Po CY2006

RESIDENTIAL wELI. coNSTRUCFIQN RECORD
North Carolina Depmonent of Environment and Natural Resources- Dlvblon of Water Quality
WELL CONTRACTOR CERTIFICATION a 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Conbactar.(IndMdual) Name
Camp's Well & P1aITID Co. inc
WellContractor Company Name
STREET ADDRESS - P O BOX
Ellenboro NC
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Npt applicable)
STATE WELL FERMIUM aPPPCabie)
DWQ or OTHER PERMIT #OI applicabie)
WELL USE {Cheek Applicable Boni): Residential Water Supply ❑
DATE DRILLED r-)�_�0(0 1/
TIME COMPLETED Il' 7 ' AMQ PM1:1
3.WELL LOCAT
CITY:
�ON:, a_ COUNTY Po Il i
t-nJbllee.sf'JK gd sae
(Saes! Name. "1ST. Community. Sub Ion. Lot No.. Cods)
TOPOGRAPHICI�L,A(F�J�D SETTING:
OSIope MalleyY'— ORidge 1Other
(drxkappmpmwb"s)
LATITUDE ..S_ aC ) . 3 Q 3
LONGITUDE aoZ�1CO
Latitude/longitude source: &SS OTopographic map
(bcatIon of wel must be shown on a GS topo map end
attached to this lam /Trot usingGp)
C1tyorTam ' State
4. WELL OWNER
OWNER'S NAME
429
28040
ZIP ode
IMay be In dere,.
minutes, seconds or
in a decimal format
ADDRESS
STRT
CIty or Town
D go rho
N C_ ole 973
State Zip Cede
Area code- Phone number
5. WELL DETAILS: (D
a. TOTAL DEPTH: r f J
b. DOES WELL REPLACE EASING WELL? YES O NO
c WATER LEVEL Below Top d Casing 49 FT.
(Use w S Above Top d Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top d casing terminated at/or below land surface may squire
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST al Y
3 6969
t DISINFECTION: Type chlorine Amount l ya. 1
a. WATER ZONES (depth):
Froth To From To
From To From To
From To From To
6. CASING: ty ry�
Front 0h / / Ft bm$eter SDZ1
From To Ft,
From To .Ft
ThIcIe s1
him
7. OROt1T: Depth Materiel Method
Fran g To 20 Ft Sackrete Hand
From To Ft.
Front__ To Ft.
e. SCREEN: Depth Ohmmeter Slot size .Material
Fran To FL —In. In.
From To FL in In.
Fran To Ft In. In.
9. 8ANDIGRAVEL PACK: Sim
Depth Malarial
Fran,, To Ft
Fran To Ft.
Fnm T_,To FL
10. DRILLING LQG
From To
0• /7
Formation Description
`na rttt
%1. yo." • LDYl5o)i Ciate d rcc_
rTn
�`
. J 2005 r
—4
11. REMARKS:
1D0 HEREBY CERIFYTHATTBB WELL WAS CONSIRUCIEDNACCORDANCE WITH
16A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND 'WA COPY OEMS S •
RECORD HAS BEEN PROVIDED TOTE WrELLLL OWNER •
SI TE ERT ED WE ' CLL ONIRACTOR 5 DATE06
UR
'games W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1Submit the original to the Division of Water
17 Mal ServiceQuality
Center— Raleigh, NC 27699-1617 Ph Phone within No. (9 9) 7intimation Mgt.,
33 9 6 ext 68.
Form GW-la
Rev.1l0S

RESIDENTIAL WELL CONSTRUCTION' RECORD
North Carolina Deparhnent of Environment and Natural Resources- Divbim, of Water Quality
WELL CONTRACTOR CERTQI'ICATION # 21 3 8 ' •
1. WELL CONTRACTOR:
James W. Camp
Wel Contractor .(individual) Name
Camp's Well & PumD Co. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City cram State Yip Code
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 501 eppocbIe)
STATE WELL PERMR#IY*Pptluble) . (t/ �I
DWQ a OTHER PERMIT ar(a aPWkaSej o K Lao
WELL USE (Check Applicable Bar): Residential Wets Supply In
DATE DRILLED 5 11 -D6
TIMECOMPLETED 3-0 AMO PME
3. WELL LOCATION:
CITY: ( p `r �^ I'/
CITY: b'' � f 5 ✓1� �l e Rd. COUNTY
g i (\
(/� ( dw)ard5
(Street Name, Numbers. urn, SobNdelon, Lot Na, Panel Ip CDde)
TOPOGRAPHIC I LAN/SETTING:
O Slope OValey AFM DRidge O Other
Km* epp,opdalboZZ) • $� it'
L"_
LONGITUDES 92 o .69
Latitude/longitude source: PS OTopographic map
(bcatbn of we/ must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER d /�'
OWNER'S NAME ‘00Y-
i 5 jl'ervn&I f; I I lit.
�C 2
late Zip Code97tx
I MaY 13.0 111601101.
1
mherroe,seconds or
in a decimal brmat
STREET ADDRESS
Y'�L1Inrl
[ya cilwm
A[code - Phone number
6. WELL DETAILS: , I
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NO q
WATER LEVEL Bela& Top of Casing 40 FT,
(Use '+' If Above top of Casing)
d. TOP OF CASING 15 1 . FT. Above Land Surface'
.tap d casb0laminated atior below iS d surface may require
a variance B accordance With 15A NCAC 20.0118.
a YIELD (gPm):.�.--METHOD OFTEST 6Uy
•326968
t. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
Fr nn To • From To
Frain To From To
From To From To
6. CASING: teeter
From 0 gel.
% Ft Dbt
Fran To Ft
Fran_ To •Ft
7. GROUT: Depth - Material Method
Frain 0 To 20 FL Sackrete Hand
Fran__ To Ft
Fran__,_ To Ft.
B. SCREEN: Depth Diameter Slot Sae .MataIS
From_ To Ft_in. In.
From__ To Ft In. In.
Fmmt,_ To Ft in. In.
9. SAND/GRAVEL PACK: Depth Size Material
Frock, ' To Ft
Frain To Ft.
From To Ft
Cuj4
ThalcMk(1pllmeau
SDR21 PVC
10. DRILLING LQG
From To • a
245
YJN 0 2006
11. REMARKS:
Formation Description
(n AM,, rick/
%pj30Irr6
Y �
Aa
rm.
• N C'fl
co
r—
I CO HEREBY CERTIFY 'HAT WELL WAS CONSTRUCTED aACCORDAME WTM
1EA IOC2C. WELL CONSTRUCTION STANDARDS. AND MAT ACOPY OE. MS •
• RECORD NIB BEEN PRCNIDEDTOTHE WELL OWNER.
( (, �A ) G
SI TURE OF CERTIFIED W EII' CO RACTOR unTE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to 1617 Mall Service Center h Raleigh, NC 27699-1017 Phone No. (9 9e Division of Water Quality within 1733 i 5 ext 568.g . Mgt„
Form GW1a
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: MILL SPRING County POLK
COUNTY LINE RD, HIGHLANDS @ WALNUT CREEK SUBDIVISION,
OFFICE TRAILER LOT
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER CHESTNUT OAK DEVELOPMENT, LLC
ADDRESS POB 454 Latitude/longitude source: ® GPS 0 Topographic map
(Seeet or Route No.) DEPTH DRILLING LOG
LAKE LURE NC 28746 From To Formation Description
City or Town State Zip Code 0 80 Clay
80 500 Consolidated Rock
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.22.443 / 82.06.363
828-429-0857
Area Code - Phone Number
4. DATE DRILLED 3/16/06
5. TOTAL DEPTH 500
6 DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES [] NO
60 FT.
s. TOP OF CASING IS 2
(Use "+" IF Above Top of Casing)
FT. Above Land Surfaces
'Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 6 METHOD OF TEST ARDM
10. WATER ZONES (depth): 100
(degrees/minutes/seconds)
it. DISINFECTION: TYPE HYPOCHLORITE Amount 22 Oz LOCATION SKETCH
12. CASING: Wall Thickness Show direction and distance in miles from at least p9�
Depth Diameter or Weight/Ft Material two State Roads or County Roads. Include the road C7
From 0 To 86 Ft 6 1/4 " SDR 21 PVC numbers and common road names. _
13. GROUT: Dv
Depth Material Method
From 0 To 20 Ft. GRAVEL MIX GRAVITY
14. SCREEN
Depth
From NA To Ft.
15. SAND/GRAVEL PACK:
Depth
From NA To Ft,
16. REMARKS:
Diameter
in.
Slot Size Material
in.
Size Material
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.
1C�S` 4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Dale
Submit the original Pi the Division of Water Quality, Groundwater Section, 1636 Mail Service center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
JUM .5 2006
IGW-1 REV. 07/2001I

