:
Contractor
L) N r• e ES
p.ell Contractor Individual) Name
Ez4U ce Ms IIIE II ad al Tamp) /-LC,
W elll9ontractor Company Name
ST,RREET ADDRESS a"731IYtW Lei IECJEQ i> y
Z Jt5SJEt lc' • a870
City or Town / State Zip Code
()- a52-- 8g962._
Area code- Phone number
WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply D
DATE DRILLED s'id-OG
TIME COMPLETED 2 • JJ AM ❑ PM Er--
3. WELL LOCATION:
CITY: /'/z,-) Sc // COUNTY ncl1oo
`re-1C 1 fa...% Cia53. mot%
(Street Name. Numbers. Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SE ING:
❑Slope [Valley ❑Flat Ridge ❑Other
(check appropriate box)
LATITUDE 3 3 ) 2. 22r
LONGITUDE r Z. (177
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: lcS ❑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 nn /� "�` /
OWNER'S NAME ,t9iLY,c. 414 1-1 /fI/j_,Z.t,q,
S
STREET ADDRESS )('ay,A$ y9t/
,t�1.17r > I a_ 3vaaS
City or Town State Zip Code
(gotfi'I-{JY9--• `f37(Q
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
War
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I/
c. WATER LEVEL Below Top of Casing: /00 F1.
(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. 7 '�
METHOD OF TESTfl jpj1J(ti q
f. DISINFECTION: Typer/pc,'..t
g. WATER ZONES (depth):
From /OO To From
From ✓' .A To From
From To From
6. CASING:
Amount 201-...4
Depth Diameter
From 0 To no Ft. /.,/2f
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
fuzz/ v�C-
7. GROUT:
Depth Material Method
From (� To ri%O FL Co/ICrefc itoi.l INJr
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. -. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
Size
To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
0 —J/ C/cq
J/- 34 S,fes/
t(
Jc-4or
11. REMARKS:
_. 27 LL;..:
-o
J
rn
100 HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED N ACCORDANCE Want
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
`tea %C 4a-t
r- ii-- 04
SIGNATURE OF ]QEERTIFIED�WELL CONTRACTOR DATE
Pi4-A/ /7 Al: Ne s "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 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 # 3 / 410
q 1
'7 urj.11, 2
1. WELL CONTRACTOR: �"
B%t,r¢N LCl i iv es
Contractor Individual) Name �
ErlasotJ /1 Jell aird Rtnp7
Well ontractor Company Name
ST,RREET ADDRESS 3731 Aid LEtA IEf u y,
LE/PES/.Et 1, c • o�i r7'S�P /
City or Town / Stale Zip Code
f )- 5 1>z
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [?
DATE DRILLED .r'!L Q&
TIME COMPLETED J2. OJ AM O PM
3. WELL LOCATION:
CITY: /!v;4c// COUNTY AF;on
%7"C.ii /J�OA/ c-ass.att
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOBOGRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 r n 7Q/2
LONGITUDE r 2 =If . ']CCI r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: g'PS ❑Topographic map
(Iocation of wen must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER ,T'� � . A• -
OWNER'S NAME Ma— pr t-�(rp /
STREJ,T ADDRESS
3aa6 5
City or Town State Zip Code
$2 )- 609-YX70
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: -rar-
e. /
DOES WELL REPLACE EXISTING WELL? YES ❑ NO �J
c. WATER LEVEL Below Top of Casing: /00 FT
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TESTAPIWIE,-Rq
f. DISINFECTION: Type CG_..-s
g. WATER ZONES (depth):
From Se° To
Amount 2Y A.0
From To
From ✓Lc> To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From Q To C/,— Ft. £/.tr .Za.ee/ fc-t
From To Ft.
From To Ft.
7. GROUT:P
Depth Material Method
From To a0 Ft. COncrctc. p(OLlf;sj
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
O-vs
4./1-
11. REMARKS:
Material
Formation Description
c/ey
Je'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WIM
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r.--a-%
SIGNATURE OF ERTIFIE DWELL CONTRACTOR DATE
DikN l.U, N'i5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
a
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

WELL CONSTRUCTION RECORD r = 4 F 0
North Conlin -D.,rfoeatafla.Loameetmod Resources -Di y9WrgrQarBry-OromdwmerSemi=
WELL oorrra*craw twme.muAL) a.sa Ph C Jerk (^ Fs ' CE[nnICATnOn r27Z%Y
wsu o snucrouCOMPANYIIAta, i wP Votclie - We// q /u.H// now sl » 519 c)yao
ErAtt WELL O@IE7aucnow WOMB AaOCIATSw WQ rOlLL7M
(ifkoolisside)
I. WELL USE (Check Appliabla Beak Rssidkati 1 o4laidp l'Publc O Isd+rhld O A$cuhaml 0
Maritabg ❑ Recovery 0 Hut Pump Water *oboe D Other 0 if Omer, List use
(ErewNon,Neweee,r...l%Sh Lem. rlrOa)
3. OWNER: J/,t/V .zjts/
Address %/ 3 ignivezli
.tt /y77Ics9r
YI4/p/4iprileirt fl7c?
Owe a abe a Cob
Amos& Ass Set
4. DATE DRILLED BD tr -7 6. D 4
5. TOTAL DEPTH: TO 5 _
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0--
7. STATIC WATER LEVEI. Heiser Top Cribs %/) FT. •
WAWA 7011WCIWIR
S. TOP OF CASINO 1S nil �FPLmove God 9srteeC
nap tn. eei- . Wks bin Ira sedum rapine •
flab asedi nwllt IM NCAC3CSUS
9. YIELD (iron): 7 ME HOD OF TEST rare i
10. WATER ZONES (depth):
LaranaLlin
11. DISINFECTION: Type t'e ite Amami /i? ,47 Show direeties asd distance is mike Rom at but
12. CASINO: Wsn Thiess two Stet Ronde or Cosy Roe& Wish the road
Ro�i � M U� sombssn and ao®es rued sem
To2O IrtajaZie S Prow`___ To I+t
From_ To Ft
13. OROOT• Dept IL _Li /
From. To 2D Prr nnc/e i °t /flvf
Prost_ To Pt.
14. SCREEN: Depth Diar Net Stir Merkdd
Prow` 6 To Ft _.. $. In.
Prom_ To Pt_m in.
15. SANDK}RAVEL PACK:
Depth Sin Mamie!
Pram To Ft
Fmse-To PL
T ,ad setting
ORidw�Mips Oweny Mkt
Oat e*egdeiWs)
Letitode/lossItsde of Won location
i/t/eeee.k.anterrare)
1LettowidIargilstie eeisecOOPSOTopqpnephie romp
(abet we)
Formation D em
Prow To
isrirt
16. REMARKS:
TEAT THE WILL WAS CON81RIJC1ID IN ACCORDANCE wan 15ANCAC IC, WELL
STANDARDS, AND TAAT AbOI'Y OP THIS • • HAS BEEN PWVICIED TOTES WRIL OWNER
Butt the wished to the Divides of Wait QsdIy, GntmdwaNr Seeds, I636 M R Ssseie Car NC
270%Atli6Piss Ns. (PM 735.1381, NRih M dsp. OW-1 REV. 0712001

'72'7s3
ant Two ale, aO+
1 )
Awed. IhasMSS
4. DATE DRILLED T-/ 7-c
5. TOTAL 1mrzd- - 0h`
WELL CONSTRUCTION RECORD
North Carolina - Department ofllavbo astut and Nona] Resources - Division of Water Quality - Oro®dwater Section
Weu.CON stacroamestenimu)ltap�(�C /t1LW6 s raTafcs'nona 27b'Y
arl w.CONTRACr�ORCOWANYNaNhlataNee Lc�r9 well r Ruin/ r>toNi a JBzgtAw9'-vyb'c
RAT! WILL CONRRRCTWO PiiR= Aa$OOA/110 WQ PWIWTI
(ihorUaebis)
1. WELL USE (Check AppleaWsBoa):laridndiei O bduaria10 Apioatmal O
Masiloeb4O Recovery 0 Beet Pegg water hjecdon 0 Other O If Otis Lin the
2. WELL LOCATION:
�T. he h4- W ..: inACIL)
/7b alga
t9f'�c C Z.B7 -3
Moat Ns. Cara isisNWe.LatNs.ttscbtd
or i
Tepowephic/Land setting
Midge Mope Malley CIFIat
(i.iye.pYrs bet)
Letilodelloositade ofwel location
w.a•et•ewh••.ae)
2 $ 75;7 i.dimddlot de so roerOOPSITt'opopaphie men
(drat km)
F.mrtion Deeedptien
DEEM
From To
6. DOES WELL REPLACE marrow WELL? YES [,7 NO r
7. STATIC WATER LEVEL Below TopafCriep�_Ff
S. TOP OF CASINO IS /FS'friPT. Above Lre
ead Sn Mc
*Tap sten inkel Wm lad rot sequins •
moms at assess USICAC 2C AWL
9. 'YIELD (w* _ METHOD 13FTEST rM t�Y
10. WATER ZONES (*g )
11. DISINFECTION: Type 'eh` Asia 10 oz
IL CASINO: To�y�v�
Pmm._ Tn
From___ To Pt,-.
13. 0PJ31JT: Dot Medd / 1 M / Proat_ To2�Pt, ax/N)� I N e X
Rm1_ _ To Pt
14. SCREEN,: Depth Diassr SatSis btrsoel
Fta To iu
Praq_To. Ft-M. I6
15. SAIIYORAVELPACK
war
SDic' ` $11,
SI-P
Fromt_A( Dapti Sae ModalTo Ft
From__To Pt
LagfanIZEUI
Show ditaeties and distance b Sas from at least
o State Ikeda or County Reek Include the rol
ambers ad oasmoa read ■ama.
tw
rn
t
0,
16. REMARKS:
IDoMOW CSt11FirMATTEIS WELL WAS osourauctio IN ACCORDAIKE WTThI ISANCAC2c, wall.
STAtIQAR IHAJ'ACOPYOPTSRECORD RASMIEN PROVIDED ToT!EWELLOWNER
SIIRNATLIRB OP PldrsoN CONS OUCIDIO THE WSL
DATE
SWIM Ss and to Si MMus W Water Qialby, (lwardwa .. Section, WM MM Iw,t a Code -Rokleb, NC
27•11-30f!be Nspa) Ti}5721,,dt I.Mtys. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
WELL. CONTRACTOR COMPANY NAME
r}r)
.a 4 .< a V S �l
North Carolina - Department of Environment and NaturalalResd Tees - Division of Water Quality - Groundwater Section /'� 2
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /� A P/� p J] i 1/ it)
r'I CERTIFICATION #n(t(/1.1J
WliiA Tt I R M 1 LI f 11t PHONE # gag3
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential 12/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring LJ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest To)vn:C�I $'V ` County
3aiIzvV16' A
(Street Najne. Numbers, Community.
rSubdivision,
L Loot No.. Zip Code)
3. OWNER:g .
' \G,LCAry I CSJ\
%V�V I�$treet or Kr;)
Address
City or Town State Zip Code
( )-
Area code- Phone number ,t
4. DATE DRILLED�I81,q(o
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: / (0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a
Topo_ ..hie/Land setting
❑Ridge I: lope ❑Valley ❑Flat
(check appropnate box)
Latitude/) it de f e loc ti
4,31c &ST D 33�
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accordaLrC with ISA NCAC 2C .0118. n
9. YIELD (gpm): r T_HOD OFT�� A( N�Q I Mae10. WATER ZONES (depth): p20C))d
11. DISINFECTION: Type IA
Amount
12. CASING: Wall Thickness
Dep _, Diameter or Weight/Ft. Material
I-rom- - To Qh Ft.
From To Ft.
From To Ft.
(3. GROUT: Depth
From To __ Ft
From Toj-f F
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
From
From
Depth
To Ft.
To Ft.
16. REMARKS:
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 I5A NCAC 2C, WELL
CONSTRUCTION ST(QJDARDS„AND TH) T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WE.I.I. -.
DATE
Submit the o'gloat to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a it
1. WELL CONTRACTOR:
h-eiv, C&(cl,wect
Well Contractor (Individual) Name
hero Qo%4d u1� �ril(� Inc•
Well Contractor Company Name
STREET ADDRESS
g51 IlJe o letceS r (4wuj
Ashe-Art I le c-- - -g gob II
City or Town State
(Fa%'» a54-36V1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(lf applicable)
Zip Code
STATE WELL PERMIT#(il applicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check AppF le Box): Residential Water Supply [7
DATE DRILLED • 5 < C (
//
TIME COMPLETED (( r' AM PM O
3. WELL LOCATION: ' 1
CITY: / .tIL/i COUNTY N "r`Se
o t2 N 6s D I-) U7y(Z,+'ro`r4
(Street Name. Numbers. Community. Subdmsion. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAN ETTING:
❑Slope ❑Valley aflat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 An .q9 D
LONGITUDE $ 31 • 1�6 3
Latitude/longitude source: 8'Li 'S ❑Topographic map
(bcation of well must be shown on a USGS tope map and
attached to this form 1 not usrg GPS)
4. WELL OWNER t1
OWNER'S NAME -1- d� C-Q Q t i^t a VALE
-)— C)
STREET ADDRESS CID SS MOB (2 o-& D
A-Ana41 Qwaia oa-.[3
City or Town State l Zip Code
May be in degrees,
minutes, seconds or
in a decirnal format
6(� ) -Daa4
Area code - Phone number
5. WELL DETAILS: 3 _
45 a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO II
c. WATER LEVEL Below Top of Casing Z1 D FT.
(Use '+' if Above Top c( Casing)
d. TOP OF CASING IS & FT. Above Land Surface
'Top of casing terminated aVlx below land surface may require
a variance Si accordance with 15A NCAC 2C .0118. 1� /)
e. YIELD (gpm): METHOD OF TEST TAG --R i 2
f. DISINFECTION: Type t-t N vie; Amount JS ? t -
g. WATER ZONES (depth):
From aa5 Toa3D
From
From
To
To
6. CASING:
Depth}
From 1 To IO6-Ft
From To Ft.
From To Ft.
7. GROUT: Depth
Fraan . To at.
From To
From To
B. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Fyn ! To
iDO
lhoC 0-a5
9 3o / - 1
11. REMARKS:
From
From
From
To
To
To
Thickness/
eter Weigatis' DI`v"lt�ial
(CVV
Material Method
Ft. Ulrtlar•rr
Ft.
Ft.
Diameter Slot Size Material
Ft.
Ft.
Ft.
Ft.
Ft.
Ft.
in.
in.
in.
in.
in.
in.
Size Material
o �ts a(2-(3L1al 6
(,CZ4,alid
G 2A.oti r(S
1
-13
t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCf0N STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO WELL HER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
�KJ
TE
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.
SEP 2 f FbhF _la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanmcnl of Environment and Natural Rcnnuccc- Division of Water Quality
1VELL CONTRACTOR CERTIFICATION #
at4-D
1. WELL CONTRACTOR:
Well Contractor (Indovdualt Name
j eLLbet., CcL &uetl C)r<<I;1ng I Inc.
Well Contractor Company Name
\ 1� Hwy
STREET ADDRESS '3S ` t €.0 . `.. cLSitr jYLtay
ksh,evcl(e 13 a\�S'o6
City or Tam State Zip Code
(zaC » a54 - 352 i
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(i/ applicable/
WELL USE (Check Appli able eon Residential Water Supply Ltl
DATE DRILLED YI bJ 0 (O TIME COMPLETED a //- 3 0 AM ❑ / PM LaJ"
3. WELL LOCATION:
CITY: MAIL-SKA !_L
COUNTY
LA31itSPealaG noes
/Y\AO(Sot
LA1J6
(Street Name. Numbers. Community. Subdrwamn, La No. Parcel. Zip Code)
TOPOGRAPHIC / LA7,4 SETTING:
❑Slope oValley afiat ❑Ridge ❑Othev
(check appropriate box)
LATITUDE 3 5 4g . 16 I
LONGITUDE & a '3R . al I
Latitude/longitude source: 42ftPS OTopographic map
(location of we/ must be shown on a USGS topo map and
attached to this form 1 not ushg GPS)
C. WELL OWNER
OWNER'S NAME Y.e,Yt 1M1fl\
May be in degrees.
minute. seconds or
in a decimal formal
STREET ADDRESS 1- • 0. 60 55 3
Araen fJc a8'104-
City or Town Slate Zip Code
fl4)- 6'41-1-110
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 05
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO
c. WATER LEVEL Below Top of Casing 60 FT
(Use -• if Above Top .e1l Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated as/or below rand surface may require
a variance n a� ycoraance with 15A NCAC 2C 0118.
e. YIELD(gpm). 17v0 METHOD OF TEST Rt('
1.
g
DISINFECTION: Type all 0 Amount
WATER ZONES (depth)
From a4- 3 To a44
Form To
Fire To
6. CASING:
Depth/�
From '. To Ci
From To
From To
7. GROUT: Depth
From 1 To aC
From To
From To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
From To
From
From
To
To
10. DRILLING LOG
From 1 To
—85
S5'- a43'
9,431- a44'
aq-4'- 305'
II. REMARKS:
FI
Ft
Ft
RA:523
Z.
From To
From To
From To
Thickness/
iall eter Weight Material
SDI p1/C
Material Method
F1 0,6MtNT Qou26D
Ft
Ft
Diameter Slot Size Material
Ft. in. in.
Ft in in.
FI in. in.
FI.
FI.
Ft.
Size Material
Formation Descrip(ion
oJe KBu2DtN
G¢.aNITE.
cal tcg - 9.0 Gel-%
C>ILA a1T6
co
fV
I DO HERESY CF POET THAT ne5 W FI I WAS CONSTRUCTED N ACCORDANCE WITH
IS NC AC 2C INFO l CONSTUCTYN STANDARDS ANO TWAT A COPY OF THIS
RECOPO HAS SF EN PROVIDED TO THE WELL OWNER
G
SIGNATU E OFD WELL CONTRACTOR D TE
I(-1 Ia .AS
PRINT FD NAME OF PERSON CONSTRUCTING THE .WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-1a
Rev 7/05

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- ('U tru axx r
WELL CONTRACTOR CERTIFICATION #: r-)I j,
STATE WELL CONSTRUCTION PERMIT#:
f`f rI ✓ ti'ri
3
1. WELL USE (Check Applicable Sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery 0 Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Mon
Nearest Town: r r I1rS {-4l Y I11 County' 1 on ) V0 C�1f� r
(Road Name Numbers Co u,Jty or Sutxivisai a ldd tot No.)
�3. OWNER t'}cnnii tS -O ,S
Address GOC t� ( (t 6 f u*
City or Town G State Zip Code
4. DATE DRILLED O-Q-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO�i
7. DOES WELL REPLACE EXISTING WELL? YES NO (
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (use•••• a Above Top of Casing)
FT. Above Land Surface
-Top of using terminated atrer below and surface requires a varinoe In accor-
dance wah 15A NCAC 2C .a 1a
10. YIELD (gpm): (METHOD OF TEST
11. WATER ZONES (depth)-
12. CHLORINATION: Type Amount
13. CASING:
11 additional apace is needed use back of form
7 Was Titaness LOCATION SKETCH
From , D To Ft (DQ1erer at Weight/FL (� j(� (Show direction and distance from at least two State
From j Roads, or other map reference points)
To Ft
From To Ft
14. GROUT:
Depth Material From 1 oao Ft. ( Q� �.t ! I Method
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:
i
l �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO F THIS RECORD BEEN PROVIDED TO THE WELL OWNER. /�
FOR OFFICE USE ONLY �O �D — ab
0
Cued No:
Sochi No.
SIffNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subeit original to Division of Waer Quality, Groundwater SeUion within 30 days
GW-1 REV. 1299

U e;
North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27599.1636-Phone [phone]..,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR' CLOLUTAY1-tf
WELL CONTRACTOR CERTIFICATION 0: a 113
STATE WELL CONSTRUCTION PERMIT.:
it n
J 0
1. WELL USE (Check Applicable Dion): Residential E Municipal ❑ Industrial 0 Agricultural 0 Monitoring ❑ Recovery [] Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: (Show` ketch of the location below) (�/�
Y 1�1 t'..,t .-awn' County: f g Il
Nearest Town:
Address L
PlOXSrtrot m ( eg R154 41 1 t4
City or Town Stale zip Cods U - -15
4. DATE DRILLED L4 I5 - L IAA <�1'Cl)'>_t :t R-
5. TOTAL DEPTH 4'. 4. 0 -
6. CUTTINGS COLLECTED YES 0 NOKr
7. DOES WELL REPLACE EXISTING WELL? YES El NO[a
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use •4 a AbOwt Top of Casing)
FT. Above Land Surfaces
Top or casing terminated attar below land surface regtdna a varianea in accor-
dant* with ISA NCAC 2C .011a ���...,,,��1���
10. YIELD (gpm): Ifl METHOD OF TEST
11. WATER ZONES (depth): J
(Road hmoer& V. or Su and List No.) DRILLING LOG
3. OWNER V! 1 { 1j� So-) CF�ram To
�� 1" b
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Dept
From 1 To
From To
FromTo-
14. GROUT:
wau TNWwas LOCATION SKETCH
Ft.!Diameter or Weight/FL _Material , (Show direction and distance from at least two State
e N panic Roads, or other
Ft map reference prints)
Ft.
Depth ,1 ,M te�riad Method
From To r� Ft 1 �1 It
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:
0 t.J /•
ft
rn
-o
v
dere-
co
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPF THIS RECORD PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Q/(i/Cf Qo (/,,
Quad Na
TORE OF PERSON CONSTRUCTING THE WELL DATE
&anal cart to Division of Water Duality, Groundwater Sedidn within 30 days
GW-1 REV. 12,99
Serial No.

2 p
u rS
*eCwAS•Depermr.efbro wwrladIlr.dlleeea-OeddmdteeterOrey.OiwIdw r111•1on
ISNSI S Oar- IM _ NSC.07NFNflapouts
I -5 7
"1 3 cl
WELL CONSTRUCTION RECORD nu. cO I ACTO1a r .Oft I'1 x'n4r r
wAJ.00NTRACTOR CEITIF CATION 6: of I IR
RAT! eel OIXINIM1C710N PNRIETrt
1.
2.
WILL lektomnit r(l eeea Oak Rwd.+r®" Uridpol limed w D AptblN s *Mob" CI
fiseaverf Hal Pump walwL:.elkinD Ode CI Netts ..c
We.lWOCA NwMdeAMMbents bible)
Toe
NeawlTor l t l Os* tAn ri (fen
IerdPONOSI IS*. Cady.wleeratw rrbpi WJ
t. OWNER iNCy-w ,t P \ flW Cl
ass pn
InnaM I-kiiiipartask4s
c
4. DATE wDRUM • Ito
5. TOTAL DEPTH S
6. CUTTwosCOLLECTED YEsQ NDtr.
7. DOES Wet REPLACE EXISTING WELT INNI Q wig-
S. STATIC WATER LEVEL Skim Top el Cap _Ft
w WeanTed Orb.
6. TOP OF CASKS a.. I FT. Meow Land sorbet
'1Maeerbe Irnirrd,W�ApR MlwInfwn- - P asseMaww.
i. Mapfple CAC2Q'K UETH0DOFTEST
\ � 10. YIELD �Imk ?C
ft WATER ZOl6TsWipe:
Pea T•
I - °t S.
Akri4q _
err
Wide
jx 1 S
OATH
Feemilla 6eer1ra!
12.CFLORINATION: Typo Arnow* 6edabldgeoobrrededwsbeak etboa
t& CASH&
WOnewee LOCATIdI sIEiCN
II DAMcs G. wttd/eR p _mol Sala olrerlw6rle
Ram To _1J R.�`z4j C Rea orOhm mur namepol)
Flan To
From Te
14. GROUT:
Dept
From l Te C1
Pram To
is. OCHelot
Dept
Foam _To_R_ b. k
Rom _To_FL_ In. In.
Ram To R. Inc In.
10. 8ANDIORAVEI. PACK
Dept Sze
Prom To FL
Ram To R.
17. REUARIRN
Holmdel Method
Fr. PtTh Crtit
FL
Olrnobr NM Nei MOWS
W
ll,
100HERBY CNR.YTHAT TNI6MILL WAS OOIMTNUC1®NACODIOMICEWITH 12A NC CN.VIM
COMITRUCTgNsTA/ONNf,AND THAT A Oren POCONO INN MOUND TOME WELCWNRA
FOR OFFICE WE ONLY ,✓7 J9IJ '� � 6 - 2 2 -C
Omer*
wma
tONll/wOFeWleereelelemlolewTlw MIL MTm
Me gala 6YYmeell erOdyr,eewrdrawarmtent70dgo
est at a

o rr e A r-
e.) .
Noah Caddo - Dwane eld.Mw..r-.nrNOSIrma - OW=slwrOrdlt•Oiard.rrrMdo.
It3rMrMNsOrnrr-11101j.NA.te slslslwn.PIWmel
WELL. CONSTRUCTION RECORD WELL COPITRACTOIk ('1 n A ri (i v f
MU -CONTRACTOR c.n.,cATIon r: _ ;) i 1 S
STATE WELL OOI1S11NICIwM PERIEfst
1.
2.
WELL USE spare sr0 Rdat donle .j . l ❑ ed AgMatre ❑ LloMorrq ❑
m
Q
Roa Had Poop Weir rMaron❑ Olen[] ■ INKUMwe
� (LOCATIOSImiorCS frh I iw If\I L5NN
err lrirrsMaws aLibY rsongOrq
i OWNER IA 11 a (tin 11A 011 11 )'
taken 2 i' C r� ir 11t 1 I
RI110S Nii ,CIC
OreTar trr >I►Orde
4. DATE DRUM -r,i) -CUD
5. TOTAL DEPTH ROC
e. Dunwos COLLECTWD veep NOCr
7. OCES WEU. mime Bans WELL? Yes O ND2
l STATIC WATER LEVEL SMtw Top i Casio FT.
fl1r ellPlrATopeOrdy
I. TOP OF CASPO IS i FT. Mom Lad Mast
nerdarMSlnirrtoef r bike reerrorood=•w1.n.Mrrwr.
drwrarrlirNCADa 1 IAA
10.YIELDOp METHOD OF TEST
11.RATER Zoer:1
OMS16 LDo CIPM
lrro To F•wrrrrrrr•h•s
I - 1 ) < ryj �. fri
i)it) n y
ucU - Quo irr,fix1 a
ui/U-yr i��
12. CM.ORINAITOR: Type Phone
13. COMM
D From�_To~�
Fran-- To
Ran To Ft.
14 GROUT:
r .edrlwNl spin m.ere toe tak d err
1r tTNrrwr 1 trpfId4 sI OI
R. ic11 rrr fleaI I( i) V e *Mks al els lboie WO Ws RON
Raid%rode orpIrmo RYON
From
Rom To FL
15. SCRIMPS
�PI1 Masi
Te s� R. � TV X )i-
D•PM Ok•rorr S$c SS
Fran _To _ In. h
From _To_FL_ h Lti
From _To_R._ Pt h
10. SANDIORAVEL PACK
Dope Elts
Rom To FI.
From To R.
17. REMARKS
Metod
S
1/40
1
o r
a.
asif
I OO HERMIT CERTIFY THAT VMS WILL WAS CONSTRUCT W M SOCCIOMaCE WITH ISA NCAC MR w0L
CONSTRUC11Q1STANDARD, AND THAT AOOROFINS MOOED MIN PRDASEDTOS EWELL OVAMR.
FOR OFFICE UM ONLY �,—z 2 —06
WrotrOITIONI rm—STNC OWL OAR
trwGala OkirsdrilorTles rwmrroorwrr. "Oda >p dqs
OM Mt RIO
Orders

4
Noes Oat or-Dsp•f feltodrormalandNaaadRraaawaa•OMR.ofWabror+v-Onadsosorrsaalm
ION w>lwdsOwn RelsInk imoNtiellesonowtgMal
WELL CONSTRUCTION RECORD Wfdd.00NTRACTOIb Gllllmo .[.f
WILL CONTRACTOR CINITIFICA110N d: Gin
STAY' Val COIMTINIOTIDN PMt. n
90=7. r
et 0 1 s .E
I. WELL unease Awe Rooldu'flD' NbAdpri YI -s D ii st l ❑ M otiwrp ❑
SIC]Ise Plop walw*sem OMr[] ROKUNUs
•
2. WELL LOCATetilhour ItsTwac bar Oat" .Cfr!t 9f,
�!d
amilMsoil rommusimoraalaraaa l1st No)
i OWNER 74, 1720.4,11.,
Ma
4.
5. TOTAL DEPTH 2Qr
0. GJITPIQS cowers) YEIiD ND0'
7. DOES WELL REPLACE E)OSTN9 WW2 YES 0 NOS
E. STATIC WATER LEVELS low Top of Clic FT.
5TOP OF CASING IN / sMeAMe
•TM Of soft kodedawrMrlwbaa--. -.- as rosee
10. YIELD (gpaffACae'r METHOD OF TEST 10. YIELD (Flak �L/l/
11 WATER ZONES LSO*
OR SPIG LOB DEP1H
, —Info /Yor To Rorr.Orr
/
getTom
DATEmum lr 2/-00
12.CHLORINATON* Typo Pant Sddliondwoo bnorddtoo book ofbun
13. CAROM
Rom ' TO An,
Fr[
Fron To
Ron To
14.OROWR:
From
Fran To
is. SCRIM
VIWIri s LOCATIDlI SIETSa1
er____ ____S boom al 1st rue e
FLl y fi _rind41R adl.sat amp Son pa)
w
R.
To ifd R P U MAW
R
Dapw Dlarwlw SIN Ski
Foam _To _ M. M.
Frew _To In. In.
Fran _To_R. Mt M.
15 SANWORAVEL PACK:
Dort lbw MlaldAal
Fran To R
Free To R
17. RlIIARft
a
9
rn
J
looNo ROTC®RlnTNATTMNrrELLS&0011WT1UCIED isszaONICEMRNIM II AL>C.WNl
OOIWIRJCRONSTANDARD&AND THAT ACOPY OFTI#IIEDO IW MOVE=TOTTEWULOWNER
FOR MRCSONI ONLY 1Lr f (� -2 2 -O 6
Cal NE
OWN NA
aaaMllIRC 111WWW DOMarmID-MM arot DWI
waaaai}rrlarlsoW arrOWNswwwiweOrnnrdaIbdap
Owl NOV. raN
r

rs
�1
Noe Aline •Drpwbw/AelEr bweMand WSW has - WAWA Gay y•awades.elae
tarMifwdwOrs- Fr- NA.2FEM onemny inn 7104111
WEU. CONSTRUCTIONRECORD wuu.cONTINCTO: ateAd.rtlit
WELLCONIRAOTOR O llOGICATION N: 2//3
STATE LME.L OOIMTIMN.'TION PNIBIV:
1. wms USEpost A,pw.r.r¢ Reddw__Er Mrd*ol ❑ bndaabl i ApsiSs 0 M.saW D
Aeae.ory(7 Hal r , wth►L - - ❑ Other CI NOSS LM1s
2 lAf.AT TIOetTIOlt_ (�wMNaA:afMiooMeo an* Inardi nr,
s
t
t TOTALDEPTFI fli-
es cur7NON caution® Tap morn'
7. DOES WELL REPLACE EXMTNO WILL, MIS 0 NO(y"
s. STATIC WATER LEVEL Din Tap olDer FT.
r. TOP OP MORN IN__ FAT Above land bear
614.Wsrlip INNIS We bins. betww..muds • =As Ye hap
derre•WWW ODAeaCJtp
10.YIELDI.* _a METHOD OF MT /7p
11 WATER ZONES�dpirK
DRL1NEiLOB
7hp
70-a r
2 cat -.290
pwdNw NaNahace.e ti■m r smile NO
awnel w
Ass— Si / eJ.t0
MO -en
ea Ole
DATE Ws `OM UM b -20 -&(p
12. CHLORINATION: Type Awed
1Z MGM
r edElard epee a needed stet d bee
eta ___ Depth ts]CJLTLDN lIaeT011
lO - loci/lor'deaths end delvese ken mime we Ws
Fnps_�To�—FL At P r1ea4.adermoprdwwsP 9
FBr-- To FL
Free To FL
14. GROUT:
Rom / re AO FL cpth � f
Fr To FL
15. SCRIM
Depth Clomothe W M Wei blelwle
Frew To FI In. h
Frew _To FL_ In. h
Fran _ To FL M. h
111. NAND IRAVELPACK
Depth
To
Fran
Fran
17. RIGINV N:
To
Ebro
FL
FL
Mdodd
1 DOHEREBY weir, THAT THIN WELL WAS CONIT1E7CIED
CONSMUCHON STANDARDS. AND THATACOPY OPUS
FOR OFFICE ONE ONLY
ooaeee
ACCOIIAMICII WA are WELL
MIINNENN FROIIOEDTOME WELL OWNER
G-Z/- 46
CPPWWW WWWW awlli WELL OWE
raMrayr/epAloodaiwOelWEerniee lletwhinSTdaps
anal eeY, wee

From
From
17. REMARKS:
North Carolina - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. C)eani -fir
WELL CONTRACTOR CERTIFICATION,: a I l3
STATE WELL CONSTRUCTION PERMIT,:
41 CI, n
FIL
j i.
1. WELL USE (Check Applicable Box): Residentiatla Municipal ❑ Industrial 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 1 u t f.Ys -th (I County: ' In `l,Cid ( CL)i'l
(Road Name and Numbers. Community. or Subdivision and Lot No.)
(-1
OWNER r 11(C'1.P r l cI n
Address reef LYYI o.
1V�i1YS�"(l 1 I Street Roues d
City or Tow gay
4. DATE DRILLED i-t-Din
5. TOTAL DEPTH r�`M
6. CUTTINGS COLLECTED YES El NOrn'
aS--1s3
zw Coda
7. DOES WELL REPLACE EXISTING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 1 (Use **ail Above Top or Casing)
FT Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance in actor.
dance with 15A NCAC 2C Ain
10. YIELD (gprn): t ) METHOD OF TEST t t
11. WATER ZONES (depth)-
12. CHLORINATION: Type Amount
13. CASING:
Agricultural 0
Monitoring ❑
DRILLING LOG
From To
Loa- 14q
t e14 - atop
DEPTH
Formation Description
c s-flg d Chi n
G\tz t >_C
}e
ft additional apace is needed use back al form
Wall Thickness LOCATION SKETCH
From t DeptTo h Da Ft C is or W cab }� (Show direction and distance from at least two State
T`�"x'�� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material Method
From I. ToQ° Ft COrr.efl
From To Ft
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To_
To_
Diameter Slot Size
Ft in
Ft _ in. _
Ft. in
Ft.
Ft
Material
in
In.
in
Size Material
cn
rn
-o
tat)
O
0
F1wL.l is -a; KI .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S1 iNATI(E OF PERSON CONSTRUCTING THE WELL
FOR OFFICE USE ONLY
Quad No:
1-ft- O�
DATE
Submit original to Division of water Quality. Grotattlwatsr Saaion within 30 days
GW-I REV. 12199
Ssdtl No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR- CI.POAtr.12. x
WELL CONTRACTOR CERTIFICATION Y: -7// 3
STATE WELL CONSTRUCTION PERMITY:
C^nct
ar ht tr a.
1. WELL USE (CMekAppticebieaox): Residential❑' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Gst Use:
2. WELL LOCATiON:AShow sk tch pf the location below)
Nearest Town: r t 1l 1r, til L t County
(Road Name and Numbers. Conrnunly. or Suodivision and tot No.)
. OWNER Phu CID )Qc.V%-1
Address Q 1 Lilo ri1 Rou�ri n 71 1
1;cKrn t.adrL d, a )
City or TownZip Cods
4. DATE DRILLED I— I Z-Ot&
5. TOTAL DEPTH ,or
6. CUTTINGS COLLECTED YES NOjj
7. DOES WELL REPLACE EXISTING WELL? YES NO `
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (the'•• iAbove TOP of Casing)
FT. Above Land Surface'
'Top of easing terminated st/or below land surface requires a variance in accor-
dance with 15A NCAC a11a
10. YIELD (gprn): Y`� METHOD OF TESTP1 q
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Wag Thomas
Dept Diameter or W eight/Ft Material
From __L__To Ft u2 'Ai picotC
From To Ft
From To Ft
14. GROUT:
Depth Material
From To rA0 Ft ('linrvir)t
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To _ Ft _
From _ To _ Ft
From _ To Ft
16. SAND/GRAVEL PACK:
Depth Size
From To Ft
From To Ft
17. REMARKS:
In in
in In.
In in
Method
Material
Material
Agricultural ❑ Monitoring ❑
DRILLING LOG
From To
l_c�y
et4- lq9
DEPTH
Fonnalion Description
33.rm0 96 Citrt
C5rCla 1.11-e
&Gal AC
t additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
T urr1 iS
n)P
?Seed, C-11erA
RC,. —O
soic+be
_ I
Eorratdsvillt= bit
ku)t1 I4-;3N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY,QF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad Ne:
A.c 1
7—l3—Div
TIME OF PERSON CONSTRUCTING THE WELL DATE
Sutra origk4 to Division of Water Ouaay, Groundwater Section within 30 days
GW-I REV. 1219g
Sedal No