RESIDENTIAL WELL coNSTRUCTIOMRECORD
North Carolina Department of Environment and Nature) Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Wel Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PC Box 204
East Flat Rock, NC 28726
City or Torn State Zip Code
828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID flit applicable)
STATE WELL PERMIT#(if spokWble)
DWQ or OTHER PERMIT f(1 applicable)
WELL USE (Check Applicable
/ Box): Residential Water Supply ID
DATE DRILLED 3 G (o
TIME COMPLETED 5' U D AM ❑ PM t$-
3. WELL LOCATION: n y
CITY: mt 1\ Sri sly COUNTY 10� F—
&1 l at IS PI eost Aare 5
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 35CaIl33 iv
LONGITUDE t7g2—o Q5t o2I I/3
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 14GPS ❑ Topographic map
(location of wel must be shown on a USGS topo map and
attached to this farm Inot using GPS)
4. WELL OWNER T ,,f�
OWNER'S NAME C�In+on Justus
STREET ADDRESS I t tBo t LILL1 S
f�CI Spirt rich NC. Z-5" JSk
City or Town State Zip Code
(i2V)- t zs • 9SI
Area code - Phone number
6. WELL DETAILS: sn
y /
a- TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (y
c. WATER LEVEL Below Top or Casing: 3 0 FT.
(Use -*- I Above Top el Casng)
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 rib 15A NCAC 2C .0118.
e- YIELD (gpm): I METHOD OF TEST Air
a-;
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
From L /40 To It From
From To From
From To From
6. CASING
Amount
Depth apreter
From 0 To 100 Ft. MO
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
�t•� P✓c,
7. GROUT: Depth Material
From 0 To 2 Ft. SM,SPIZI<og
From 3 To 7� Ft.��ytty {aw
From To Ft.
Method
1 eOr
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in.
From To Ft. in.
in.
in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From
From
To Ft.
To Ft.
10. DRILLING LOG
From To
to-
11. REMARKS:
Formation j?ascription
r
1T.
o
1 DO HEREBY CERTIFYTHAT THIS WELL WAS CCNSTRU(-ItU IN ACCORDANCE W m,
15A NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO E WELL OWNER
`l -I%-cc
SIGNATURE F CERTI IED WELL CONTRACTOR DATE
/fiAc-not 5d'sg+h
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 connurrloN RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Wee Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID i(11 applicable) (�
STATE WELL PERMIT/(a applicable) w Po Coo
DWQ or OTHER PERMIT eV applicable)
WELL USE (Check cable Box) Residential Residential Water Supply 0
DATE DRILLED 6 I fl O6
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY:
COUNTY Pr) I'C
(Street Name, Numbers. Community, SubdMN61or1. Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
°Slope °Valley ❑Flat Qf%dge ❑Other
(check appropnate box)
LATITUDE _g° 22-1
O 9 A/
LONGITUDE OF2° / 1, !L_�,/'
Latitude/longitude source: PS ❑ Topographic map
(Sicilian of wa must he shown on a USGS topo map and
attached to this loan I not using GPS)
May be in dogma,
minutia, seconds or
m a decimal formal
4. WELL OWNER
OV✓NER'S NAME SG
I—D/111 1
ST EET ADDRESS D I Ce-rZ0, c ✓tz_ );-P
�s(rn�
2`6T p&5 —.3n4-
Area code - Phone number
6. WELL DETAILS: �j _
a. TOTAL DEPTH: .3- 13
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO ar-
c. WATER LEVEL Below Top o( Casng: He FT.
(Use': a Above Top a Casing)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
Top et casing terminated ator below land surface may require
a valiance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST Air
1_ fr.
ci M i
/. DISINFECTION: Type HTH
g. WATER ZONES (depth)
From La' To /C 7/
i
From D To %l
From To
6. CASING:
Depth
From I To G 5Z Ft.
From To Ft.
From To Ft.
Amount
From To
From To
From To
Diameter
y
Thickness/
Weight
Material
('442-
7. GROUT: Depth Matenal Method
From G To )r Ft 54/444-/6 .A4 ,) 7 ti).'.,c
From 3 To 2, / Ft. /3.:., c.- (n- A1.YVY�.Si
From To Ft
8. SCREEN: Depth Diameter Slot Size Matenal
From To Ftin in.
From To in. in.
From To in. in.
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
0 -/0
40- 'A6/
17-GO
L G - 6 'r7
11. REMARKS:
Ft.
Ft
Ft.
Ft.
Ft
Sae Matenal
Formation Descnpoon
i) "2*
5*,.d Sc•/
}}o f is kc 1
art./.te
O
C71 mir?1
r
I DC HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W nH
1YA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A Cam' OF THIS
RECORD HAS BEEN PR W IDED TO THE WELL OWNER
/ 7 /4..t/ �Atrof f /G -z14
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
l3R hide J•r7,1-)
PRINTELYNAME 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 coNslRuc ion RECORD
North Carolina Department of Environment and Natural Resources- Division ul Water Quality
WELL CONTRACTOR CERTIFICATION N Q 6'7 I
1. WELL CONTRACTOR:
Well Contractor (Individual) Nacre
6ree—r1 ?-% er
Well Contractor Company Name
STREET ADDRESS pUjoc cR
Fast Y Ja t Roc,K- K.)( tis 7c2,(0
City or Town
( k )- 695—)2-0o
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of appaable) _
W F�7 obo4D
State t Zip Coda
STATE WELL PERMIT#(a apaiable)
DWQ or OTHER PERMIT Cif app6ab4)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED / —7 -d L
TIME COMPLETED 3 ,3 0
3. WELL LOCATION:
CITY:
AM ❑ PM I3
5 a-JL-1.A-r-t a-- COUNTY CLI'
Lot q L.44-}1e. lddrrlor rdrl `[slzxiei
(Street Name. Numbers. Communey. Subdinaion. Lot No . Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
O Slope [Valley OFlat ❑Ridge ❑Over
(check eppropnale box)
LATITUDE ii // /tr/
LONGITUOS912../ 3 %41
Latitude/longitude source: LSZPS ❑Topographic map
vocation or war must be shown on s USGS fopo map end
inched to this form not using GPS)
4. WELL OWNER 1� �+ � —
OWNER'S NAME GC CA &VOSS' S i1e.1 A bh3
SIRE TADDRESSGRI3D ErVi"ire Ck Rd
d lA.5a-fluid-9 PC S 7q2
City or Town . State Zip Code
( 424s )- Co 8 5— 9 w9
Area code • Phone number
May be in degree,
minutia, seconds or
n a decimal runner
6. WELL DETAILS:
a. TOTAL DEPTH: -T .J
b. DOES WELL REPLACE BUSTING WELL? YES 0 NO (fr.-
c. WATER LEVEL Below Top of Casey: /0 FT.
(Use': 8 Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of wing terminated at/or below lard surface rrey require
a vary na in accordance Lvkei 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST /ir2,
y 4ii
f. DISINFECTION: Type Pr TN Amount
g. WATER ZONES (depth) (9V/r1
From 1' / 5 To / 2 From To
From 'tf(O ` To L5—2SFrTo
From To From To
6. CASING: Thickness!
Depth ` Dia ter We M Material
From 1 To Q ivFt L.K L�.—
From To Ft
From To Ft
7. GROUT: Depth Material Method
From 0 To 0 H. get-keit/L � it,')fs4g
From To FI.
From To Ft
8. SCREEN: Depth Demeter Slot Sue Matenial
From To FI. in. In.
From To Ftin. in
From To Ft in n.
9. SAND/GRAVEL PACK:
Depth Sze Materal
From To Ft
From To Ft.
From To Ft
10. DRILLING LOG
From To Formabo scrption
/-e5�ay
13_ _ — `' 5fi-,..dy p f
F/ S -- 5735,4 // /7r r�
T 5 — 4415— 15Dow/ c-
11. REMARKS:
CD
CO HEREBY CERTIFY TINT THIS WELL wAS CONSrRUC1ED IN ACCORDANCE W rtH
I A NCAC 2C, WELL CONSrRUCTON ANDARDS. AND TNT A CCPY OF THIS
RECORD HAS BEEN PRO✓OED TOTf1 WELL OWNR
SIGNAT RE d{CERTIFIED WELL CONTRACTOR DATE
t3aeg s//1;Fk
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. At1n: in
1817 Mall Service Center- Raleigh, NC 27899-1817 Phone No. [phone] ext
anon Form°6RECEIVED 5
MAR 0 8 2006
Asheville Regional Office
to