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR• .If-a1 {/U )per
WELL CONTRACTOR CERTIFICATION 0:.31 2,
STATE WELL CONSTRUCTION PERMIT«:
1. WELL USE (Check Appliceb b Sox): ResidentiatC27 Municipal ❑ Industrial 0 Agricultural 0
Recovery [] Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCA ONN Show sketch. of the location below)
Nearest Town:?� \ �n ►1 County: , `11nC`i1S(in
i ' (Road NameAnd Numbers, Comnurvty, or Subdivision and Lot No.)
3. OWNER ll"j , S ( �\„„-
Address
,,,,
niume
City or Town Lp Cad
4. DATE DRILLED
5. TOTAL DEPTH37
6. CUTTINGS COLLECTED YES NO&
7. DOES WELL REPLACE EXISTING WELL? YES NOEJ
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 1 (Use a Above Top of Casino)
FT Above Land Surface'
'Top of using terminated aver below lend surface requires a variance In actor -
dance with 15A NCAC 2CM16
10. YIELD (gpm)' i METHOD OF TEST�L
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount
13. CASING:
Monitoring 0
DRILLING LOG
From To
i-►an
►� _aq 2)
a
a40 - 3? S
Depth Diameter
From 1 To ► a° Ft. UN
From To Ft.
From To Ft
14. GROUT:
From
From
15. SCREEN:
Depth
Toc
To
DEPTH
Formation Description
ainci a- ck r4
OlairOun
ere( )iC
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or W&IptlWFt. P at r� (Show direction and distance from at least two State
CRoads, or other map reference points)
Material Method
Ft. enn*-
Ft
Depth Diameter Slot Size Material
From To Ft in in
From _ To Ft _ in In
From To Ft. in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
�gd3N.
rn
r*1
-D
vD
Sett
Cn
Pe,
txrihe &
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Qfi THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/2?-fri,evn 7-1$ --o C-
FOR OFFICE USE ONLY
Quad No:
S*GNATpRE OF PERSON CONSTRUCTING THE WELL DATE
Submit obginal to Division of Water Duality, Groundwater Section within 30 days
GW-1 REV. 1299
Soft No.

North Carolina - Depanment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-PhOTM [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. CAP(ltr axz es'
WELL CONTRACTOR CERTIFICATION 0: Z \13
STATE WELL CONSTRUCTION PERMIT#:
61 rl n O, 9 0
1 RELL USE (Check Applicable Box): Residentjat' Municipal 0 Industrial ID Agricultural CI Monitoring ❑
veryeco0 Heat Pump Water Injection 0 Other Q If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MOCCrflU County: rnnil1SOn
• (Road Name and Nurnberg, Convnuney, or Sultan/Won and tot No.) DRILLING LOG DEPTH
--3. OWNER C le_b re e_ Ptrr . +in From To FomuuonDeseAption
Address 014U7 ! {'}^� =y(t , h -Pck -
k,4q n K HI (( (Street orl�QC No ll" -515-1+
City or Town State Zip Cade
4. DATE DRILLED 1 �LI GI Q ,2J-V1 - (0 CS 1
5. TOTAL DEPTH (arn
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (use•� • 9 Above Top of Casing)
FT. Above Land Surface'
'Top of using terminated ator below land surface requires a variance In actor-
danq with 15A NCAC 2C .0115
10. YIELD (gpm): a METHOD OF TEST i. t 1
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If addkbna! apace is needed use back of form
13. CASING:
Depth was mamaDe
FromJP �^� Diameter or Weight/FL Material
To Ft. I (�1Cn-hC
From To Ft. T
From To Ft.
14. GROUT:
Depth Material Method
From To &n Ft r TheX it
From To Ft
15. SCREEN:
Depth Diameter Slot Sinn 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:
LOCATION SKETCH -
(Show direction and distance from at least two State
Roads, or other map reference points) -trS} �L-. bltinC(dLl'r(
rn
II b cc2
t7
tT C3
R`*y
J✓C,�7' S t�-�-t
w(I aS=10
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
E OF PERSON CONSTRUCTING THE WELL DATE
Submit anginal to Division m watw Monty. Groundwater Seam within 30 days
GW-I REV. 12199
FOR OFFICE USE ONLY
Clued Na
Serial No.

From
From To Ft.
17. REMARKS:
North Carolina . Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section
1636 Mai Service Center - Raleigh, N.C. 27699.163&Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR- ( tocutt` ha/ -
WELL CONTRACTOR CERTIFICATION S: r91 121
STATE WELL CONSTRUCTION PERMITS:
J n C c
} c1 R
1. WELL USE (check Applicable Sox): Residential ! Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery 0 Heat Pump Water Injection O Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: / 'v1N-..Mria) p
County
i (Road Name and Numbers, CwmnyNty, or Subdivision and UV No,)
3. OWNER \! I , nI rG,� L-
Address (i G 1 ,X
Mit-l' rz( "..Rir la a`. CD8—)S3
City or Town Stale Zip Cod
4. DATE DRILLED 7 c 4 -OLD
5. TOTAL DEPTH Sax
6. CUTTINGS COLLECTED YES❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO t/
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (use." a Above Top of Casing)
FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.o 1a
10. YIELD (gpm): )() METHOD OF TEST RI 1]
11.
A lcScn
WATER
ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
It additional apace is needed use back of form
' Was Thickness
De th�2amater or Weight/FL
Material
From�To 9' Ft 12.4CH
I
C
From To Ft
From To Ft.
14. GROUT:
Depth Material Method
From ( To Ft. Cone
From To Ft
15. SCREEN:
Depth Diameter
From To Ft _ in
From To Ft in
From To FL in
16. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
Slot Size Material
in
in
in
LOCATION SKETCH
(Show direction and distance from at least two State son
Roads, or other map reference points 1 - `' -'�\e
c.e" 3 (a
COCS"`rpSer 5'ea)
a
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS REC/O�RD H EEN PROVIDED TO THE WELL/OWNER. �C
FOR OFFICE USE ONLY • / LL`ZS'C�6
Ouad No: E OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Ciliation of water Ouatlty. Groundwater Senidn within 30 days
GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Maul Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ,ter " '
WELL CONSTRUCTION RECORD WELL CONTRACTOR. CX upt.�x Q
WELL CONTRACTOR CERTIFICATION a: c; 1 I
STATE WELL CONSTRUCTION PERMITe:
9 /: ( fl C. r;
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: INAa S kth 1 \ County MnC t s &n
r (Read Nams end Numbers, ty, or Subdivision and Lot No.)
3. OWNER t jrnn (ii�(�(I e\d
Address Q1o1 - �j(� t 1 A\/P_
_'ore .4 � j( IR�,"t 3 ci )
City or Town Stay Zip Code
4. DATE DRILLED s D(O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO[]-7
7. DOES WELL REPLACE EXISTING WELL? YES NCO -a
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (Use •• a Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in actor.
dance with ISA NCAC 2C .011S
10. YIELD (open). '/.A. METHOD OF TEST RI 1
t 1. WATER ZONES (depth)• q
12. CHLORINATION: Type
13. CASING:
Depth
From_ To -I0 Ft.
From To Ft.
From
14. GROUT:
From _.
From _
15. SCREEN:
To Ft
Amount
DRILLING LOG
From To
—1(r)
- ,94-01
S40-chi
5 - ct(o'
DEPTH
11 additional apace is needed use back of form
Wail Thickneaa LOCATION SKETCH
or WsIgnwt. !7.Ji,L,rC(Show direction and distance tram at east two State
Roads, or Other map reference points)
Dept_hl n p#(� Method
To -i . Ft. ` u 1 Y a )�
To Ft
Depth Diameter
From To Ft in
From _ To _ Ft._ in.
From To FL in In
16. SAND/GRAVEL PACK
Depth
From To FL
From To Ft.
17. REMARKS:
Slot Size Material
in
In
Size Material
Sever -'tI
cV, t lEt
ria
rr1
-o
Nciccenbe
O .f� Q1
iduptie-Al6 YncLrciSYt(It 8,
let . 3 N
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP,Y�F THIS
�REECORRD}tAS SEEN PROVIDED TO THE WELL OWNER. /�
FOR OFFICE USE ONLY /�" i / e��i► !J r Y 7- 2 to "O rP
Quad No:
ran(
Sedan No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL OATE
Submit original to Division of Water Outlay, Groundwater Section within 30 days
GW1 REV. t2/99

From _L.._ To CIO Ft
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] r ^ /i a.r ,,� �, o ,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR• Cli —t lA ` A�--
WELL CONTRACTOR CERTIFICATION *: r�1 L3
STATE WELL CONSTRUCTION PERMIT*:
sj yin 1 0
a L'
1. WELL USE (Check Applicable Box): Residential127 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection I] Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch pf Abe location below)
Nearest Town: Wrf\1P.YVl t1 P Count I i\CtCCAGY)
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
f3. OWNER i11�Il in °� L )\j 1(� (\(L r I From To Fo moon DeseApbon
1A�ddrress�s �t5� 31/j; f v-v- ' , ,gatr-1 �'il .�^�_ ^��j-� _ D
V u Ct\x! V I. � Il'�ulei
aff \ I( d- " ^ �'UCiO 10 I 2-P -c-14ct
Cny or Town sun Zip Code
QUQ t-15U
4. DATE DRILLED I Ei.s Qsn - 14(75
5. TOTAL DEPTH -1 -a-7 -r2+
6. CUTTINGS COLLECTED YES NOEfr
7. DOES WELL REPLACE EXISTING WELL? YES O NO[ 7
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS fuse•� • if Above Top of Casing)
FT. Above Land Surface'
top of easing terminated odor below land surface raluhaa a valance In "tin'
dance with15A NCAC 2C .0118
10. YIELD (gpm): LI- METHOD OF TEST (CD\
11. WATER ZONES (depth):
•
12. CHLORINATION: Type Amount 11 additional apace is needed use back of form
13. CASING:
Wall Ttvdwas LOCATION SKETCH
Depth'J/ Diarreter or Weight/Ft. ,Maatteriice al (Show direction and distance from at least two State
J " 1 `
From�_To ° Ft. f`--r 4ta,a._C Roads, or other map referendolt)From To Ft. f
From To Ft.
14. GROUT:
Depth CQ Mate Method
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 FL
17. REMARKS:
N9.
mo
LO
Nw\� Ic( -a3N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CORY FF THIS RECORD HAS
EEN, PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / wT �i`h[Tv, -T� Zg 6
Quad No:
Selig No.
S=ONATURE OF PERSON CONSTRUCTING THE WELL OATE
Submit original to Division of water Ouakty, Groundwater Section within 30 days
GWl REV. 1299

0 0 sf
0 j
Frain
Font
17. REFIARIOk
Muth Cowepta Ospenment Wass aid Nowitawas•Min wastois Essaiwassion
MS NM Eon* Osier - RS" I1aEnna MR Weal
WELL CONSTRUCTION RECORD ni. COIMIACT011:- (Xi k n-'1C Y-
MOU.CONIRACTORCIPMPICAMONII: c4‘ -2,
'TAM WILL oolansucnost
1. WILL USILonostApplbobb Ows6 Rodinillel Er iiinkOnl0 nai 13 A pkr Rene 0 mwmodne CI
twang Hod Pomp Wan :: .0 oSe0 NOW, MOW
2. was tocAra,T,t remytorst et nbegan sego _
Name That • •
.514111litui 1,1 Nalibills._r 4eliatidint alga Whi
& OWNER 1-`), I MO '
Addiall or, 111±iii,crim;;44p
ir) or
Clly e1s
4. tan atm 5s
5. TOTAL OEM tnC
e. 0.771110311 cougars) vas No(Zy/
7. DOES WEIL REPLACE EXISTING WSL? YES 0 Nola"
a. STATIC WATER LEVB. Robe Top el Oar FT.
rum ••• mem be or mad
t TOP OF CASING 15 FT. Ahem Land Snelooir
'Twat meg indoWpol IISS. tm Nebo it wawa b apop
dionnt WANCACX1.11011
10. MD Sop 1--> 'ammo array
11. WATER Zan IRS
ns
Pa To
4$""
JCL--
51114117,1?7--11,1"
• r i • ••-'4
- r0 k
- ECUs —
12. CHLORIPLIMON: Typo Awned
13. CAROM
Dopey
Root To
Rant---- Te
Front To
14. GROUT:
Rom
From Te
15. IICRIOnt
t.4
I odabnel spoon nitooded wo book of Nat
TADS
orVISSIFt Switallopt mans awe WSW Ws WS
.0-L.—I-- 1 C. Rena w taw monslonnon pant
FL
R.
Dopes Ihulhod
To p.rne,tr‘i-v-
On+ Olonneur Maki
Rom — To _ F1 • M. In.
Rem To FL In..
Faint — To —.__ FL
16. SANDIORAVEL PACK
Dopes
To
F!•
To FL
In.
Woe Molorlol
• r
-a,' c-
C
1
I NONERWY CERTIFY MAT 111111 Ma WAS Owinnucieosi ACCONOINCE VAIN ISA MACSC. WELL
CONSTRUCTER STANDARD& MID THAT A 71111 MORD WS W1W1 PROPACEDTO THE WEU.ORNEt
/ke-G1071) 37-/ 9 -04:
FON once OPE ONLY
0SM
11•1011n
SflUtflWr—pnuunll MIL DUE
SS. WOW INENNetWarOWIN. Wowesamandit 30 WED
5104nt SI

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] ,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR• C AY Curs ) 4
WELL CONTRACTOR CERTIFICATION la
STATE WELL CONSTRUCTION PERMITm:
o41,
1. WELL USE (Check Applicable Box): Resident/a- Municipal ❑ Industrial 0 Agricultural 0 Monitoring Elry ❑ Heat Pump Water Injection Other ED If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: (-ln 1' S Fit (l County 1\1\(1 C11
(Road Name and Numbers, Community. or Subdivision Arad Lot No.)
3. OWNER R,0nn P Wh 1 -14
Address IL4C130( R (juwre I --kGI
„strMt or \/ul� No.)
City or Town Star Zip Code
4. DATE DRILLED
5. TOTAL DEPTH (o (
6. CUTTINGS COLLECTED YES ❑ NOQ/
7. DOES WELL REPLACE EXISTING WELL? YES NOU
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I FT. Above Land Surface')
'Top of easing terminated atler below land surface requires a vananee In accor-
dance with 1SA NCAC 2C .0118
10. YIELD (gpm): L(a METHOD OF TEST �I'CA
11. WATER ZONES (depth)-
12. CHLORINATION: Type Amount
13. CASING:
Dept
From To
From To
From To Ft.
14. GROUT:
Ft
Ft
DRILLING LOG
From To
I
aC(Q - 3(-n
21)n
DEPTH
Formation Description
If additional space is needed use back of form
Was Thickness LOCATION SKETCH
or Weight/FL Material (Show direction and distance from at least two State
C Roads, or other map meta n§r cry, 1( co Z
Deg�/-� � Ma��ari�all L Method
From To SELL Ft. ti.1 t t+t-1 11
From To Ft
15. SCREEN:
From
From
From
Depth Diameter
To Ft
To Ft
To Ft
16. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft
17. REMARKS:
Slot Size Material
in __ in
In .__ In.
in in
Size Material
Neil -QV)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C F THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY " r �— " OC
Quad No:
Sena No.
TIME OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DivUlon Of War Quality, Groundwater section within 30 days
GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources • Division of Water Ouelity . Groundwater Section
1636 Mail Service Canter - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• C I Ont i 1M F-c r
WELL CONTRACTOR CERTIFICATION e: \ �3
STATE WELL CONSTRUCTION PERMIT#:
r. n, c —
0 ri J e9
1. WELL USE (Cheek Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT1QN: (Show sketch of the location below) \
Nearest Town: (\no f,� �7 \ \ county 1u3 xc\.l c)\r)
r+ T fl ^m
3
(R0ad NarnsAnd Numbers, Cornra,ty. or Subdivision and Lot No.) DRILLING LOG DEPTH
'3. OWNER oenntJ 7 llcicli-e. From To
Address CI.Q� rN)w C Y' -- c1
Mix cr1' Yjj A »t MC, a8K1S3
City or Town Stab Zip Coda
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO62(
7. DOES WELL REPLACE EXISTING WELL? YES NOD'
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (�'' 9 Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated aUar below land surface requlne a variance in accor-
dance with 164 NCAC 2C 1j1.,
10. VIEW(gpm): flon4 v METHOD OF TEST
11. WATER ZONES (depth)*
LCP
12. CHLORINATION: Type Amount
13. CASING:
Was Thickness
Dept t3neter or Weight/Ft.
FromTo Ft
From To Ft.
From To Ft.
14. GROUT:
Depth
From L Tod . Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft in
From To Ft. in
From To Ft In
16. SAND/GRAVEL PACK:
Depth Size
From To FL
From To Ft
17. REMARKS:
Material
in
In
in
Material
I3r) -Ito
Formation Description
SRe A +C i'( --
11 addltionsi space is needed use back of form
LOCATION SKETCH
hOw direction and distance from at least two State
Roads, or other map reference points)
m lc oo .
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF THIS RECORD BEEN ROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Clued No:
Serial No.
E OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Seaton within 30 days
GW1 REV. 12199

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• l (� kon xt&fk r
WELL CONTRACTOR CERTIFICATION #: r^)I )3
STATE WELL CONSTRUCTION PERMIT#:
R n r' n
0 iLcJ t.j i
1 WELL
ecoUSE (Check Applicable Box):Residentialpp MunicipalIndustrial ID Agricultural El Monitoring El
very ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCA110 • (Show sketch of the location below) �1 r 1 �rv� Nearest Town: , ' 1t AJ J �l County: J t� /� v tl\ A (Ul J )
' (Road Name and Numbers, Community. or Supervision and tat No.) DRILLING LOG
i3. OWNER iTh�-1�\ iCC] `F fentj We ISS From To
Address S1_�1y� ��i f 1 l i !1 ,,. , , _ - 1- l Q o
Ac5nev I.VIXX
City or Town a Oo4
s zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES El NOEr
7. DOES WELL REPLACE EXISTING WELL? YES [] NO0
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (eie . a Above Top of Casvtg)
FT. Above Land Surface'
'Top of casing terminated ar/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .Otte �
10. YIELD (gpm)' 15 METHOD OF TEST aitresi
11. WATER ZONES (depth)*
eel Or
12. CHLORINATION: Type Amount
13. CASING:
Wa4 Thickness
Depth rDia ter or WelgnVFt. Mats*From�To �0 Ft.
From To Ft
From To Ft
14. GROUT:
From Depth rv� ,�.M�atteeriaa!
To sin Ft. CQ. nc C 1
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft in in
From
From
To _ Ft _ in.
To _._ Ft. __ in.
16. SAND/GRAVEL PACK:
From
From
17. REMARKS:
Depth Size
To Ft.
To Ft
in
in
Method
Mittens!
Material
Roo - , 9
3�a-�
34S O
11 additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A GO OF THIS RJCORD HI)4 BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No:
Serial No.
SIQNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subnit original to Division or Water Duality, Grotmdwatsr Section within 30 days
GW-1 REV. tx199

North Carolina • Department of Environment and Natural Resources • Division of Water Ouality - Groundwater Section
1636 Mail Service Center. Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL. CONTRACTOR• (11 AQXViOJCX
WELL CONTRACTOR CERTIFICATION 0: aI IZ
STATE WELL CONSTRUCTION PERMIT*:
?n 0 ti
i ti J
1. WELL USE (Check Applicable Sox): Residen5a112 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATIeRNn: Rhow sketch of the location below)
Nearest Town: , Y 1 it1-1-1I I coin,. ��;\C�I son
(Read Name Numbers, Community. or Subdivision and tot No.) DRILLING LOG DEPTH
3. OWNER �t2��h�n fl Mtn H TP ` From To Grai Formation Description
Address
5 0 Cnj El l n' p -4 t -t.oS �a-t n �lr
1/t )lesL S 1 1 1( Street dr N`' t Os- aoQ
y or Town Stay Zip Code c A Cl- I n
4. DATE DRU.LED 'IO-OU' & o -c7V S
5. TOTAL DEPTH a4S
6. CUTTINGS COLLECTED YES ❑ NORre
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO21
6, STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS ' (Use -+ a Above Top of Casing)
FT. Above Land Surface'
-Top of casing terminated aver below land surface requires a variance In actor.
dance with 15A NCAC 2C .0115
10. YIELD(gpm): an METHOD OF TEST--Plifl
11. WATER ZONES (depth)•
12. CHLORINATION: Type Amount If addltonal space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
—A_____.
Ft l Diameter or Weg*VFL Mate (Show direction and distance from at feast two State
From IOD i(
Roads, or other reap reference points)
From To Ft
From To Ft
14. GROUT:
Depth $ 44.tterriaL Method
From � To an Ft. Cvt t tr.►' ll
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:
L0_u
�n�
.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP' .QF THIS RE�(.ORD HASJ(<EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Cued No:
%n
Seem No.
SIGMATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DMdon of Water Duality, Groundwater SMion within 30 days
GW4 REV. 17A9

North Carolina • Department of Environment and Natural Resources - Division or Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �y
WELL CONSTRUCTION RECORD WELL CONTRACTOR- l /� lla-,, -A
WELL CONTRACTOR CERTIFICATION a: a t 13
STATE WELL CONSTRUCTION PERMIT#:
0 ei.t J!i
1. WELL USE (Chock Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT(QNw hosketch of the location below) �^ ,,
Nearest Town: I V t rn County F u N ,in i SOr%
rr3
CCT C 2 ?r_'.u3
'Mud and Numsta Convmw or Subdivision and Lot Nc.) DRILLING LOG DEPTH
�3. OWNER char eS k- .lclef)
From To Formation Desalptien
Address Do X k_x
Mar \S h-u "10f / ) � °' a,8154
Cray or Town Stare 2Ip 4. DATE DRILLED co- I I Code
y(� O
5. TOTAL DEPTH 3i i
6. CUTTINGS COLLECTED YES O NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOQj•
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use ite II Atm* Top of
9. TOP OF CASING IS I FT. Above LandSurf )
flop ct casing terminated aVor below land surface roguing a variance in accor-
dance with 19A NCAC 2C .01111
10. YIELD (gpm): Ik METHOD OF TEST PI t CI
11. WATER ZONES (depth)-
12. CHLORINATION: Type Amount
13. CASING:
It additional apace is needed use back of form
Wei Thickness LOCATION SKETCH
From DeTpth 5 Ft tDiamor Wad` Matei & (Show direction and distance from et least two State
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
From To rfli
Depth Method
coo .Ft Oo'
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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QJf THIS RE
RD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY NA ire/ Z —06
SIG TORE OF PERSON CONSTRUCTING THE WELL DATE
Sulmil might to Division of Water Welty, Groundwater Section within 30 days
GW-t REV. 12199
m
7-1
0'
Quad No:
Serial No.

North Carolina - Department of Environment and Natural Resources Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] /� � ,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR- el-O L1 1.
WELL CONTRACTOR CERTIFICATION 1: t�
STATE WELL CONSTRUCTION PERMIT#:
C' A
a 4
1. WELL USE (Check Applicable Box): Residentia121 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCAT/I�O/N: (Show sketch ‘of the location below) f1/�/ �t
Nearest Town: Ann r i Ins ;i1 I I County: I V o I I Ian
(Road Name and Numbers. Community. or Subdivision and Lot No, ) DRILLING LOG
3. OWNER Ctflc CI NAM #WrQ o
0 C,Iler� ,
are of No.
City or Town Strue Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO[/
7. DOES WELL REPLACE EXISTING WELL? YES [� NO .E
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (Use �. a Above Top of Casing)
FT. Above Land Surface'
'Top or easing tarmlrated aUor below land surface requires a variance In accor-
dance raids 15A NCAC 2C .011$ n
10. YIELD (gpm): e METHOD OF TEST 9119
11. WATER ZONES (depth).
Address
Mout
12. CHLORINATION: Type Amount
13. CASING:
11 additional apace is needed use back of form
Wall Thickness LOCATION SKETCH
From Depth ,� Ft Demeter or W�Wt. Matt(/ (Show direction and distance from at least two State
�_ To 1 P Ci Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:Dth
From 1 ToepaO Ft e h ' g 1C^11 Method i', i I L Jt7
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:
-v
0'
ON
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO IF THIS CORD
AS BEENPROVIDED TO THE WELL OWNER. NE
FOR OFFICE USE ONLY / `�} /.G��%L!/Y� p '9-61
Quad No:
SOON No.
TORE OF PERSON CONSTRUCTING THE WELL DATE
Submll original to Division of Water Oualty, Groundwater secion within 30 days
GW-1 REV. 12199

WELL_CONSTRUCTION RECORD
3 oL 37
North Carolina - Demons of Bovieenmear and *opal Rawness -D'`ide* of Water Quay - GmwwSsrr section
von cOMACTORONINVmpA4 . h`//tr) c node, SK Corruresaon e2.75t f'
wetiooN7RAclaeaaesrANrerAss 'et (.v,9 /' we!! %'ccmsr� raosae®1a►6%�v</go
STATIC WILL COr tIWc inn rIC on slikmatw wQ 1 11a
/i soo iaeble) fifeppNo�41
1. WEIL USE (OmeicAp,Bmble Borax IE itteeli-i 0' MScIpsYPublie O brB-Rid O AScioaNred
Mania* 0 Remaly 0 Beet Amp Water *aim D Omer 0 If Other, Lit Use
s. WELL LOCATION:
Names Ton i leigkil Canny lk,76--4. 0v
35 r nncX /W 2875 ?
Mrratnr,Nsa6ROewsstel JeSLetne,sCob)
Topqpnpide/Lond setting
CDJdis Mope Malley aid
Lldaloogimds ��i000doo
3. OWNER: pa / /*yw e t issar.arl
Address 3,-nit, taa.'ffersc it r/ Tadmde9apede.meoe:DOPSOTepographie min
mtrater/%!/97riiiIiii lti'Gt+.' 'n'7i�3 (eealttey
Clyoefar. erb sot To ImesMI r pd
L} Pomades Da.triptim
Mee sob. fie Sr
4. DATE DRIfLD 7 /e 'cal6
S. TOTAL DEPTH: 51'21-
6.. DOES WELL REPLACE EIQBTINO WELL? YES 0 NO er
?. STATIC WATER LEVEL Below Top (Meier JET.
�, (ttr'w lfAM. TgdClri t
R TOP OF CASINO IS. / 6 FT. Above Land Sa*ts'
flap done r.i.t.irMrSlaw Inda.rfal natal.
miss lse vensuevie IeAMAC 2CADA
9. YIELD (gpm):. Z METHOD OF F TEST iiingel
10. WATER ZONES (deplb):
11. DIsENFBCITON:Type CC /7 Amount /O ez
12. CASINO: Marc Wag Dirks
Dors Ilfelsblak ISM
Print 0 To 27 Ftja or 5Pk 2/ Lie
Prom______ To_ Pt
Prom_ To Ft
13. GROUT Demo Mort
From•.(j.To 72 FLCaie/el? r.,c rh,X
Prart_TO A
It SCREEN• Depli Dieter MetShe i_owiel
Print To Ft, __,-ie. d
Ftoa___To P _ _ ia. In.
15. SAND/GRAM PACK:
Sim Maid
From Depth Ft.
FrooL To FL __
16. REMARKS.
/ '5W
UrareiTIMSKEICii
Show Anoka awn diseases in miles from at least
Om as. Roads a County Reeds. Windt the road
m ei= sod maann mad tames.
1 DO EMBRY%.aa,wYTBATIME WELL WAS Coterie» iN ACCORDANCE van! ISANCAC2C. WELL
•. HAS BEBNPROVIDED TOTHE WELL OWNER
CONSTRUCTING THE WELL DATE
SnbslttYorigin, tothe Dighton etWtQaaRy.Grea dw,srSaese,M Mai ME Smite Crier -RYai NC
3SI- aPWsNo.e ni'►.tS.d33t,wYYeSSdays OW4 REV.072001

WELL CONSTRUCTION RECORD
Nottil Carolina -DapaInnit efBwbaaa.a.t and Need Rtuaemeoe - Diviaig. of Wee Quality - Otoaedaater section
WELL cart.ucroagio VIDVAI4I4 aM/e'al c /�/1c;-(E sL' corrarc�none z 7
M�RILGOlfYRAG7btCOeQANY ee tur'S�1/YV well 9 / ut*// ruoea a jam h`/9-t ve c.
stirs WELL OOMars t alon tEReatat ASIOQAI:D FQ MOIMI
tiessabio
332532
1. WELL 118E (CbrtAppYrable Bo* Rnidosdel CI i4idpaYtoblie O 1aieMi l D Axle lunal 0
Mo iloties O bowery 0 That Pomp Waver *aim 0 Other O IfOther, Lint Use
2. WELL LOCATION:
Now* Topa/rs/�i91/ Cooay isol ,'
1175` iG "ys WWlA octave,'
3
tRr.era.r,r.+.t.(x+.e.N.arR/-1t tatei"IiCar)
3. OWNER: )91, y' Lel
Ades �7i fl//t ej� s �ir,t
arlarte lie)
m is/iv// PVC
Ze75 ?
gyelle n w tip Ovi r
ASode- rsnun
4. DATE DRILLED F-7-0 4.
5_ TOTAL DEPT* -2Q.5-
6. DOES wal. REPLACERESTING WELL? 174 DD NC: 0
7. STATIC WATER LEVEL Below To, ot:.:aL /n PT.
(UseMAMAS,NOSE&
S. TOP OF CASINO Is ]?�r " r Above Lad smaceE
"TT+'-9!* tiemdmiL4 iGiP Wiror had *Etta milt■
panne IN reoNeorata ISA NCAC 2C Alt
9. YIELD Cs* / 7 METHOD OF TEST if
10. WATER ZONES (SO):
Taco�a�Lic/land a
�tidse Tactic/land
LNaUrS M ut
— maples boa)
Latindinlongiode of well bastion
AMES
bitaado
�tr..r nntr ?h+c nap
nRI WNfitrip
Fotrstioa Derniption
RWNt� QUPt�t
MOE
From To
11. DJSINPECTION: Typ. CC//. Amos J.O c7
12. CASINO: Mali Tiiikote
,�/ Dard m Mir.
Pra.t__{�To 25 SDj--2/ Ce.
Aran_ To
Prom_.... — To Pt_ —
13. GROUT: Dope./ ��tWrerttYYyy
Plo.iTo 2C Ptca
PLORt_ To Ft
)Mod
p'r.'t' a,,
14. SCREEN: Dope DiaMir dietSiae Mode
Prcat_. _. To Ft_in. in.
Ptoo _T0 FL —in. in.
15. SAND/ORAVELPACC:
Depth Sim idatedel
Prom ' To Pt,_ --
Pro___ —_To FL--
Shot -=fit= taws in mile from at Iwo
two Silva Rods c Canty Role. Whtde the rood
•
NN-N)
16. RD.LARYS:
IDOHEREBY MUM mATI=WSLS.WAS cortrutri ix
OF PERSON r•
"",,...^s.N. wrm !SA NCt..c •.n .. t.
nAE BEEN Paw". Y'u^'t,pvD TOTIlo" WELL OW)c"a
Tlm VITAL
c-7e'‘
DATE
;;;;I 74;._;:;.: _.. ....__Quaky.Gredamaareaaw.,a6LwsladeeCeeeer NC
27.0406 Pi±ne No. v1!) 733 3221, _11U. 30 Ben OW4 REV. 07/2001

333524
ragdiarillallalpralgan
Nadi Calks -Dyaenataf___saa! lam in*Ws Quaky• anm.•.,,rrSoak*
MIL ao111240a.0aa•1Ma aaea : in c Rl+ed4OS Xie aunseunnton•?7ZY
wou.coorsoasoCOMPANIMANPLCl ve we!! f�.r. , e y�•vyac
aTATSNa1L 1MR71allala� AMOQATf•a10N
i1>•lnalel
akommeasai
1. WILL Uill(0e* Mr+wa klddaaideC Leo Muhl t3 ma*
labia bia Deaf O Nat PMOMlrrbloods 0 Ole 0 VOis.Lillie
t WSL LOCATION:
Nam Tat ill 4 1Ail dt,rq, Mat
ZS7_ H''(/ s Z.?75"7
as16.8.110sCoasMa olou tea.;aaa1
3. OMa .`34c.'t fry fu
ANN. 7 5-'Z. 'j1 6 t
>?tinkli r /VGA 2F7C-3
art as ;Cub
b.ae►Ieaaaaaale
I. DAISOl1122D g f 7-O A
S. TOTALD11,111; a 05-
6. DON WILL IMPIASE Ts10 flu Tel 0 NO
7. STATIC WATS LIVE. Mow TS otOrist (i0 PT.
Saftaisolipstalial
S. TWO/ CASINO IS /I, FT. As sloadlodlown•
tif,da.YseasunaaYvIns r..r
to WATlltBONIN*NO
TopTejed eaatal
r
Snit .. ep DPW
aalta6/Owe hooka
sislosafonso
taeludNlagMMaaaave�q nblorP
ME$ paLINILLai
has To Faauliaa Daeaeipim
11. newa!t.'110erwi f - j /0 cY
it CASDO vim Wilflea lIksrlil
l This
1A QOIIT. 1I�.d
_a.(ennaefy_ Wet r».Y
Pa.—. I--1,1
14 Dam D --- Qkl1a __
1S. WAiOSAVS.TACC:
13.6 she Mal No*fi %�_1k.......�. Sisk.
WriNnalpan
Now Solis sod Sow boas Ike* e
awSIMbob oCosy Raab. baba Ike sad
sobs
21'
•
l- -
16. MAW:
moma 'a!Tr illeTlrrllLMM Iw,wv tan4n1 DR111IMANCAc24 Mnz.
aal!nataat A ean,A Car
NININNfw� 07111"SU.OWIIIR
nn ^ C. aowsv6icaa p- /7-C ‘
snf&TOnefNN 01 T11tNUL OATS
let flair sneer-tray*Pc
l7a10•fralLnaNa.tMq'11N1aY.Web Aldan 011-1 REV.07/2a01