CONTRACTOR
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcparvnmt of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION M d S q
„sok.
Wel Conoadbr (Individual) Name
Grezn verinle\
Well Contractor Company Name ,1
STREET ADDRESS ?CD os ao T
ast iC ha t -Rocic_ N ( o� iS ` c2 (t,
City or Town State y Zip Code
IPCC )- 693-)2-00
Arse coda- Phone number
2. WELL INFORMATION:
SITE WELL ID HPr appcabie)
STATE WELL PERMIT#(9 appiwable)
(.ti 255-oqN
DWG or OTHER PERMIT t(l applable)
WELL USE (Check Appicable Sox): Residential Water Supply ❑
DATE DRILLED I ' S -Q 6
TIME COMPLETED 41 3 C%
MA ❑ PM Er
3. WELL LOCATION:�� (j,�
CITY: S Up-.x_.cd a - COUNTY rack
to ( a alt.bv092 •
(Street Name. Numbers. Community. Subdieagn. Let No.. Parcel. Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
O Slope OVdlay OFlat r}Kldge 00ther
(check appropnate box)
LATITUDE ii li• 'SLT /V
LONGITUDEara 2,,0 03 u-
Latitude/longittde source: DCT'S DTopographic map
(bcatbn of wet must be shown on a USGS topo map and
attached to tl,S form Y not using GPS)
4. WELL OWNER I/
OWNERS NAME Irrv1 \LUr Ture(r1, Q.
STREET ADDRESS (pi ( UQd'TOnc o•
n C o f 11 3
City or Town State Zip Code
q �F9 (197
May be in degrees,
minutes, .oco da or
m a deem al format
AIM code • Phone number
6. WELL DETAILS: ��11 nn —
a. TOTAL DEPTH: 7 (l 5
b. DOES WELL REPLACE EXISTING WELL? YES O NO (9.-"-
c. WATER LEVEL &Sow Top of Crime: f 00 FT.
(UM'4" Y Above Top of Casing)
d. TOP OF CASINO IS I FT. Above Land Surface'
'Top d casing terminated Won below land surface may require
• variance in accordance elm 15A NCAC 2C .0118.y�
e. YIELD (Oprnr / 2 METHOD OF TEST !7 / &
A
f. DISINFECTION: Type !! / I Amount
g. WATER ZONES loepm)
From 3 SD To ,383 From To
From To From To
Frorn To From To
6. CASING:
Thickness
Depthm glare( Weight AQOte/� I
FroTo Or Ft. 6 2i. r(/C�
From To Ft
From To Ft.
7. GROUT: Depth
From /9 To -26
From To
Frorn To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK'.
Depth
From To
From To
From To
10. DRILLING LOG
From To
- 2i
gv
Tl0 -'/O
11. REMARKS:
Material
Ft. 6TJN.fs
Ft
Ft
Method
Demeter Slot Size Material
Ft.
Ft n. in.
Ft in in
Ft
Ft.
Ft.
Sae
Matenal
r 4 (J c n
in
3,a
0
i DO HEREBY CERTIFY TMAT 'IMPS WELL WAS COFISTRUCIED IN ACCARDANCE WITH
15A NC.AC 2C. WELL CQNSTRUCTC' STANDARDS. AND 'THAT A COPY OF THIS
RECORD HAS BEEN PROV OE D TQ7HE WELL (7yNER
/-6-06
SIGN �7�/URE OF CERTIFIED WELL CONTRACTOR DATE
g y1RJt Snt,f'Lt
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Ir
1617 Mall Service Center- RalsIgh, NC 27699.1617 Phone No. [phone] e
tonna.R EC E I V E D
Lt 568.
MAR 0 8 2006
Form C W-la
Rev. 7P)5
Asheville Regional Office
Aquifer Protection