1. WELL CONTRACTOR:
CHAD HARTNESS
Well Contractor (Individual) Name
AIR DRILLING COMPANY
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD.
STATESVILLE, NC 28625
State
City or Town
70( 4 1_ 872-7614
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)__
DWQ or OTHER PERMIT #(if applicable)
TIME COMPLETED
3. WELL LOCATION:
CITY: MARS HILL
WOLF LAUREL
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
CSlope CValley ❑Flat ❑Ridge ❑Other__��
(check appropnate box)
LATITUDE .L
LONGITUDE_
Latitude/longitude source: 0GPS oTopographic map
(location of wed must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME W. E. SCHROEDER
STREET ADDRESS 1200 RIVERPLACE BLVD. - SUITE 90L
JACKSONVILLE, FL 32207
State
Zip Code
WELL USE (Check Applicable Box):
DATE DRILLED 08-15-06
10:25
City or Town
Area code - Phone number
Residential Water Supply
AM® PM❑
COUNTY MADISON
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH:1200 FT.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use "+" if Above Top d Casing)
d. TOP OF CASING IS 1 1 /2 FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2 METHOD OF TEST AIR
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2901
f. DISINFECTION: Type NTH
g. WATER ZONES (depth):
1173 To 1174
From
From
From
6. CASING:
8. SCREEN: Depth
From To
From To
From To
From.
From.
From
Qameter
Ft. 8
Ft.
Ft.
Material
54 Ft GROUT
_ Ft.
Ft.
9. SAND/GRAVEL PACK:
Depth
From.
From
From
J 2
. d
Amount
To
To
To
Thickness/
Weight
Method
PUMPED
Diameter Slot Size
Ft. in. — in.
Ft. in. __ in.
Ft. in. _ in.
To Ft..
To Ft.
To _Ft.
10. DRILLING LOG
From To
0' 54'
54' 1200'
11. REMARKS:
8" DRIVE SHOE
Material
Material
Formation Description
DIRT
ROCK
I DO HEREBY CER11FYTHATTHIa ELL WAS CONSTRUCTED IN ACCORDANCE WITH
1 rr�NC 2C, WjrLL COfjIP�{UlC NST DAR NERD ETA COPY OF THIS
dE70Rb HAS 9YEN PROVR� 0
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
CAN C.Kk-NN-eSC -
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
116 Submit Mail Servicge Centerh Raleigh, NC 2 699-16117 Quality oriinal to te Division of Water Phone
o within eNo. 9 9) 733 7015 extn68.�on Mgt.,
Form GW-la
Rev. 7105

1. WELL CONTRACTOR:
CHAD HARTNESS
W ell Contractor (Individual) Name
AIR DRILLING COMPANY
Ind Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD.
STATESVILLE, NC 28625
City or Town State Zip Code
70( 4 )_ 872-7614
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *if applicable)
STATE WELL PERMIT#Qf applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
gi
DATE DRILLED 08-23-06_—
TIME COMPLETED 4:10 AM ❑ PM
EI
3. WELL LOCATION:
CITY: MARS HILL
WOLF LAUREL
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form # not using GPS)
4. WELL OWNER
OWNERS NAME W. E. SCHROEDER ..
STREET ADDRESS 1200 RIVERPLACE BLVD. - SUITE 90/—
JACKSONVILLE, FL 32207nte Zip Code
City or Town
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 1130 FT.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
200 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 1/2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 5 METHOD OF TEST AIR
COUNTY MADISON
May be in degrees,
minutes, seconds or
in a decimal format
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2901
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
From 1102 To 1103
7. GROUT: Depth rvlalC+io
From 0 To 64 Ft. GROUT F
From To Ft. From To
8. SCREEN: Depth Diameter in.Slot Size in.
From To
From
To Ft. in. in.
From
To Ft. in. _ in.
9. SAND/GRAVEL PACK: Size Mater
Depth
From To Ft
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W Ini
15A NC C 2C, W CONS UCTI N ST DARDS, AND THAT A COPY OF THIS
q�L�R HAS 0 NPR D TH ER �\ ^i\ Q
SIGNATURE OF CERTIFIED WELL CONTRACTOR D�
Q.,\N 'ho rk \N-e s s
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617in 30 days. Attn:
Mail Service Center —QualityRaleigh, NC 2 699-1617 Phone Information Mgt.,
eNo (9 9) 733 7015 ext 68.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
,,-LDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 12oh1 Ai I/1%GIJC! / n CERTIFICATION #�O
WELL CONTRACTOR COMPANY NAME 6/ee»e eaTBrs Oita d /"(j10 PHONE # t 9 64/93/76
STATE WELL CONSTRUCTION PERMIT# fY OZ- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential l Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Na/shQ.i'1 County Had/SON
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: J ho/nit Sku-Ayou
Address 19.D. d eI( /9/ig
(Street or Route No.)
sheaf(l� /lf C 28816
City or Town State Zip Code
e )- z3/-415-2-5.
Area code- Phone number
4. DATE DRILLED B -29.17 is
5. TOTAL DEPTH: 3 65'
6. DOES 'r\/i'.L1. REPLACE 1:VISrWEl l ? YES LA nui
7. STATIC WATER LEVEL Below Top of Casing: /o b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordaac,g with ISA NCAC 2C .0118.
9. YIELD (gpm): 10 METHOD OF TEST 2 gots
10. WATER ZONES (depth): 2 90
11. DISINFECTION: Type NW Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 4.r Ft. 4"
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To Lv Ft. eern ea f Th-
From To Ft. r-
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Pvc
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope OValley tfat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
Formation Description
Pig..
From To
66' 30
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
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTIOPnTANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
9-27-0
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

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: Ca Ott rLCr�132,r
WELL CONTRACTOR CERTIFICATION #c I) 3
STATE WELL. CONSTRUCTION PERMITS:
1. WELL USE (Check Applicable sox): Residentialrf Municipal 0 Industrial 0 Agricultural 0 Monitoring ❑
Recovery 0 Heat Pump Water Injection
0 Other ❑ )(Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) -
Nearest Town:
County:
(Read Name end NumQ%
3. OWNER
Address
Coy or Town State
4. DATE DRILLED® a
5. TOTAL DEPTH �Q5
6. CUTTINGS COLLECTED YES NO�
7. DOES WELL REPLACE EXISTING WELL? YES NOE
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS ___ W+e'•' a Above Top of Casino)FT. Above Land Surface'
'Top of casing terminated at/or batow land su4aca requires • variants In accor-
dant* with 15A NCAC 2C .0 1e
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
. or Su • • sion and Ust No.)
From
From
From
14. GROUT:
From
From
15. SCREEN:
f
Depthg�
- To Ft
To Ft
To
Ft.
Di
Amount
Code
DRILLING LOG
From To
drhri-
��p )-h
�(a )t Cart te
DEPTH
Formation Description
10�4-(C-1S
loss - 70S"
)3 t
If additional space is needed use back of form
ter wa Tessa LOCATION SKETCH
or WelgtnR, Material . (Show direction and distance from at least two Slate
YlO »iA+.
Roads, or other map reference points)
Depth Material Method
Mae_Ft. P? rn7 T' w
To Ft
Depth Diameter Slot Size Material
From To Ft in. _ _ in.
From To Ft. in. In.
From To _ Ft. In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
1I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IFGZrvar
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit origlnai to Division of water Duality. Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
Seea1 No.
424
GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mali Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION u:s t3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residentjai� Municipal ❑ Industrial ElRecovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: Show sketch of the Location below)
Nearest Town: ) (�
Coy
'Mad Name mentality. or Suot vision and Lot Nal
.-d Numbers. Co m
3. OWNER plan C�i_
Address
Town
4. DATE DRILLED
5. TOTAL DEPTH6.
7.NGS COLLECTED YES N
DOES
WELL REPLACE EXISTING WELL? PEES ❑ NO
8, STATIC WATER LEVEL Below Top of Casing: FTn
Ur " _,-��_
S. TOP OF CASING IS (U7e •+. a Above Top of Cask'91
ove Land Surface'
'Top of easing tarminalsd at/or below SU acs require a vsrfanc. In eccor-
danee with 1SA NCAC 2C MID
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
334241
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To rFomyton Description
tia
l ToDeptC..
From Ft.
From To FI.
From — To Ft..
14. GROUT:
Zip Code
Amount
ft additional space is needed use back of form
Wall Thickness J OCATION ¢KETC
or Weight/FL trial (Show direction
and distance from at,least two State
Roads, or Other map reference points)
Dep�t�hf� Material
From �_ To \ Yl I Ft. .,2 y2.... _ Method
From To Ft. -�_ -�K1
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in.
From In.
To Ft. _ in. ---__ In.
From To Ft. - In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
H`a
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC EC, WELL
CONSTRUCTION STANDARDS, ANp THAT A COP
FOR OFFICE USE ONLY
Quad No:
Swim No.
OF THIS RECORD FlAS BEEN PROVIDED TO THE WELL OWNER.
TURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division or water Duality, Groundwater Section within 30 days
Z —tit%
DATE
GW-1 REV. 12/99

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Diyisii n of Water Quality
1VELL CONTRACTOR CERTIFICATION a a , 4 0
1. WELL CONTRACTOR:
RtA.Lbe,h C R-Lag- l
Well Contractor (Individual) Name
(Zea)ete C0.1dLLell Or; :(1 Inc.
Well Contractor Company Name
STREET ADDRESS 3S 1 1\-e,tss �I ce.1tr Hui
PsKe v-c Lk. ►JC a W7 6
City ot Term State Zip Code
(gac a4-358!
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID F(il applicable)
STATE WELL PERMIT#(a applcable)
DWQ or OTHER PERMIT a(il applicable) /
WELL USE (Check Applicable Bo ) Residential Water SupplyQ'
DATE DRILLED 10 /S / O 6 /
TIME COMPLETED '1, o 0 AMP PM 5
3. WELL LOCATION:
CITY: W€A4eSM,VIL,t COUNTY OnANSeta
13AI IAoLct ac ea-fki c, I
ISbeel Name. Numbers. Canmundy, Subdmsran. Lot No_ Parcel, bp Code)
T rOGRAPHIC / LAND SETTING:
iieSlope °Valley ❑Flat °Ridge °Other
(check approprialeebox) 1
LATITUDE 3 5 4e)-. 360
LONGITUDE It_ a saC L-4IS
Latitude/longitude source: ID.e S °Topographic map
(location or wel must be shown one USGS topo map and
attached to this form 1 not usrg GPS)
4. WELL OWNER (�
OWNER'S NAME l tAL0 ItnN6E21.1�
STREET ADDRESS 13a, Not-ComeE, GR.a oc44
May he in degrees.
minutes, seconds or
in a decimal formal
lAliAJ€a.v1L.LE kg -IS/
City or Town Stale hip Code
( say, ). force - 31 I
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH: 445
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
d. TOP OF CASING 15
100
FT
FT_ Above Land Surface'
'Top of casing terminated avor below yard surface may require
a variance in accordancew ,lh 15A NCAC 7C 0118 IILL e. YIELD(gpm) Ia METHOD OF TEST R{l^j-+ry{Q,
c. WATER LEVEL Below Top of Casing
(Use'•' 11 Above Top d Casing)
1
1. DISINFECTION: Type
g WATER ZONES (depth)
From 3C45 To +0D
Faun
From
6. CASING.
To
To
from
1 ° oth15 Ft E. to Iglul
From To Ft.
Eton To FI
From
From
Frorn
To
To
To
Thickness/
7. GROUT: Depth Material Material Method
EtoEtonj rr�� To ` ° FtrC4
frerr QBVge'D
From To
From To
FI.
FI
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To in.
From To
in.
9. SAND/GRAVEL PACK:
Depth
Fins' To
Frorn To
From To
Material
Material
10. DRILLING LOG
From �_ Toi Formation Description
Ci R44 Ci
4Go' - 9�15' e�ltc.t - t a 5 Pin
-0-395'
gqS'- 4-Oo
Ft in
FI in.
Size
FI
Ft
Ft.
11. REMARKS:
NtLtiVEL
OIV, :F- byq; bF' QUAI (Ty
NUV II s 200s
I DO HEREBY CE STAY THAT MIS W Ftl WAS CONSTRUCTED N ACCORDANCE Writs
IAA NCac ]C WELL CONS!". UCTxaa S LANCIA/LOS AND THAT A COPY OF MIS
REcono HAS Elf EN PROVIDED TO ME WELL �OWNER/�
«9 a JQ < oQck.1AAQ11 10/b/G6
SIGNATURE OF ERTIFIED WELL CONTRIAI-TOR D TE
__ kjtLL.1L, OASV'1
PInttFU 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.
Forrn 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 Caldwelrs Drilling, Inc.
Wel Contractor Canpany Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 ). 254-3581
Area code- Phone number
L WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(itapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable ox): Residential Water Supply 0
DATE DRILLED \ O / I /3 0 (0
TIME COMPLETED Z . o o AM ❑ PM L(
3. WELL LOCATION:
CITY: AkAQ5tkII_+—
COUNTY TV\A f-)iSU li
A lq D A2d(- GcS,)ts-_- O-cAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
O Slope ❑Valley [3ri/Lat ❑Ridge ❑Other
(check appropriate box)
LATITUDE _ k 5 1 - 9' 19
LONGITUDE L a 37 - 0 3 4-
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS ❑ Topographic map
Ration of wel must be shown on a USGS topo map and
attached to this form Nfnot using GPS)
A WELL OWNER 1 {� 1
OWNER'S NAME "---/A,v S tJ V 2!-` Inn
STREET ADDRESS 1\r5 Cp2.pe.r 12y6f-i'/c
C) kpic fPtP YA aa`to
City or Town State Zip Code
( tea)- 'a5-sbga
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 9 b5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
WATER LEVEL Belau Top of Casing: 10 U FT.
(Use °+° if Above Top ,f Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gem): I 5 METHOD OF TEST RIG -A 11l`
f. DISINFECTION: Type di ^I co-/ Amount
g. WATER ZONES (depth),.....--
From t D 'a To i 1 5 From
To
From To From To
From To Fran To
8. CASING: Thickness!
,I Depol Diameter W ''ght.
From -L To 3 0 Ft. L^ Y 5 �uC� i
From To Ft.
From To Ft.
7. GROUT: Depth
Material
JG
Material Method
From 9 To aD Ft. C6Mb D T PCJQeb
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.
From To Ft.
From To Ft.
10. DRILLING LOG
From , To
-
a5
r'5'.- 2Arji1T6
• C \ • c2Eitce - (5 Gem
%r a .,r vejtatr
11. REMARKS:
Fgrmation Description
0S(t�a2(S i20213
K'c.rl0 ,'QD�i
I DO HEREBY CERTIFY THATTHIS 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.
L1/4161"44 I i /ob
SIGNATURERF CERTIFIED WELL CONTRACTOR /DATE
6IL,i_,6 SAS
PRINTED NAME OF PERSON CONSTR CTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTL4L 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 (IndMdual) Name
Reuben Caldwell's Drilling, Inc.
Weft Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State
Zip Code
( 828 )_ 254-3581
Area code- Phone rumba
2. WELL INFORMATION:
SITE WELL ID #(f applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(d applicable) /
WELL USE (Check Applic/y,�Ie Bo : Residential Water Supply
DATE DRILLED , (/ 15 fo b
TIME COMPLETED 1 I 0 0 A PM ❑
3. WELL LRCc_ATION: p
CITY: 15A R+JA(LbSV'i 1-1-6/y�
6 COUNTY I r \A®1 SD1'3
Sb‘Fsrt One PIS Str:4 lSi o 6`N
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT G:
❑Slope DValley ❑Flat ienidge oother
(check appropriate box) ..L
LATITUDE 5 4'cb . 1 D S
LONGITUDE aa c� h Et M
Latitude/longitude source: oGPS oTopographic map
(location of we# must be shown on a USGS topo map and
attached to This form Anot using GPS)
0. WELL OWNER 11��I /'. d
OWNER'S NAME &e cr `1t I%1&S . Ca-r n
STTtEET ADDRESS P• G ate {, b S
4jArP-j A4511LOt fi$Ci $%l 0 1
City or Town State Zip Code
cio y l — 0
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: 5
a. TOTAL DEPTH: S O
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO li%
c. WATER LEVEL Below Top of Casing: 1. O Q FT.
(Use -1" if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surfacee
*Top of casing terminated atla below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): 1pp
® METHOD OF TEST 1�i G ` A le
f. DISINFECTION: Type 1\-rrl 1 r� Amount ! 0 cZ'. .
g. WATER ZONES depth):
From Y 2 5 To 3 -
From To
3 ,
From To
& CASING:
FromDepth giati.ter
To SS Ft. b
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 1 To a" Ft. -`'°e N (
From To Ft.
From To Ft.
Fran To
From To
Fran To
Thickness/ ry�
ni 3`r
Method
S iu2
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Fran To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size Material
From To Ft.
10. DRILLING LOG
From ; Toy
SS' — 4 15
�a5r 4-3u
4-30 '— sos'
Formation Description,
Cr t2-t. + c- r-c
C ALn rvCt. + 'v. G tr"^
&bar rt -
RECFIVED
Div. cW yuATFR auALI f 1`
11. REMARKS:
DEC 0 7 NUQE
JAN U . 2037
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(j.Q.c LLeLQ
SIGNATURE OF ERTIFIED WELL CONT CTOR
c'tRA€ to S
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.
Foim GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION REco: D
North Carolina D..natnrent of Environment and Natural Resources- Division of K'a:er Quality
WELL CONTRACTOR CERTIFICATION #- 3%3L
1. WEEU- CONTRACTOR: ^— - 1 �pc
�Y LI\�C A �4A''� eie\s
Wel Contactor (Individual) Name
Q\1JJct'Q ' S4a..1i E-es * `.�Or1.
Well Coidracta Canpany Narhe
STREET ADDRESS \y%8 S \\L.Jy ao9
1-ko4 wc;nQ NC s-v-i3
City or Twin eee -Zip Code
(8'..%)- (p(OS- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ad( applicable)
STATE WELL PERMITegrappecable)
DWQ or OTHER PERMIT R(H apprxabie)
WELL USE (Check
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
Apialicable Box): Residential Water Supply
5/10‘)AMD PMQ../
CITY: /^c d(
0
COUNTY /✓LCLIr/�iGYf
�gyy�{ CNarbma, Camtnumay, 5� Ica, Lot No.. Parcel. Zb Code)
T POGRAPHIC / LAND SETTING:
Q Iope °Valley ❑Flat ❑Ridge 0O9mr
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minims, seconds or
in a decimal font
Latitude/longitude source: DGPS °Topographic map
(bcation of weirrrustbe shown on a USGS fopo map and
attached to form inct uskg GPS)
4 j WELL OWNER
OWNER'S NAME 4 0
STREET ESS
6 IC46-
City or T State
ga;'- c279— i 6V'/
Area code - Phone number
IY ,5-6/
Zip Code
S. WELL DETAILS: a / �S
TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
e- WATER LEVEL Bebe Teo of Casing: f FT.
e'+
(Us' 0Above Top of Casing)
V
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 wdh 15A NCAC 2C .0118.
e. YIELD(gpm): /o METHOD OF TEST R•'S
t. DISINFECTION: Type4 . % t$
g. WATER ZONES (depth):
From To
From To
From To
From
From
From
Amount T
To
To
To
6. CASING: Thickness/
from__Yeto Fl. := .-.+,
From To FI.
From To R.
7. GROUT:Depth Mate-ice
From s a'� _Togo Fl. CP/Y(o!f{'.
From To FI.
From To P.
e. SCREEN: Depth Dianeter Slot Ste Material
From To Ft m. in.
From To Fl. in.. n.
From To FI. in. _ in.
9. SANDIGRAVEL PACK:
Depth Size
From To FL
From To FL
From To f t
10. DRIWNG LOG
From To Formation Desaiption
L
ife A.reesi
3i /45 4,324,1.9
11. REMARKS:
1 DO HEREBY CERTIFY TW.T INS WEL L It 'AS CONSRtt01ED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSrRUCTVN:TP NOARD3. AFT TAT COPY OF The
RECORD HAS BEEN PROVIDED TOTNI¢ w °COMER.
,.� y1720.4.
S c ' ' TU- E OF CERTIFIED N t [(TRACTOR DATE
1702 . CA' INeo h Swans
PRINTED NAME OF PERSON ..ONSTRUCTING 'TIDE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information M3t.,
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/OS