�' `�84
El
RESIDENTIAL WELLCONSTRUCTIO'N RECORD
Nora Carotin. UepNnanl 07 Environment and NMprL Kcwu.tor LJ'par n
WELL CONTRACTOR CERTIFICATION • 2571
1 WELL CONTRACTOR.
Bryant Snn
Web Conv.c or (Ywnwu.0 Nero.
Grow River W.0 S Pump Company
Wee Cat.Gor Convent Name
STREET ADDRESS PO Bo. 204
Ent Fai Root. NC 26724
Gay or T ov.1
L62.5 ). 693•1200
Nos Coat Phone nunne
Sole Zp Coo.
2 WELL INFORMATION
SITE WELL ID &Or epPUP.I I�1
STATE WELL PERMITS(/ afprrwo.l W Poo 77
DWO or OTHER PERMIT s(f appecaow)
WELL LISE (Choc.QQplcape Boo RwrORM.I W.I.r Supply ❑
GATE DRILLED // /s- ©L
TIME COMPLETED 2:&o AM O PM Q--
2 WELL LOCCATION.
CITY l_AJW/SIDkS COUNTYr7OI
3797 w1c4c rate id-,7 2d
lanai Nam. NteIIPIt Communa), Ssca son La No Peon 2 P Cow)
TOPOGRAPHIC / LAND SETTING
OSap. OVMAT Oft C Kc . ODowr
Ices= appwWna. OW / ,, r
LATITUDEE�{� ( YI'/"r
LONGITUDE °) 3 3410J
LautTde/IongiTude source *CPS 0Topographic map
(ocaron d wag moor w Mown on . LSGS typo map arra
satchel to VNe roan F nor pang CPS)
May .a w d.po.
muua, mono, a
. a accrual Galan
a. WELL OWNER
OWNER'S NAME AI' e?14 Ska
STREET ADORRE,SS f 0 II S1 1721 iyr
QL
I—e-i tN1C{ IUrI l ✓ r� 907oP-
CEy a Than S1WI, Zip Coo.
t'u3,. (003-3a'7
Nr COO. • Phone Mums/
6 WELL DETAILS: _ /
e. TOTAL DEPTH: (CO
O DOES WELL REPLACE EXISTING WELL? YES 0 NO 5
c WATER LiVELBoo« Togo( Casing 2.40 FT
(U1.'•' f Nairn Top d Catnip
O TOP OF CASINO IS I FT ADo.. LsrC Sutlac.'
'Tap or casing wrmrwl.a epa Pea•. Iarld surface may /spurt.
• ea n ery/orponce wall ISA NCAC 2C 0116
r IELD (9Pm1 /�- METHOO OF TEST AP
•
1. DISINFECTION Type "1
p. WATER ZONES iQrpm,
From 2.90 ro Ayf
From
From
6 CASINO
ro
to
NOn
From / to GO F
From
From I
rot,/
F rpm
From
TnrcRM.a
e O.ler 2L G MPNre
7 GROUT D.pn From D T0 Ft 51Mfi/F;;;4 AY- t
From To _ FI
From - to Fr
8 SCREEN
Flom
From
From
Dapp,
10
0
To
e SAND/ORAVEL PACs
Deptn
o..r..rn Sat Su. Mat or 'at
Fr n n
Fr n n
Fr n n
fran Ip Fr
From To FI
From To FI
10. DRILLING LOG
From To
O — e0
/B - i'O
to - J 7>
SO -L©S`
II REMARKS
Su.
rgtor'
CO
m
0
Crs
DOnEAEUT ['Ann nn T mi5 nt.. aa$ CO•SWOCIED.• ACCOFID.r.C! wpm
ISA CAC 7C w(tt CO•.S1A iKW. stk./way ono flat a Cep, co ma
AECDAD nw3 Bf E w nu O. a
SIGNATUA2 OF CERTIFIED WELL CONTRACTOR
RRS,¢ Son,'-k
PRINTEWNAME OF PERSON CONSTRUCTING THE WELL
L
SUCMI Vw original f0 the Division of Waive. Quality wltn'n 30 Gays. Arm nformaDon Mgt..
1617 NISI S.rvic. Center - RaSlgh. NC 27699.1617 Pon. NO. [phone] to 568
o.mCW ra

RESIDENTIAL WELL CONSTRUCTION RECORD
Nona Carobrm Oraatntall of Environment and NMonJ Kew. rocv U'•'a• ..I n•mi IJr.Wn
WELL CONTRACTOR CERTIFICATION R 2571
t WELL CONTRACTOR
Bry.nt Smith
WM Contractor (WON 0u.11 Nano
Crean RN* Wog S Pomp Company
W M CavmWor Company Name
STREET ADDRESS PO Bo1204
Ent Fat Roa. NC 26726
City or Town Sato
t 5211 ,. 597 1200
AM cal► PNon. Narrow
1. WELL INFORMATION
SITE WELL ID Wm sarcasm)
Zp Coo
STATE WELL PERMIT/it .p .aa.l
OWO r OTHER PERMIT a(/ appac.DMl
WELL USE (Chock 491CROm Boa) R..roantol Wow SLIPPY ❑
DATE DRILLED 4/30 I0%
TIME COMPLETED I/'ou AM 171 Par0
3 WELL LOCATION.
CITY
COUNTY PO IC
Lot 914-t"lock- C-ossc j
(9r.a1 Nana. Num0a. Commonly SotOo an Lr NO Pawl Zip Coo.)
ip NCAI P OFAP/ LAND SETTING
&Sop. VMay OFMI ORro9. 0CRNN
Iowa acorn tool
LATITUDE 350 a7' 38N
LONGITUDE O l c O L/ J 0
Lautudc/bngnudc stays EGPS ❑Topograptuc map
(*NNW d wW mast OR Worm on • VSGS Logo mop and
ROWANS to Or arm / not wing GPS)
.. WELL OWNER
/1
. Cr!'Jus4w go' �P4s
OWNER'S NAME C L Cr
T
STREEADDRESS FL' GK Z ��
f'l l ,(t y A✓ C
co reT Sire Zp Coo.
I ,. 2-g9 - 41 co 42
May 6o r alma.
aziaiws, Noma or
o • i1.ca•l forma
Atom Pol. Rhone n.11TGa
6 WELL DETAILS:
•. TOTAL DEPTH:
D DOES WELL REPLACE EAISTINO WELL7 YES O NO 0-
c WATER LEVEL Boca Top of Clang 3 0 FT
(Us. '•' 1 Ace.* T op d Caang)
1. TOP Of CASINO IS I FT. Maw Lard Scanoe'
S spar arrow and audios nay rqulr.
'Top al moan; tom -meted Nan 1 SA NCAC 7C .0116
• ,.nano. n aw/rlapa
• YIELD (oral 5 METNOO Of TEST N
I. DI SIFfECTiON Type .1Tn
9. WATER ZONES L0 PIN/
S
flan �+z0 lc V-or
From
hem
10
From
From
From
Amount
f CASINO
0.pin
m q D. I«
FroI To 3Ft e
Flom__ to 4.6,
Ft C1
From 10 Ft
7. GROUT DWI
From et) To C
From C To 20
From To
1p
To
To
T Nova.",
W.pm Mal.ra
21.c ?kr-
_La Ctat/
Material
Ft
FT eark..r62:
f SCREEN Dlrprn D.•r.al•' SKR Soo
From
From
From
Io FI
10
To
f. SAND'ORAVEL PACs
D•rn
From
From
From
10. DRILLING LOG
From To
0 440
0 - /D-O
�5 D -
I1 REMARKS
Ft
Ft
Ft
FI
M.AOR
MT�c nv
Mal.iI&
Sa• Mal•rip
8
CD
1 •
r COnEREam Winn. n#1 T"45 ntti OAS CO"STRUCTE o.. .CCCND•"CL nlTM
ISA .CAC 7C Alm CO.S11wuC TO, 5',.r.0.P05 AAO DIP, a CON O TNO
RECORD MS BEE. <RO.IX C 'C ''E`' flit`OeRff—•----
SIGNATURE F CERT iFIEEDWt)/ELL CONTRACTOR
i�t Ala th
PRINTED
E OF PERSON CONSTRUCT mG Teat WELL
ty within
0
11117 Suthe larnit
i Service original
.41a( - Rai&gh, NC 27999-9117�tIPhone No. 919) 713-7015 esi 56eapon MpE.
f=3� flc
DA,E
o m GW •le
N.. 1105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION N a757
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor (.oMpany Name
STREET ADDRESS PO Box 204
East Flat Rods
NC
28726 •
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT/kif applicable)
P�ao45
DWO or OTHER PERMIT S(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply)j.
DATE DRILLED L4-/a7Ia b
TIME COMPLETED I1• ti0 AMP'L PM�
3. WELL LOCATION: (�
CITY: 3o JU-a_ C/COUNTY POI
(4 v. Haven - gese's dr¢ec.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑Otter
(check appropnate box)
LATITUDE 3 SLY 79 AJ
LONGITUDE012-c /I„/ 03
Latitude/longitude source: ts*PS ['Topographic map
/location of wet must be shown on a USGS topo map and
attached to this Porn %not using GPS)
4. WELL OWNER OWNERS NAME -Do n �1M(C1 Sul idevs
STREET ADDRESS PC I.XJ Y S I s
2-Lech N(. a 8 r773
City or Town I State Zip Code
(2z2 I- 744—/ L, 20
Area code - Phone number
May be in degree,
minutes, seconds or
in a decimal format
6. WELL DETAILS: a n
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ¢G
c. WATER LEVEL Below Top d Casing:
(Use'." if Above Top of Casing)
TOP OF CASING IS 1 FT. Above Land Surface'
'Top d casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
YIELD (gpm): / 5 METHOD OF TEST Air
d.
e.
f. DISINFECTION: Type HTH
g. WATER ZO�NES (depth):
From / ?/ To /9y From
From
From
6. CASING:
Depth%y R.
Diaroeter
From � To iY
From To Ft.
Amount
To From
To From
From To Ft.
To
To
To
Thickness/
Weight
2/
7. GROUT: Depth Material
From 0 To 3 Ft. .S,i/T/ rit_r_
From 3 To 3 0 Ft. j r4P ii.'i tee
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To
From To
From To
Materjel
n/C-
Method
/N:y YP&ac
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
— !J
�s- -o
S—D —6r
Formation Description
Rcd arc
vakr
4n Aed 35tc c&
0
-712.3
MITI
1... C7
JU'1 0 6 1053
11. REMARKS:
C r-t
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W mV
15A NCAC 2C, WELL CONSTRUCTION ,bTj ANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO W ELL OWNER.
-.28"-oc
SIGNATUR6F CERTIFIED WELL CONTRACTOR DATE
/JiZy,ror Sm!th
PRINTED41AME 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