RESIDENTIAL WELL CONSTRUCTION RECO:2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ails 36
1. WEU. CONTRACTOR:
Wen Contractor (Individual) Name
Wen
Company Nadre
STREET ADDRESS
rick• c;•4 - a8l 13
ppMCity or Town
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID M(iit applicable)
STATE WELL PERMIT/Re applicable)
DWQ or OTHER PERMIT Eti applicable)
WELL USE (Cheat Applicable Boar Residential Water Supply V"
DATE DRILLED T_�--- ,
TIME COMPLETED_ c
3. WELL LOCATION:
CITY: � count -e!
{Beset Name. N . Community. Subtle/Mon, Lot No.. Fermi, Zip Code)
TOPOGRAPHIC! LAND SETTING:
[YLaiope Qvsley ❑Flat ❑Ridge DOther---�—
(check atWiopdate box)
LATITUDE
LONGITUD€, _
Latitude/longitude source: °GFS °Topographic map
(location of well must be shown on a USGS topo map and
attached tothfs form fret using GPS)
e. WELL OWNER
OWNER'S NAME
STREET ADDRESS
A
Zip Code
AM O PM
May be in degrees,
minute, seconds or
in a decimal format
uJec-vase a
City or Town State LP Cock
(Q ;t9 rya-orii
Area code - Phone number
B. WELL DETAILS:d
a. TOTAL DEPTH: _ -
b. DOES WELL REPLACE EXISTING WELL? YES 0
Use'4-LEVEL FT.
c.WATER(dAore Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
.Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST 31—
NOV
g•
.335292
f. DISINFECTION: Type 4i\1S Amount /s
WATER ZONES (depth):
From To From To
From To From To
From To _ From To
6. CASING:
iarVer
FraL nSt D Ft._10 TA
From To R.
From To Fl.-
T. GROUT:Depth Material
From,�i�C�To_a- —Fi. Ceskra 1{".
From To Fl.
From To FI.
Thickness/
W.�flat+e41
8. SCREEN:
From
From
From
Depth
To
To
To Ft.
9. SAND/GRAYEL PACK:
Depth
From T°_ From To
From T°
E t.
FL_
It
Dianeter Slot Size
Fl. in.
P. _n.
Size
Material
"at
T.
Material CD
n
O_
10. DRILLING LOG D cm
From To Formation
%l)rjr 6
11. REMARKS:
1 ITV
Li
1 DO HEREBY CERTIFY THAT THIS WELL WAS COtsn'UCtvD NACCORDANCE writ
15A NCAC 2C, WELL CONSTRUCTION TTANDAREC. AND THAT COPY OF lib
RECORD HAS BEEN PR0'VED TO THI: %ELL OWNER.
Sa NATURE OF CE
CC etc it�L1t0.4'vy 431.J'vecX
PRINTED NAME OF PERSON CONSTRUCT tT _ G WELL
Submit the original to the Division of Water Quaiity within 30 days. Attn: information Mat,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] eXt 568.
NTRACTOR DATE
Form GW-la
Rev.1105

RESIDENTIAL WELL CONSTRUCTION RECO:3D
North Carolina Department of Environment and Natural Resourccr Division of VI'a:er Qua) ty
WELL CONTRACTOR CERTIFICATION # V 3�
1. WELL CONTRACTOR:
Os- Mrs -kV \
Ste' ieC
Well Contractor (Individual) Name
WellCddracta N�
W
Company
STREET ADDRESS 111yWS . ettN1 Q0q
4io�k Scsr:ncS) NC = -Cnuk3
City or Torn a -Zip Code
(8 )- ca(0s- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mff applicable)
STATE WELL PERMITS(! applicable)
DWQ or OTHER PERMIT SOT le)
WELL USE (Check Applicable Box): Residential Water Supply V ry
DATE DRILLED / /9 -6
TIME COMPLETED tali 0 AMID PM '
3. WELL LOCATION: •- /' �/'
CITY: n-//Yr3PG l/ COUNTY
,E4S/� A.)% 11
.(Sbeet Name Numbers. Canmunay. Subdivision, Lot No.. Parcel, ZIP Cope)
T9POGRAPHIC / LAND SETTING:
gSbpe °Vailey Fart ❑Ridge ❑Other
(cheek appnwriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, swords or
in a decimal format
Latitude/longitude source: O GPS OTopographic map
(boaypn of wet must be shown on a USGS topo map and
attached Wires form Trot ushg GPS)
0. WELL OWNER (\ 1
OWNER'S NAME fl(3 t 4 -
ADDRTS P
l:�✓1
S
n
City or Town STaze
(95ae). ate- iga4
Area code - Phan number
{a�
Zip Code
S. WELL DETAILS: g.
a. TOTAL DEPTH-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
c. WATER LEVEL Below Tcp of Casing: for)d FT.
(Use •+'ifAbove Top ofCasing)
d. TOP OF CASING IS i FT. Above Land Surface'
?op of casing tmrended at/or below land surface may require
a variance in accordance With ISA NCAC 2C .0118.
e. YIELD (gpm): ice) METHOD OF TEST (C' s� .,I
335293
f. DISINFECTION: Typed l lS Amount 9
g. WATER ZONES (depth):
From To From To
Fran To Fran To
From To From To
6. CASING: Thickness/
�y Dbam W,ei
F40
From -}'�Do0:335 Fl. tO'ia_ '1
From To FI.
From To R.
7. GROUT: Depth
Depth .l Material
From 0 To 0`20 Fl. &01' art
From To fl.
From To Ft.
e. SCREEN: Depth Da notes Sat Size Materiel
From To fl. in. in.
From To P. Ir. . in.
From To Ft. _rc. in.
9. SANDIGRAVEL PACK:
Depth
From To FL,
From To Ft.
From To Ft.
10. DRIWNG LOG
F/tom T ation
T. gam, �'� FormA
G-rb•t}e_
Size Material
11. REMARKS:
DO HEREBY CERTIFY THAT NOS WELLY'AS CONSTRUCTED N ACCORDANCE WIN
15A NCAC 2C, WELL CONSTRUCTION t rTANDARDS. AtSTIMT A COPY OF THIS
RECORD N PROVIDED TO THE W ELLS TER.
C
SIGNATURE OF CERTI' ED',TRACTOR DATE
�
—ne. C►t. }CEO. y 1? T.J'T2e3
PRINTED NAME OF PERSON CONSTRUCTING THE WE
1 Ubmit the 177 Mail Servicegi CCenter-r - Raleigh, NC 27699 16 Qualityivision of Water PhoneonNo. (9 9) 733-74 ext 68 information Mat
Form GW-la
Rev. 7/05

1.'WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti
Well ontractor CompanyL Name
STREET ADDRESS �Ff^may
i� /�% (1 to •
City or Town State
Zip Code
Area
code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)
—�--
DWQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Box): Residential W
DATE DRILLED %—
TIME COMPLETED
AM PM
3. WELL LOCATION:
CITY:
COUNTY
(Street Name, Numbers, Community, Subdivision, Lot No., parcel, Zi
TOPOGRAPHIC / LAND SETTING: p Code)
❑Slope 0 Valley ❑Fat L0RidTI�ge ❑Other
(check appropriate box)
LATITUDE 3 S
LONGITUDE J Z
Latitude/longitude source: ErGt'S 0Topographic map
(bcatbn 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 7r a Jp r�/•i
S R ET ADDRESS
City or Town State
Area code - Phone number —�
5. WELL DETAILS:
a. TOTAL DEPTH:
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ey
c. WATER LEVEL Below Top of Casing: /C'a
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Lan
d
. `Top of casing terminated al/or bet and surface may Surface*
a variance in accordance with 15A NCAC 2C .0118. equine
e. YIELD (gpm): Ve) METHOD OF TEST 1 r
- I
Submit the original to the Division of Water Quality within
1617 Mail Service Center-
0
Attn:
Raleigh, NC 27699-1617 Phone No. 919) 733 7015 Information Mgt.,
( ) 7g15 ext 568.
• 3 3 5 1 8 4
f, DISINFECTION: Type�
Amount
9. WATER ZONES (depth):
From "IV To
From T 70 To To
From J"D 7 To
ToTo
6. CASING:
From To Ft.
From
From Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
7G
11. REMARKS:
From
From
From
Diameter
Ft.in.
Ft in.
Ft in.
, J2[Metethod
Slot Size Material
in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
WRH RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR //L TE
DATE
•
A y
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev. 7/05

e. YIELD (gpm): (+ _ METHOD OF TEST
City 0rTown t
State Zip Code
Residential Water Supply p/
1. WELL CONTRACTOR:
II Contractor
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
ndrvldual) Name
r ,
Welllontractor Company e
STREET ADDRESS 3 col
Area code- Phone number
er
2. WELL INFORMATION:
SITE WELL ID *(if applicable)
STATE WELL PERMIT#(if applicable)_
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box):
DATE DRILLED /O=7(✓
TIME COMPLETED JJ.CO
----�_ AM IJ PM p
3. WELL LOCATION:
CITY: /! -.r 4COUNTY .".: 4 ,
(St et Name. Numbers, Community,
muniw, Subdivision, Lot No., Parcel, Zip Cope TOPOG )
RAPHIC / LAND SETTI�NNG:
❑Slope °Valley ❑Flat QiFidge °Other
(check appropriate box)
LATITUDE 3 F ,f- i.i/Z + May be in deg.
d( LONGITUDE minutes,seconi
z_ r :�_ �n a duimal foi
Latitude/longitude source: L3 PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNERS NAME
STP ET ADDRESS
City or Town State
Lai)- !nvg_ y87!
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 64
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c. WATER LEVEL Below Top of Casing:
(Use "+• it Above Top of Casing) �FT.
d. TOP OF CASING 1S _I__
FT. AbLd Surfaces
"Top of casing terminated auor below and surrfface may require
a variance in accordance with 15A NCAC 2C .0118.
t
Submit the original to the Division of Water Quality within
1617 Mail Service Center -
30 days. Attn:
Raleigh, NC 27699-1617 Phone No. (919)733_7 15 ext 568.
Information Mgt.,
f. DISINFECTION: Type C` 4,•• ".t
g. WATER ZONES (depth).
��'
From To
From fig) To
From To
6. CASING:
Depth
Fran- To -ifFrom To
From To
7. GROUT: Depth
Fro- To
Fromm To
From To
8. SCREEN: Depth
From To
From To_
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
11. REMARKS:
From
From
From
Diameter
. Ft./lam
Ft.
Ft.
335172
Amount 2..
To
To
To
Weight
Diameter Slot S
Ft in.
Ft. in.
in.
Material
Method
plaziesti
Material
in.
in.
in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-Ca. lrr ,
SIGNATURE OF CERTIFIED WELL CONTRACTOR /L I3-Ji
A DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev. 7/05
0

STATE
1. WELL CONTRACTOR:
Weill ontractor Company
STREET ADDRESS
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water
WELL CONTRACTOR WELL
CERTIFICATION k /
City or Town State -1 A
Zip Code
Area
Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply Cr'
DATE DRILLED //% • _ �i
TIME COMPLETED /I `Jp
AM PM
3. WELL LOCATION:
CITY: j'7L, ./v
COUNTY /"f_pl__
(Street Name, Numbers, Community, SubdiNsion, Lot No.,parcel, Zip Code
TOPOGRAPHIC / LAND SETTING: )
CTSlope OValley ❑Flat ORidge ❑Other
(check appropriate box) —�
LATITUDE �-
3 r, 4244, May be in degrees,
LONGITUDE t Z minutes, second al
9 � •'^a decimal formal
Latitude/longitude source: g6pS OTopographic map
(bcatbn of well must be shown on a USGS topo map and
attached to this form it. not using GPS)
4, WELL OWNER
OWNER'S NAME
SIRE T ADDRESS
City or Town
tState
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO D
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS
'Top of casing terminated aUor �n land surf Land y Surface'
a variance in accordance with below
surface may require
NCAC 2C .0118.
e. YIELD (gpm): __
METHOD OF TEST '
1 F a
9
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.
e.
351'7r,
f. DISINFECTION: Type ('/c.-...i
�_ Amount ! yi.,
9. WATER ZONES (depth):
From!% To
From .<< To From To
From To
To
ro
7a From
To
Thickness/
Weight Material
/ vvr.
6. CASING:
Depth
From_ To r.)
From To
From To
Ft.
7. GROUT: Depth
Material
F ���` ToQ Ft. Concrete.
FTo
From To Ft.
8. SCREEN: Depth
From To
From To
From T
o
9. SAND/GRAVEL PACK:
Depth
Size
From
To
From To
From To
10. DRILLING LOG
From To
11. REMARKS:
Diameter
Ft._Ze IL_
Ft.
Material
Method
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED,T�OyTH„E WELL OWNER.
SIGNATURElb
OF ERTIFIED WELL CONTRACTOR/v 2d co
A * — DATE
a . 4
MUTED NAME OF PERSON CONSTRUCTING THE WELL
Fong GW-1a
Rev. 7/05

FT.
d. TOP OF CASING IS
*Top of casing terminated at/or �n land surfacef Lam Surfacer
a variance in accordance with 15AoNC 2C01may require
NCAC 2C .Ot18.
e. YIELD (gpm):
METHOD OF TEST '•
• ��
1. WELL CONTRACTOR:
RESIDENTIAL WE
North Carolina Department WELL CONSTRUCTION RECORD
P ment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
•vaus{ontraclor Company
me
STREET ADDRESS
City of Town State
(Area "_"`- Phone number �9 a
2. WELL INFORMATION:
SITE WELL ID kit applicable)_
STATE WELL PERMIT# ira
( PPlicable)��
DWQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Box): Residential WaterSupply DATE DRILLED S - / O ='
TIME COMPLETED -7 OJ
3. WELL LOCATION: AM El PM�
CITY: 5 1-Z/lpeer
COUNTY a1-_.
Lime. et
(Street Name, Numbers, Community, Subdivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LAND
SlopeSETTING:
0Valley ID Flat Qfhdge ❑Other
(check appropriate box) -�
LATITUDE 3 --L f C st.&
LONGITUDE
Latitude/longitude source: et6pS ❑T
4, WELL OWNER
Zip Cale
May he in degrees,
minutes, seconds or
in a decimal format
(location of we// must be shown on a Topographic map
attached to this torn if not using GPS� GS topo map and
OWNER'S NAME 1
STREET ADDRESS
City a Town
Area code c(��¢.���)- ate
/� �/ `
Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use'+• if AbWe Top of Casing)
f. DISINFECTION: Type c/may,
g. WATER ZONES (depth): Amount
From To
From To To
From To To
6. CASING:
From
From
From
Depth
To 7i
To
To
From
From
From
Diameter
Ft. G.rc'r-
Ft.
Ft.
7. GROUT: Depth
From% _ To_Q Ft.
From To
From FL
To Ft
8. SCREEN: Depth
From To
From To
From T
S. SAND/GRAVEL PACK:
Depth
From To
From Ft,
To Ft.
From To
Ft.
10. DRILLING LOG
From To
.`— Formation Description
[aG2j �_ _C'/t
/- ZLy� .5.../Sfmz
To
Thickness/
Weight
att•-•
11. REMARKS:
Material
Cone ret
Material
Method
Diameter Slot Size Material
Ft in.
in.
Ft. in.
in.
Ft. in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTJN STANDARDS, A ACCORDANCE
RECORD HAS BEEN PROVIDED TO THE END THATA COPY OF MIS
WrIl1
WELL OWNER.
SIGNATURE OF ERTIFIED IF 5
WELL CONTRACTOR
t. .
HINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water
Sub it t Service Center— Raleigh, NC 27698-
Qualy whio 30 days. 7Attn:ois information Mgt,
16171617 Phone No. [phone] ext 568.
DATE
Form GW-1a
Rev. 7/05

STA)?
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Na
tural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ((,�
Well onlractor Company�Nd
Name
STREET ADDRESS 3
City or Town t
State
Area coda-
Pho
ne number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITS/Orappllcable)
DWQ or OTHER PERMIT #(it applicable)
WELLUSE (Check Applicable Boxy Residential Water Supply p/ DATE DRILLED %' • e
TIME COMPLETED %.•-7e
3. WELL LOCATION:
CITY: ,( Jl
COUNTY jdy
(Street Name, Numbers, Community, c�!"^ L• Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND S.E�TTING:
❑Slope 0 Valley 0 Flat 17KIdge 0 Other
(check appropriate box) —�
LATITUDE 3 S` n .0 ree May lx in degrees,
LONGITUDE r Z </ minutes, seconds or
._� d"/ � in a decimal format
Latitude/longitude source: ptrpS
❑
(Iocat/on of well must be shown on a UGS topo map
ndp
attached to this form if not using GPS) map and
4. WELL OWNER
OWNER'S NAME Pell
ST TADDRESS
Zip Code
City or Town
State
number
Area code - Phone numbe
5. WELL DETAILS:
a. TOTAL DEPTH:_ (/_ /f
b. DOES WELL REPLACE EXISTING WELL? YES
c. WATER LEVEL Below Top of Casing: Go
(Use "+" if Above Top of Casing)
Zip Code
NO Dj
FT.
d. TOP OF CASING IS
'Top of casing terminated at/or FT. Above Land may Surface*
a variance in accordance with 115q land 2Csur.0118.require
NCAC 2C .0118,
e. YIELD (gpm):
METHOD OF TEST 1 ; +'
Submit the original to the Division f W
1617 M
From
From
6. CASING:
Depth
From — To SZ
From To
From To
Ft.
7. GROUT: Depth
From,.�0 Material
To — Ft. CO/)C J4 `r
To
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9, SAND/GRAVEL PACK:
Depth
From To
From To
Fran To
335131
f. DISINFECTION: Type /
g• WATER ZONES (depth): AmountyL
From /Go To
Sec From To
To From
To To
From To
Thickness/
WeightJ. Material
tee,
11. REMARKS:
Diameter
Ft
Ft
Ft.
Ft.
Ft.
Material
'j���j,EMeetthod
Size Material
1 Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
*-1J
SIGNATURE O TIFI DD WE CONTRACTOR�ZA p
- A i
R DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
aft Service Center — ° ater Quality within 30 days. Raleigh, NC 27699-1617 Phone No. [phone] Information Mgt.,
7015 ext568,
Fonn GW-1a
Rev. 7/05

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and Natural Resources- Divionn o CORD
Water
WELL CONTRACTOR CERTIFIC ATIONpWELL
�/��
vven�ontraclor company
e
STREET ADDRESS
City or Town State
K f� Zip Code
Are Phone number
2. WELL INFORMATION:
SITE WELL ID #(inapplicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply GI/
DATE DRILLED S- /- 94.
TIME COMPLETED,..)r7 /
AM C3' PM
3. WELL LOCATION:
CITY: c {
COUNTY f0� _-_
(Street Name, Numbers, Community,
Su division, Lot No, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
mope O Valley 0 Flat 0 Ridge ❑ Other
(check appropriate box)
LATITUDE 3 5--.3--e
OVj • May be in degrees,
LONGITUDE -P. Z. yS� — _ minutes, seconds or
Sre2 in a decimal format
Latitude/longitude source: LirdPS
(location of well must be shown on a ❑USGS topo
Topographic anddp
attached to this form if not using G p topo reap
4. WELL OWNER �--
OWNER'S NAME
I$>a5')- lo�lq f'87� Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: ifle
FT.
d. TOP OF CASING IS
*Top of casing terminated aUor Fla Above Land may require
a variance in accordance with 151q land 2Csur.0118.require
NCAC 2C .0118.
e. YIELD (gpm): r
---_� METHOD OF TEST I '
(Use "+• if Above Top of Casing)
f• DISINFECTION: Type
Amount
9• WATER ZONES (depth):
From 4-7C0 To
From_ o� From To
From From To
To From
6. CASING: To
From
From
From
Diameter
Ft. [...dz.,-
Ft.
Ft.
7. GROUT: Depth
Frraon� To�Q Ft.
To Ft.
From To
Ft._
8. SCREEN: Depth Diameter Slot Size
From To Ft Material
From To Ft. in. in.
From To Ft in. in.
.�_in. in.
8. SAND/GRAVEL PACK:
Depth
From To Size Material
From Ft.
To Ft. �------
From To
10. DRILLING LOG
From To
o_ .7y Formation Description
?Yvj C` <
VJ—fc.%
11. REMARKS:
Material
Cone reic
yam''[",Mee "thod
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS
ISA NCAC 2C, WELL CONSTRUCTIONANTHAT
A ACCORDANCE
RECORD HAS BEEN PROVIDED TE WELL OW AND 1HATq COPY OF gE WITH
WELL OWNER
•
SIGNATURE OF R IFIED WELL CONTRACTOR
�' OG
� > ' DATE
Aft
lor
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt",
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. g19
Y
( ) 733 7015 ext 568.
rrt
n
t—s
0
0
rn
3H
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nart�urralpResou ces - Division of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print
\/�/'tVJ..t� IVE,Ils CERTIFICATIO/NSt(g413�
WELL CONTRACTOR COMPANY NAME 4 "t (J SSLY Vtj J „ PHONE # (gA )p^3^Qta
STATE WELL CONSTRUCTION PERMITS' ASSOCIATED WQ PERMIT#
(ifappiicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential & Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT{ON:
Nearest Town: ,YVI` Pig5\g1,
County INVO 56N
(Street Name, Numbers, Commun. , Subdivision, Lot No.. Zip Code)
3. OWNER:DP(Vtb . st•1� Z .
Address S q HGPD
ACZ
(Streg[ prete No.)
City or Town State Zip Code
Topogra Ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitu a of ell location
33 'ES 9'f ltOz `f'.r2510�1
(degrees/minutes/seconds) CIE✓. W (0€
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number
4. DATE DRILLED 1 L I arA I3(p
5. TOTAL DEPTH:' y. -
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO YY
7. STATIC WATER LEVEL Below Top of Casing: /h 0 FT.
(use "+' if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. r, /-� ��� �
9. YIELD (gpm): c32. METH D TEST\T7i(,\JOl�I AURA
'l
10. WATER ZONES (depth): Cg , 19-0
1I. DISINFECTION: Type li 5%61 (1± Amount 2_
12. CASING: Wall Thickness
FromDepth Diameter Diameter or Weight/Ft. Material
To iD(' 4Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To r-3 F
From To 1 -' F
14. SCREEN: Depth Diameter Slot Size
From To Ft. in, in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
Material Method
Q�-fL
From
From
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.
Ut f. 2 /Drib
I DO HEREBY CERTIFY T- AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STAND DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ciZ
SIGNATURE OF PERSON CONSTRUCTING THE WELL IATE
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
CZ
G�'J
teD

STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ pERhtlTit
(if applicable)
(ifapplicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME/J(print /`/lee cos g
WELL. CONTRACTOR COMPANY NAME // I(V/ (� vtrn ,[,%��((% CERTIFICATION t. GOOL
PHONE
la r
a3.9o2Z?a,
1. WELL USE (Check Applicable Box): Residential L2Y MunicipaUPublic 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest Town:
County) £16��
(Street Name,
Numbers Community, Subdivision, Lot No., Zip Code)
3. OWNER: Nip
Address r ((nQ`-O
($trees or Rour.)
City or Town I/!/ State Zip Cod
( )-
Topogra Ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
�•t.kJc5, oc%,of
(degrees/minuteeconds)CV 2
5
(/l71
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number
4. DATE DRILLED /i/21/6(p
5. TOTAL DEPTH: (j
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO CY
7. STATIC WATER LEVEL Below Top of Casing: [Q 0 FT.
8. TOP OF CASING IS / (Use-`+^ if Above Top of Casing)
FT. Above Land Surface*
*Top of casing terminated at/or below laud surface requires a
variance in accordag95ge vith ISA NCAC 2C.0118. /� /� - v
9. YIELD(gOm)E (db METFLODyF,7' l7A/OGO1c'Q1Q�
10, WATER ZONES (depth): }f Q C�
1 I. DISINFECTION: Typ6Q,itje Amount
12. CASING: Wall Thickness
FromDepth Diameter or Weight/Ft. Material
To T Ft.
From To Ft.
From To Ft.
13. GROUT: Dept .7
From - TO
From F
To
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:
Material
Slot Size
in.
in.
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.
pr rg ? ?DOE;
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDAZ(DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL 1 021/0CP
DAT
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
m
m
ov
c:.,

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME NA(priinyt)) L y �{'✓d��,�t
WELL CONTRACTOR COROCIA
:NIPANI' ME W ,tJ CERTIFICATION # •tro
Y- cud' PHONE # {Kslg)GS3.4.1att
STATE WELL CONSTRUCTION PERMITS(
(ifapphcable) ASSOCIATED WQ PERMIT#
(if apphcable)
1. WELL USE (Check Applicable Box): Residential G1- unicipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring LI Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: { w ('el.`CountylD 1 Ol4
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accords a wt I5A NCAC 2C .01I8. II
9. YIELD (gpm): METHOD O TEST�1�'l. C'OLIt,'I.Eg,
10. WATER ZONES (depth): I4iC71a,(�
11. DISINFECTION: Type IF}61Qji-' Amount 9--
Topogr4hic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code) (check appropnate box)
Latitude/longitude of well location
3. OWNER: • t lCL{ (�� iJ3 i�/IO es/ w�i %Ciq
Address : t f ui (degrees/minutes/seconds)
PgraP (Bract or Rome No.) Latilude/longitude source:❑GPS❑Topographic map
���% DEPTH (check box)
UtyorTown State Zip Code DRILLING LOG
- From To Formation Description
Area code- Phone numbs
4. DATE DRILLED `d
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L7
7. STATIC WATER LEVEL Below Top of Casing: IOO FT.
(Use'4" if Above Top of Casing)
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To /GQ Ft
From
From
13. GROUT:
From
From
14. SCREEN:
Froth
From To Ft.
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Ft.
Ft.
Ft.
To Ft.
To
Depth
To 3 Ft.'
To_ _La_ Ft.I
Depth Diameter
To Ftin.
in.
Size
Slot Size
in.
in.
Material
Material
LOCATIONSKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL 'AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL.
Let
G'�2
cc
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

North Carolina . Depanment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT*:
1. WELL USE (Check Applicable sea): Residentiairae Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection 0 Other CI If Other, List Use:
2. WELL LOCATION• (Show sketcpt of the location below)
Nearest Town:
(Road Name and Numbers,
3. OWNER
Address
Q9' or TStale
u_,,
To
__L_._ Depth
To
FOR OFFICE USE ONLY
Quad No:
Seriat No.
From
From
17. REMARKS:
From To Ft
From
14. GROUT:
From
From
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
Ft.
Ft.
Ft.
4. DATE DRILLED
5. TOTAL DEPTH8.
7. DCUTTINGS COLLECTED YES OS O WELL REPLACE EXISTING WELL?S NO6
6. STATIC WATER LEVEL Below Top of Casing: FT.
� ( "+• a Above Top of Casing)
9. TOP OF CASING IS
d Surface"
`Top of easing terminated at/or below land surface req ir. Above ps a variance In actor -
dames with ISA *CAC 2C A
la
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
County:—i=)LLiCIALI,
he, or Subdivision and tot No.)
Amount
Dept Diameter Wad TNeknass
D To t - a eight/Ft. Material
Zip Code
From Ft l 0 110, t
Material Method
Ft. a __
Ft.
Diameter Slot Size Material
Ft in. in.
in. In.
In. in
Size Material
FL
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 BEEN PROVIDED TO THE WELL OWNER.
A A_
..e ,ram /p-26-04
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of water Quality, Groundwater section within 30 days DATE
DRILLING LOG
From To
Agricultural 0 Monitoring ❑
It additional space is needed use back of form
DCATIDN SKET( H
(Show direction and distance from at least two State
Roads, or other map reference points)
344 Ca`
Cran
UIV, OFRW. ATER QOUAUTW
.IAN 0 6 20U/
wet-ks+ (-iroA t; Qfid .
oi,u patx- / Ear l-lait/1I f C
lel-d3N
GW.1 REV. 12/99

CAD
G72
orti
h Carolna • Environment 1636ort Mar Department of Enronment and Natural Resources - Division of Water Quality - Groundwater Section �'
N
rvice Center - Raleigh, N.C. 27699.1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR• Cie
^2
WELL CONTRACTOR CERTIFICATION 0: 010,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Ape:Ica a Box): Residential Municipal ❑ Industrial 0 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection
❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town' IV\O_n km(L t County.
"(Road Name end Nu era. Community. or SubtSvision and tot No.)
3. OWNER nnirla.then I11'YY-Yo I rr .
Address Cr
tn
INACIrEril
(tSffset Of ct(eN
City or Tovm Sty Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOCO-
7. DOES WELL REPLACE EXISTING WELL? YES NOta
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use9 Above Top of Casing)
FT Above Land Surface'
Top of casing terminated at/or below land surface require tverlanee in accor-
d
ance with 15A NCAC 2C .51.1111
10. YIELD (gpm)• METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13, CASING:
Depth
From _._L`To 1Ic%
From To
From To.___
14. GROUT:
Amount
Wall Thickness
Ft Diameter or Weight/FLM en
ON
Ft
Ft.
Depth Material Method
From I To .nn Ft. Oarnertt,
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
From To
From To
17. REMARKS:
Size Material
Ft.
Ft
It addWonaf space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at east two State
Roads, or Other map reference points)
RECEIVED
S\t ` t DIV. OF WATER QUALITY
irkil(\` Pc UST
JAN U 5 200/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAA%BBE�E.�N PROVIDED TO THE WELL OWNER.
SIG RE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DJvislon or Water Duality, Groundwater Section within 30 days
GW-t REV. 12199
FOR OFFICE USE ONLY
Ouad No:
Serial No.
i

FOR OFFICE USE ONLY
Ouad No:
Serial No
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.163&phone [phone]
WELL CONSTRUCTION RECORD
1. WELL USE (Check Applicable Boa): Resident)ait2r
Recovery ❑ Heat Pump Water Injection Q
2. WELL LOCATI N. (Show sket h.of the location below)
Nearest Town: y�ry
County: t t I
(Road Na
3. OWNER
Address
City or Town Stale
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO
tir
7. DOES WELL REPLACE EXISTING WELL? YES NOV
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I+-- (Use ��� ifAbove Top of Casing)
AboveFT.
'Top of casing terminated aUer below land surface requires a valance in accor-
dance with 1SA .CAC 2C 011a
10. YIELD (gpm): . METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
From
From.
From
14. GROUT:
From
From
Dept T
-To � Ft.
To Ft.
To Ft.
—�-_ To pd1i Ft.
To Ft.
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From To
From To_
17. REMARKS:
Ft
Ft.
FL
er
Wall Thickness
or Weight/FL M_ atetial..
a(sa Method
Diameter
in.
in.
in.
Ft.
Ft
Slot Size Material
in.
In.
In
Size Material
WELL CONTRACTOR: CI OOJ'lA nIXX
WELL CONTRACTOR CERTIFICATION ft: a113
STATE WELL CONSTRUCTION PERMIT.:
Municipal ❑ Industrial 0 Agricultural ❑
Other ED If Other, List Use:
Monitoring 0
771
t`a
N additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at oast two State
Roads, or other map reference points)
teeiCti
DIV OF WATER RECEIVED
AN 00 5 NU?
LAPP
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Oft THIS RECORD HAS LfEN PROVIDED TO THE WELL OWNER.
AJ
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Oually, Groundwater Section within 30 days
GW-1 REV. 12199

CTd
Cat
OD
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION le: <-9 j )
STATE WELL CONSTRUCTION PERMITS:
North Carolina • Department 01 Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
1. WELL USE (Check
Recovery ID
2. WELL LOCATIQt•
Nearest Town:
Applicable Sox): Residential Municipal ❑ Industrial 0 Agricultural 0 Monitoring ❑
Heat Pump Water Injection [J Other (I If Other, List Use:
w sketch of the location below)
County: IV C/r I SOO
(Road Name and Numbers. Conmuni or ubdNsion and Lot F No.) DRILLING LOG
�3. OWNER
Address , ; i Frgm To
City or own st
4. DATE DRILLED Li)
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOp'
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[02
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS- FT. A 9eAbove Top of facmp)
FT. Above Land Surface'
'Top of Using terminated at/or be ow land surface requires a variance in accor-
dance with 15A NCAC 2C at
10. YIELD (gpm): (le
p METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth S' 1
From --_,To Ft
From To Ft.
From To Ft.
14. GROUT:
Depthe n /1 f rl�
From To A I FA QN Y WN'�--T
From To Ft
15. SCREEN:
Amount
Method
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:
-
(c
(Sag - �u
Wa0-10.i
DEPTH
Formation De bon
d-aif
It additional space is needed use back of form
LOCATION SKETCF lV A RECEIVEDAAQUALITY
(Show direction and distance from at least two wet.
Roads, or other map reference points) JAN o s 2Q(]7
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI ECORD HAS BEEN ROVIDED T THE WELL OWNER.
FOR OFFICE USE ONLY �� 1/— 7 —06
Quad Na SIGNATURE PERSON CONSTRUCTING THE WELL GATE
Serial No. Scat mil Original to Div4ton of Water Ouanty, Groundwater Sateen within 30 days
GW-1 REV. 1299