forth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
.636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
I . WELL USE (Check Applicable Box): Z Residential 0 Municipal U Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
1045 HWY. #9 S. DRILLING LOG DEPTH
'Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3.OWNER JAMES SHEEHAN. JR
Address 1045 HWY. #9 S.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/14/06
5. TOTAL DEPTH 27
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 21 FT.
(Use "+' if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 6 METHOD OF TEST: STEEL TAPE
11. WAIERZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3
13. CASING:
Depth Diameter
From 0 To 27 Ft. 24
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in
16. SAND?GRAVEL PACK:
Depth Size
From 21 To 27 Ft. 78M
From To Ft.
17. REMARKS:
Wall Thickness
or Weight/Ft. Material
CEMENT
Material
GRAVEL
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT @ MAILBOX #1045.
SINGLE -WIDE TRAILER.
rnitt
rrx
N
0
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG TURF AF P
Submit original to Division of Wa
o� c'(- eft
ONSTRUCTING THE WFI.I DATE
ty, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Dt.yuatrrent of Environment and Natural Resources — Division of Water Quality — Groundwater lion
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: TRYON County: POLK
587 THERMAL VIEW DR. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER RICARD OHRSTROM
Address 587 THERMAL VIEW DR
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
4. DATE DRILLED 08/17/06 L'. 3S` 141 ilk, 43" Ni
5. TOTAL DEPTH 605 (sty, 2° (-1, $r{.' &
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ►� NO
8. STATIC WATER LEVEL Below Top of Casing: 305 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 6 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 7.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 50 Ft. 6-1/4" SDR21 PVC
From To Ft _
From To Ft _
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUILKRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in._ in.
From To Ft in. in.
From To Ft in. in
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM COLUMBUS. RT. ON SKYUKA RD.
LEFT ON THERMAL VIEW DR GO 1/2 MILE. GRAVFT DRIV
ON RT.
rn
rn
rV
7
0 . r-
I DO CERTIFY THAT THIS WTI WAS CONSTRUC1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WFJ T 0
FOR OFFICE USE ONLY
Quad No:
Serial No.
r 1-a• f'—/ 2_ C 6
SIGi`ATURE OF PERSON C STRUCTING THE 4VNT.L DATE
iginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Vorth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
i636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
9')n('('
el 3 4; 'y el
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: TRYON County: POLK
587 THERMAL VIEW DR DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER RICARD OHRSTROM
Address 587 THERMAL VIEW DR
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
4. DATE DRILLED 08/17/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WFJ.I 7 ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 605 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 Ft. 6-1/4" SDR21 PVC
From To Ft
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in. in.
From To Ft. in. in.
From To Ft. in._ in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
If additional space is nested use back of form
LOCATION SKETCH
. (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM COLUMBUS. RT. ON SKYUKA RD.
LEFT ON THERMAL VIEW DR GO 1/2 MILE. GRAVEL DRIVE
ON RT.
0
nl
IV
0
rn
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
neieeiL
SIGNATURE OF PERSON ONSTRUCTING THE WELL DATE
SubmiNoriginal to Division of Water Q nlity, Groundwater Section within 30 days
GW-1 REV. 12/99
6(

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
V "
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal U Industrial U Agricultural U Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
9818 HWY. #9 S. DRILLING LOG DEPTH
(Road Name and Numbers, Comnntnity, or Subdivision and Lot No.) From To Formation Description
3. OWNER LINCOLN RUSSELL
Address 9818 HWY. #9 S.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/22/06
5. TOTAL DEPTH 57
6. CUTTING COLLECIE) 0 YES ® NO
7. DOES WET .i REPLACE EXISTING WFI 19 ® YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 37 FT.
(Use "+" if Above Top of racing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with I SA NCAC 2C.0I 18
10. YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 57 Ft. 24 CEMENT
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 37 To 57 Ft. 78M GRAVEL
From To Ft.
17. REMARKS:
If additional space is needed use back of form
ci
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. APPDX, 2 MILES ON RT.
DRIVE BETWEEN 2 BIG BROWN COLUMNS. ORANGE
MAILBOX ACROSS ROAD FROM DRIVE.
ran
n
N
0
al
I DO CERTIFY THAT THIS WFI I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
NATURE OF
Submit original to Division of
N CONSTRUCTING THW071.1 G
Quality, Groumdwater Section within 30 days
P ,? -GL
DATE
GW-1 REV. 12/99

forth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
536 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): El Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
dearest Town: COLUMBUS County: POLK
581 HWY. #108
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
.OWNER DELVIN HORNBECK
lddress 3581 HWY. #108
Street or Route No.)
;OLUMBUS NC 28722
;ity or Town State Zip Code
4. DATE DRILLED 06/07/06
i. TOTAL DEPTH 665
i. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
I. STATIC WA IER LEVEL Below Top of Casing: 20 FT.
Use "+" if Above Top of Casing)
). TOP OF CASING IS 1-1/2 FT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a variance in accor-
lance with 15A NCAC 2C.0118
10. YIELD (gpm): 1-1/2 METHOD OF TEST: ARD
t 1. WATER ZONES (depth):
L2. CHLORINATION: Type: CHLORYTE Amount: 18
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 140 FL 6-1/4" SDR21 PVC
From
From To
14. GROUT:
Depth
From 0 To
From To
15. SCREEN:
Depth
To
From _ To
From To
To Ft
Ft.
Material Method
20 Ft QUILKRETE POURED
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft in. in.
Ft in in.
16. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
DRILLING LOG DEPTH
Formation Description
i SC2 11 r-fC" ry
(.un `62' IO'24.•41"11j
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM MILL SPRING. APPROX 3/4 MILE ON
RT. (3581 ON BOX)
RECEIVED
•
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
A�o�llxJ /,V•W A-7-
SIGN TORE OF PERSON CONSTRUCTING THE WEEL DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
AUG.;'
{{U�uua ( Lire

lorth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
I. WELL LOCATION: (Show sketch of the location below)
4earest Town: COLUMBUS County: POLK
11138 HWY. #9 S. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER SUSAN SEARS --..__ - -.--
Address 11138 HWY. #9 S.
"Street or Route No.)
COLUMBUS NC 28722
City or Town State
4. DATE DRILLED 07/07/06
5. TOTAL DEPTH 365
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WEl .l ? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface"
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with I5A NCAC 2C.0118
10. YIELD (gpm): 12 METHOD OF TEST: ARD
11. WATER ZONES (depth):
Zip rode
12. CHLORINATION: Type: CHLORYTE Amount 9.5
13. CASING:
Depth
From 0 To
From
From
14. GROUT:
Depth
From 0 To
From To
15. SCREEN:
Depth
From To
From To
From To
I6. SAND?GRAVEL
Depth
From To
From To
17. REMARKS:
Wall Thickness
Diameter or Weight/Ft Material
80 Ft 6-1/4" SDR2I PVC
To Ft. _
To Ft
Material Method
20 Ft OUILKRETE POURED
Ft
Diameter Slot Size Material
Ft. _ in. in.
Ft. in. in.
FL in. in.
PACK:
Size Material
FL
Ft
35° W 3C,5g°r1
$2 ° 3' 3.1-) IA)
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. NEW DRIVE ON RT. 2/10
MILE BEFORE S.C. STATE LINE.
0
0
0
nr_
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit
4cAZ, * .- '7 - 6
IGNATbRE OF PERSON ONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