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center -
Raleig
h, , N.C. 27699.163&phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CAPIX.f lA.".Q.r
WELL CONTRACTOR CERTIFICATION a: a(I3
STATE WELL CONSTRUCTION PERMIT*:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial 0 Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection
1 0 Other Ej If Other, List Use:
2. WELL LOCATION Show sketch of the location below)
i rsv u
County:
Nearest Town:
(Road Name and Numbers. Comnunf or Subdivision and Lot No.) DRILLING LOG
®3. OWNER c%nhof rc& L-1ISlA7(7fr
Address From To
\Ain'e rtli � StrNtor��. a. as<ls-7
4. DATE GRILLED I F$tU'
5. TOTAL DEPTH ?175
6. CUTTINGS COLLECTED YES NO[n/
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO/
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING tS. I (Use �� a Above Top of Casing)
ve Land Surface'
-Top of casing terminated aUor below land surface FT. Crequires a variance in accor-
d
ance with 1SA NCAC 2c .011a
10. YIELD (gpm)• \ t/a _ METHOD OF TEST
11. WATER ZONES (depth):
City or Town;
Zip Cade
•
12. CHLORINATION: Type
13. CASING:
Amount
l Dept G w
Diameter or e Thickness
From _To t1 Ft 1 Q
From To Ft
From To Ft.
14. GROUT:
Depth
From To Ca Ft
From To Ft
15. SCREEN:
DO
I 0 CC-'j0f
DEPTH
esojptlon
It additional space is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at teas( two State
Roads, or other map reference points)
Material ) Method
Oepth 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:
kit �' DIIV.. OF RECEIVE
Cif
00
r+
JAN (1 F, 200/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
i
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
`J-I- to •
DATE
GW-1 REV. 12,99

ea
ten
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C)fft IJUCAI' 00
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT.:
1. WELL USE (cheek Er
Applicable Box): Residential pp Municipal
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]
RecOVefy El Heat Pump Water Injection
❑ Other
© )f
2. WELL LOCATII[)N: Show sketch of the location below)
Nearest Town:1!- nr�l
Court':
;"(Road Na
3. OWNER
Address
and
4
Moen, CommuNty. or Su
se or •.re`o.
City or Town State
Zip 4. DATE DRILLED Coda
5. TOTAL DEPTH - J
6. CUTTINGS COLLECTED YES NO
7. DOES WELL REPLACE EXISTING WELLS YES NO1E:1
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use••• 11 Above Top of Casing)
FT. Above Land Surface'
'Top or casing termjnatad at/or below land surface requires variance In accor-
dance with 15A .CAC SC .011e
10. YIELD (gpm): SD METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
• and tot No.)
'ln,.
11 Depth
From To
From To
From ._ To
14. GROUT:
Depth
From To an
From To
15. SCREEN:
From
From
From
From
From
17. REMARKS:
Depth
To
To
To
16. SAND/GRAVEL PACK:
Depth
To
To__
Ft.
Ft.
Ft.
Industrial ❑ Agricultural ❑ Monitoring ❑
Other, List Use:
DRILLING LOG
From To
'4101- UIO�
41oa-U�5
H addNjonal space is needed use back of tom,
Diameter LOCATION SKETCH
I Qi or Material. (Show adectmapdistance from
encafeast two State
papal Kl Roads- r map reference points)
Material Method
Ft. e. Del.
Ft
Wall ThkWrss
Diameter Slot Size Material
Ft __ In. In.
in. ._ In.
In. in
Size Material
eL
crime
fri
REC I ie
DIV. OF WA . - F tlI 414
JAN 9 s 2007
Hum19a3N
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OE THIS RECORD HAS SEEN PPP�QVIDED TO THE WELL OWNER.
Ft.
Ft.
FOR OFFICE USE ONLY
Owed No:
Serial No.
Ft
Ft.
04
SIGNATURE OF PERSON CONS UCTNG THE WELL DATE
Submit original to Division of Water Duality, Groundwater Section within 30 days
GW-1 REV. 12/99

.RESIDENTIAL WELL CONSTRUCTION REco:w
North Carolina I1..ynrtlnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 0- of l ate
1. WELL CONTRACTOR .
1�. N2 YkQ�Th aa'�'^IE.fS
W eR Contractor (Individual) Name
Qa..ijC-CS
Wen Contractor Company Nahe
STREET ADDRESS \WEi5 Nstt; r1 aock
Ho4 5r;h ) NC a8'l*-13
k tOn
[T]]
���,ppCity or Town e� Zip Code
(Ba(6)- to(os— Oaaa
Area code- Phcne number
Z. WELL INFORMATIOIt
SITE WELL ID Ma applicable)
STATE WELL PERMfTN(dapplioNe)
DWQ or OTHER PERMrF 3(rtal)p,,,,eLti
WELL USE (Check AAperpII mbl Elm): Residential Water Supply VDATE DRILLED `/ /a ^ �Q
TIME COMPLETED t v a AM IJ PM p/
3. WELL LOCATION:
CRY:
/
COUNTY Ne �,llo!?'
Numbers. CamnuMy. Sufdivisipn, Lot No.. Parcel, Znp Code)' -
TO RAPHIC / LAND SETTING:
bPe OV/Rey ['Flat DRidge ❑Other
(check appmpdate boot)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Iatitude/)onlgitude solace: OGPS DTopographic map
(%cation W wenmustbe shown on a USGS typo map and
aRar.Jref Weds form lnot using GPS)
4. WELL OWNER
OWNER'S NAME 701-\ e1. Pc, Cc
STREET ADDRESS UN 3O C C )% Nit.,:
Mrschh,kt Ai( "y
City or Town ' State 2p Code
(13 Fir &al 44‘i
Area code- Phone number
5. WEILL DETAILS:
a. TOTAL DlPT-ti C
7V("\
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO1
c. WATER LEVEL Seim Teo of Casing CSC F r.
(Use'+' fAbove Top of Casing)
d. TOP OF CASING IS : FT. Above Land Surface'
Top of casing t!ernftrlated aWor bebw land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): pi7 METHOD OF TEST 1.4:0S
337522
t. DISINFECTION: Type.* t a _Amount /y
g. WATER ZONES (depth):
Flom To From To
From To From To
From To From To
6. CASING:
Thickness/
Depth D"grrr�t WagM2 1_ fry % i
From To Ft.
From To Fl.
7. GROUT: Depth Material MFArotl
From 0 To 00 R. (p/h oAtt pet. `
From To Fl.
Fran To P.
8. SCREEN: Depth Dia neter Stet Size Material
From To Fi. in in.
From To R. in. in.
Frorn To R. in. M.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft
From To Ft
10. DRILLING LOG
From To Formation
h0rr &'
/lK .2C
II. REMARKS:
(a.r
ANla(4.mot
100 HERESY t.tN ler-HAT THIS WELL V 'AS CA SWP.LCSm N ACCORDANCE WM
15A CAC 2C, WELL CONSTRUCTION .:TPNDAROS. AND TNATA COPY OF' NO
RECORD WAS BEEN PROVIDED TO TM- OWNER.
SIG RE OF C
1 CONTRACTORDATE
O eD.Et, 643.1A
PRINTED NAME OF PERSON :ONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information M3t.,
1617 Mail Service Center— Raleigh, NC 27599-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

337443
WELL CONSTRUCTION RECORD
North Carolina -Depart mentofEnvironmentandNaturalResources-DivisionofWaterQuality-GroundwaterSection
WELL. CONTRACTOR (U:DIVIDUAL) NAME lgeistl /%%ln dt° �- quern zcAnows 2 7 8 /
WELL CONTRACTOR COMPANY ' W i e w /i 4.-' / 9 ' n r rB A Owen h igzeSg0
STATE WELL CONsmucHoNfl* MIT# ASSOCIATED WQ PERMITS (if applicable) / Crf plieable)
1. WELL USE (Check Applicable Boa} Residential L MMmicipal/Public D ind sstria1 ❑ Agcicultutai ❑
Monitoring D Recovery D Heat Pump Water Injection D Other D If Other, List Use
2. WELL LOCATION:
Nearest Town: M,�/s1w11 County MJ1sc.^
(o5 C..w�Qa AILFr 3 Xi57.
SawaNmapN®Wa. Camay, Subdivision, Lot Na, Tip cox)
3. OWNER P000�o.\ Pk. �� yen
Address G, < la"pa Rita kJ,
(Stator Race No.)
Mc.f,L \ uVc �iS9Si.
Myth Town State hp Code
Ares emir Thine ember
4. DATE DRILLED �-13-1)
5. TOTAL DEPTH, A S
6. DOES WELL REPLACE EXISTING WELL? YESp NO tJe-
7. STATIC WATER LEVEL Below Top of Cesium IL FT.
/ (Use r ifAbas Top of Casing)
S. TOP OF CASING 1S / if FT. Above Land Surface*
'Teti orcadagtermbamd Mier below toad a wfato requires a
vartane he amerdaorwith ISA NCAC 2C MIA
9 YIELD(gpm): 30 METHOD OF TEST Ti ned
10. WATER ZONES (depth):
Topographic/Land setting
Malley DFlat
(cheeks iaoprimebox)
Iatcde/Iongidide of well location
( )
Latitude/longitude sowce:DGPSOTopographic map
MEM( DRILLING LOG
From To Formation Description
11. DISINFECTION: Type CC H Amount l/) 07
12. CASING:
Depth
From V To WO
From To
Wan Thickness
Diameter orWeig//ht/Ft Material
Fta g'R .� t ...L
Ft
From Front To Ft
13. GROUT Depth Matai�l Method
Front To ah Ft. (orvrc c. Wit yvtdg
From To FL
14. :Cam To
From To
15. SAND/GRAVEL PACK
n Depth
From jag To
From To
Diameter Slot M Mee Material
Ft_jn in.
in.
Size Material
Ft
Ft.
LOCATION SKETCH;
Show direction and distance in nukes from at least
two Cate + .. 4 n J ��qRoads. Include the road
n
iota .° 700
16. REMARKS:
1 DO HEREBY CERTIFY THAT TfnS WELL WAS CONSTRUCTED IN ACCORDANCE WHI115ANCAC 2C, WELL
CONSTR%tCTiON STANDT A e a OF THIS RECORD HAS BEEN PROVIDED In THE Vilna. OWNER
CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Seetlon,1636 Matt Service Center -Raleigb, NC
27699-1636 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 # 3 l 73
1. WELL CONTRACTOR:
2.21-A) t•fi/ ES
II Contractor Individual) Name
leSZAb LI Ic-II ant d amp) lied
Well9ontractor
Company Name
STREET ADDRESS a73I Lt(AoIE2 y
.
1(tSEe. a87gp City or Town / State Zip Code
SCR )-52-• 849Gz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(11 applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Cr-'
• DATE DRILLED /2 - Ln— OG
TIME COMPLETED AMI]' PM❑
3. WELL LOCATION: // //
CITY: An /f' /r COUNTY "e/Tc-o
;• At" bsfz/sr
(Street Name. Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI G:
❑Slope ❑Valley ❑Flat . idge DOther
(check appropriate box)
LATITUDE 3 / 0.874
LONGITUDE Y L a
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
�'
OWNER'S NAME rt? SQ5 Rider (Ltpj -fiLt"
STREET ADDRESS Q b c'i 17 3 4,
l�er�ur�d;I1-e- NC 418987
City or Town State State Zip Code
( Sta1 W)- (o /(45 - 300 0
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: ..?Y ,
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1
c. WATER LEVEL Below Top of Casing: /Q 8 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): '7 METHOD OF TESTjIPallef Q
3
Aw21
f. DISINFECTION: Type('&%" a(. Amount to
2
g. WATER ZONES (depth):
From 224? To From To
Fran toTo From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 284. Ft. /,/tr CAW/ rc-c.
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From P To so Ft. COX'rcfe pOL(f!ly j
From To Ft. ..11
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
�Frrom To
V /JJ
/at - /a,
11. REMARKS:
Formation Description
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 CERTIFIED WELL CONTRACTOR DATE
D, 4A) if I.J, `,ke
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti 3 / iO
ci ,r ^ s3 n
tr w; Cw V
1. WELL CONTRACTOR: // //
ZKi+A WiJ ES
II Contractor Individual) Name
Er CanJE/I ant J u
s h/np
Well ontractor Company Name /3 %� / r
STREET ADDRESS �6.1Z
/1(5s/Ea /yC• , a'r79,9
City or Town / State Zip Code
8,R8 )- 52- 8L{96z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED /2 - Of"
TIME COMPLETED /0 - ale AMU" PM ❑
3. WELL LOCATION:
CITY: /fir„ It
Cclr t#'e. ir/t„
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
�TOO/POGRAPHIC / LAND SETTING:
IG�lope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 S- j J• /vr
LONGITUDE Y z
COUNTY /Inds mn
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DGPS ❑Topographic map
(location of wen must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
ST EET ADDRESS
(c
/YC
Ci or Town Slate
112_2_)-We'- 5a
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO gi/
c. WATER LEVEL Below Top of Casing: /CO FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): -70 METHOD OF TEST I ." I
r
f. DISINFECTION: Type �O—•>•t
g. WATER ZONES (depth):
From f-40 To From
From sp-O To From
From To From
6. CASING:
Amount /a o z .
Depth Diameter
From 0 To ft Ft. C.,/,2/-
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
Svc'LZ f'vC
7. GROUT:n Depth �rMaterial Method
From f0 To ©o Ft. CONCr'Cte p;ijiflN4
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
in.
in.
in.
Material
Material
10. DRILLING LOG
From To Formation Description
4/7 - J L 5491/
SL - %or
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 PROVIDED TO THE WELL OWNER.
K'S--m%
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
JRIP,A�j f f, l.J, fives
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 # 3 / "T3
1. WELL CONTRACTOR:
BIZtrf-/11 LUy'/WES
II Contractor Inndividual) Name �--�
Erc}°Cents 8la/1 and ''limp ,CLC,
Well ontractor Company Name
STREET ADDRESS r7(y� rc,w L JEQ If/,
L ie sJE,t MC. a8'70
City or Town / State Zip Code
(2 S )- a52 gg912_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L"
DATE DRILLED /2 `4. -- 0(
TIME COMPLETED f:/c7 AM ❑ PM [�
3. WELL LOCATION:
CITY: ,»7 ft//
'�' de, Ja..,la.-
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope [/alley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 , c/4: r r— n
LONGITUDE S' L 4/2. t/ Z
Latitude/longitude source: QRrPS ❑Topographic map
(location or well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME rryl
STf2fET ADDRESS 3. O
COUNTY . ice‘yo7
May be in degrees,
minutes, seconds or
in a decimal format
(
City iv `f State N 706 6 0
ip Code
)- 3_417-31a7
Area code - hone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I3'
c. WATER LEVEL Below Top of Casing: v'2 FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING I5 / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
t ,
e. YIELD (gpm): Z �L METHOD OF TEST1i'bL1Jtdy- r9
0
f. DISINFECTION: Type eh', :.i Amount le 4"2--
n,.
g. WATER ZONES (depth):
From .2 /O To From To
From 2J't7 To From To
From .J3'0 To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 29 Ft. r5..4r Sd,l1/ .."-C
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material Method
From P To 20 Ft. ConC_rete i1011fhi
From To Ft. ..JJ
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D- /i
/t- z/
2 d- air
11. REMARKS:
Formation Description
CA?
f -//
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.
-06
SIGNATURE OF ERTIFIIEDWELL CONTRACTOR DATE
Di/f» J f / J, i/es
PPRINTED 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. 7105
223

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 /.0
1. WELL CONTRACTOR:
Ba,4 & i ES
I�II Contractor Individual) Name
tE SoNs It aivd J wnp L�..C.
Well ontractor CompanyName/1
STREET ADDRESS r/J /r3/All) LEIL E IE(L j(GUy•
City or Town / State Zip Code
(8.1}3 )- 52- 8y91.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITS/(II applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Id
DATE DRILLED %t Z%'- 76
TIME COMPLETED ..r; O a AM ❑ PM Ir.
3. WELL LOCATION:
CITY:
f ,.1SaN COUNTY
Wives .tr
(Street Name, Numbers. Community. Subdivision, Lot No„ Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat QHidge ❑Other
(check appropriate� box)
LATITUDE 3 r C4, Di,3 6
LONGITUDE b L <Ai (,y
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 8'GPS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME 'p&( LUIS*
STREET ADDRESS So life( lo g--(_,pt/yerlad
Ar.s kw/ He a8 753
City or Town State Zip Code
(g;-Sy 1P4/9-ay27
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ,?fi)'
b. DOES WELL REPLACE EXISTING WELL? YES O NO Cc
c. WATER LEVEL Below Top of Casing: o FT,
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD ••��
(9Prn), I9 METHOD OF TEST11'bL!:AG- , r
f. DISINFECTION: Type
Amount '?‘..z
g. WATER ZONES (depth):
FromeSCJ To From To
From4 ,/-To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To 40 Ft, tsr riti'a .4;J+i4--
From To FL
From To Ft,
7. GROUT:/T Depth Material Method
From N To No Ft. Concrcjc much-0 j
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
Cher
4cr - nor
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
x
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Pig/J, 5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD 3 4 1 6 6 9
North Carolina - Depart ofBavirotment and Natural Resources - Division of Water Quality - Groumdwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME ,. s / n ' � , r° cPAT1wICATION # 2 7 $ V
s
WELL CONTRACTOR COMPANY - e e k' . - HONE 0 fiz$) (0 5�9'--) 0
STATE WELL C NSTYUCTION PERMIT/ ASSOCIATED WQ PL*MIr#
Cif applicable)
(if applicable)
1. WELL USE (Check Applicable float): Residential flfnnicipal/PubTic 0 Industrial O Agricultural 0
Monitoring O Recovery 0 Heat Pegg Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Neatest Town; HA County MAD ►` CNl
YJE-A1Z- Q1v Ee LSD �a
(SUacName,Numbed; Community. Subdivision, LaeNen Tap Code)
3. OWNER ' 'ILL- 10--1 PP
Address '31:A.t V.Jv(Ott
mowerRoweNo.)
MAN ,t. , N c. 28763
CayorTown State Tip Code
(}
Area code- Phase number
4. DATE DRILLED /2-5- b lv
5. TOTAL DEPT}I• 3Q5
6. DOES WELL REPLACE EXISTING WELL? YES O NO B'
7. STATIC WATER LEVEL Below Top of Casing r.
& TOP OF CASING IS / 0 FT. Above Land Surfaces
flop ofeasing ter attar below taadsrkss req.kssa
va,taace m accordance MI6 15ANCAC 2C.011&
9. YIELD (gpm): S METHOD OF TESTTI Mgt
10. WATER. ZONES (depth):
Topographic/Land setting
CIRidge OSlope Malley UFlat
(cheek appropriate boa)
Latitude/longitude of well location
()
Latiwdellongnude source IIGPSOTopograpbic map
(cbed(boo)
DEZILi DRILLING LOG
From To Formation
11. DISINFECTION: Type (1.i4 Amount 10 02. • w direction and ,. • in awes from at least
12. CASING: Wall Madmen two State Roads or •• , Roads Include the Tad
From ToFt 4IF weirbtqt, R�&DPI t. nmnbera and common road names.
FromTo Ft.
From To Ft
13. GROUT: 1 Depth Material
Ftaro_(_ To Z S Ft.CONtlef
FTC__ To Ft.
14. SCREEN Depth Diameter S1atSize Material
From To Ft —in. in.
From,_ To Ft„.____in. in.
15. SAND/GRAVELPAQC
Depth Size Material
From (� To Ft
From f To Ft.
ELev. 2494"
N 5% ZJ'�
W o 82° 445. z88
sl
'LW/
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W11H 15ANCAC 2C, WELL
CONSTRUCTION 5T I r • 111 1 THAT A COPY
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Zi MATURE OF ER CONS7RUCTING THE WELL
IZ-r/Q
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636 Phoae No. (919) 7333221, within 30 days GW-1 REV. 07/2001