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TO 39Cd

""` u' c.armma — Department of Environment and N —
1636 Mail Service Center — Raleigh, N.C. 27699-1636 Natural
73Division
3- 2 of Water Quality —Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Boa): Residential
0 Recovery Municipal Industrial 0 Agricultural 0 Monitoring
2. WELL LOCATION: (Show sketch h of the location below) Injection 0
Other If Other, List Use:
Nearest Town: COLUMBUS
S. PHIL LIPS RD County: FOLK
(Road Name and Numbers, Community, or Subdivision and Lot No.) FroDRILLING LOG
3. OWNER JAMIE SMITH & DEPTH
Address S. PHILLIPS RD.AMY CORRELL Formation Description
(Street or Route No.)
COLUMBUS NC
City or Town 28ode
4. DATE DRILLED 12/14/06 Ziptate Code
5. TOTAL DEPTH 305
6. CUTTING COILFCpEIy YES NO
7. DOES WELL REPLACE EXISTING ElTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a dance with 15ANCAC 2C.0118 variance in ac•
10. YIELD (gpm): 15 METHOD OF TEST: ARD
II. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE
13. CASING: Amount: 7.5
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 70 Ft. 6-1/4" SDR21 PVC
From _ To Ft. _
From To Ft. 14. GROUT: Depth Material Method
From 0 To 20 Ft. UILKRETE POND
From To Ft.
15. SCREEN:
From Depth Diameter Slot Size Material
To Ft. in. in.
From To Ft. in. in.FICIIII
16. SANDTo Ft. in in.
?
GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. 17. REMARKS:
If additional s is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
_E 9 S. FROM MILL SPRING. RIGHT ON COLLINS VILLE
PAVEME
NT
L
(,At t5' i2' 13.3" id
(prta B/a 5' I-i.54-" .J
FT ON S. PHILLIPS RD. LOT ON RIGHT AT END OF
RECEIVED
ply 0 F WATER QUAL T
IAN 9 5 ZOU7
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH1SRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE U.Sri rrerr v _.
SIGNIgTURE OF PE tW VN CONSTRUC"I IN WELL
ginal to Division of Water Quality, Groundwater Section within 30 days DATE
GW_1REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION 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: SALUDA County: POLK
MILLER MTN. RD. DRILLING LOG
(Road Name and Numbers, Conununity, or Subdivision and Lot No.) From To
3. OWNER RON HI DRETH
Address MILLER MTN. RD.
(Street or Route No.)
SALUDA NC 28773
City or Town State
4. DATE DRILLED 11/30/06
5. TOTAL DEPTH 985
Zip Code
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use `+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface;
"Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 27
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 30 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth 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:
DEPTH v�
Formation Description ere
Ca
Lat 3Sr Is' 2o.IaS" N
LtA) '2" Is t " "J
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM COLUMBUS. RT. ON OLD HOWARD
GAP RD. RT. ON HOWARD GAP RD. RT. ON INDIAN TRAIL.
STRAIGHT UP INTO MILLER MTN. APPROX. 1.7 MILES ON
RT. JUST BEFORE MAIL BOX #1519 ON LEFT.
RECEIVED
OIV. ()F WATER QUALITY
IIAN U 5 ZOO?
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
�. 3e - 6
SIGNA F PERSON ONSTRUCTING THE WELLDATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources —Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
y ri II({p
y 1 (I i1
1. WELL USE (Check Applicable Box): 0 Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
STIRRUP DOWNS LANE DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER SHARON ELLIS
Address STIRRUP DOWNS LANE
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/15/06
5. TOTAL DEPTH 185
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WA 1h1( LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10 YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 140 Ft 6-1/4" SDR21 PVC
From To Ft.
From To Ft _
14. GROUT:
Depth Material Method
From 0 To 20 Ft QUILKRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in._
From To Ft in. in.
From To Ft. in. in._
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
%a 35' 13' 5 4"
`wti) $ Z° 5' 4, (0`1' tit)
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RT. ON STIRRUP DOWNS
LANE, 1Sr LOT ON LEFT.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WFJ I OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON C6NSTRUCTING THE WELT DATE
Submit ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

dumb Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
n9t)r1Q
ti st : t, Co 1
I. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
I. WFI I LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
ROOUOIS TRAIL DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER FRANK CYRILL
Address IROOUOIS TRAIL
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/22/06
5. TOTAL DEPTH 445
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WET .T ? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of ('acing: 30 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land s uface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 12 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To
Type: CHLORYTE Amount: 12
Wall Thickness
Diameter or Weight/Ft Material
80 Ft. 6-1/4" SDR21 PVC
From To Ft
From _ To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From _ To_ Ft. _ in. in.
From _ To_ Ft._in. in.
16. SAND?GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
9A4 35" grf" rN
Um) SD' (g et. IS" LA)
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RT. ON COLLINSVILLE RD.
LEFT ON PHILLIPS RD. RT. 1/4 MILE ON IROOUOIS TRAIL
(GRAVEL RD.) LEFT a Y.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
< � � :ri,> 1 OP"eta-
SIGNATURE OF PERSO CONSTRUCTING THE WELL DATE
iginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Lkpartm .nt of Environment and Natural Resources —Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
32
1. WELL USE (Check Applicable Boz): 0 Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
S. WILSON HILL RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER DAN BOLT
Address S. WILSON HILL RD.
(Street or Route No.)
MILL SPRING NC 28756 F. 35` M' s.7z" N
City or Town State Zip Code
4. DATE DRILLED 08/25/06 Z ` I' c% q 4 " t.J
5. TOTAL DEPTH 145
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WF3.1 REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing. 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WA1JiRZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 55 Ft.6-1/4" SDR21 PVC
From To Ft.
From To Ft. _
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. _ in. in.
From To Ft. in. in.
From To Ft. in. in.
16.SAND?GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft _
17. REMARKS:
If additional space is needed use back of fonn
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. RT. ON WALKER RD. STA
STRAIGHT ON S. WILSON HLL RD. CROSS GREEN RIVER
BRIDGE. 1sT DRIVE ON RT.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
\._SIGNAt uxt OF CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
SrP2
GW-1 REV. 12/99

4orth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service renter — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential U Municipal U Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
MELISSA BROOKS DR DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER BENNY HINES
Address MELISSA BROOKS DR
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/16/06
5. TOTAL DEPTH 54
6. CUTTING COLLECIED 0 YES ® NO
7, DOES WELT REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 36 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 18 METHOD OF TEST: S I EEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 8.28
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 54 Ft 24 CEMENT
From To Ft
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in._
From To FC in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 36 To 54 Ft 78M GRAVEL
From To Ft
17. REMARKS:
If additional is needed use back of form
u ,r
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads or other reference points)
HWY. #9 S. FROM SANDY PLAINS LEFT ON OLD CHESNEE
HWY. LEFT ON MELISSA BROOKS DR (NEXT TO MIN.
VIEW STORAGE BLDGS) 316) DRIVE ON RIGHT.
I DO CERTIFY THAT THIS WEI.I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFI.i
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGN
Submit original to Divis
.9/La-- /ice — C
CONSTRUCTING'. tH WELL DATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

From To
14. GROUT:
1. WELL USE (Check Applicable Box): ki Residential U Municipal ❑ Industrial ❑ Agricultural
2. WELL LOCATION. (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
NORTH HIGHLAND DRIVE DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER MICHAEL BRANDSTADTER
Address NORTH HIGHLAND DR
(Street or Route No.)
MILL SPRING 1J 28756
City or Town State Zip Code
4. DATE DRILLED 09/21/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 600 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 115 Ft. 6-1/4" SDR.2I PVC
From To Ft. _
Ft.
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. _ in. in.
From To Ft. _ in.in From To Ft. _ in._ in.�
16. SAND?GRAVEL PACK:
Depth Size Material
From ToFt. _
From To Ft.
17. REMARKS:
1n+
limo
35' I.Yt" iJ
l4' Zs' oK" 4J
North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
❑ Recovery D Heat Pump Water Injection ❑Other If Other, List Use: _
U Monitoring
DEPTH
Formation Description
RECEIVED
DIV. OF WATER QUALITY
OCT 0 6 2006
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. LEFT ON SILVER CREEK
RD. LEFT ON NORTH HIGHLAND DR ( LAKE ADGER) 1ST
DRI. ON LEFT.
RECEIVED
OCT 1 7 2005
Asheville Regional Office
Aquifer Protection
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WET
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
S NA ' OF PE ON CONSTRUCTING THE J`/� ll d / I � /
Su i 't originalDATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] Quality Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Boa): ® Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
COLLINSVILLE RD, DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER STEVE & AVA BURNEY
Address COLLINSVILLE RD
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 09/26/06
5. TOTAL DEPTH 485
6. CUTTING COLLECTED ❑ YES y NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 25 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated aVor below land surface requires a variance in accor-
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
From
From
From
Depth
0 To
To
To
Type: CHLORYTE Amount: 12.5
Wall Thickness
Diameter or Weight/Ft Material
40 FL 6-1/4" SDR.21 PVC
Ft.
14. GROUT:
Depth
From 0 To 20
From To
15. SCREEN:
Depth
From _ To
From To
From To___
16. SAND?GRAVEL PACK:
Depth Size
From _ To Ft. _
Fmm To Ft.
17. REMARKS:
Ft.
Material Method
Ft.OUICRE•I'E POURED
Ft.
Diameter Slot Size Material
Ft. _ in.____ in.
Ft. in._ in
Ft. in. in.
Material
le.t. 3S'I3' z o•." t'J
(on) SZ° S' to. vU
RECEIVED
DIV. OF WATER QUALITY
OCT 0,6 2006
If additional space is needed use back of fort
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RIGHT ON COLLINSVILLE
RD, APPROX 2 MILES. RIGHT AT LARGE BRICK COLUMNS
WITH GATE.
RECEIVED
OCT 17 2 Q3
Asheville Regional Office
Aquifer Protection
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
GNATURE OF P.. ON ONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Boa): ® Residential 0 Municipal [] Industrial --
0 Recovery 0 Heat Pump0Other H Other, Water Injection0Agricultural ❑Monitoring
2. WELL LOCATION: (Show sketch of the location below) er, List Use: _
Nearest Town: COLUMBUS County: POLK
HORSE POWER RD. DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER COOPERRHS
Address HORSE POWER RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 09/05/06
5. TOTAL DEPTH 70
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 70 Ft. 24 CEMENT
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in._ in.
From To Ft. in._ in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 50 To 70 Ft. 78M GRAVEL
From To Ft.
17. REMARKS:
$3S°i( S14""J
('.`) In-. 9 '-iG 15" w
DEPTH
Formation Description
v A
RECEIVED
OCT ] '/ ZjLv
Asheville Regional Office
A*uiter Protection
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING. LEFT ON HORSE POWER
RD. ONLY HOUSE ON ROAD.
DIV.O RECEIVED
WATER QUALITY
OCT 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
0
SIGNh1URE O1IPERS
Submit original to Division of Water
• r:•
4: •i
%iTho i SC-0�
STRUCTING THE WELL DATE
ty, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): U Residential 0 Municipal ❑ Industrial ® Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
HONOR LANE DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER GENE WII,SON
Address HONOR LANE
(Street or Route No.)
MILL SPRING NC 28756 •35' LC' $;, o5"N
City or Town State Zip Code
4. DATE DRILLED 09/26/06 iono $ Z' io' 44t b t ' W
5. TOTAL DEPTH 41
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WA TER LEVEL Below Top of Casing: 26 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: S IEEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 6.9*
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 41 Ft 24 CEMENT
From To Ft. _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From ToFt.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in.� in
From _ To Ft. _ in. in.
From To FL in. in.
16. SAND7GRAVEL PACK:
Depth Size Material
From 26 To 41 Ft. 78M GRAVEL
From To Ft. _
17, REMARKS:
RECEIVED
OCT 17 2Ui
Asheville Regional Office
A*uifer Prote tiOn
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING. LEFT ON BIG LEVEL .
RT. ON WOMACK RD. LEFT ON HONOR LANE. 1st, DRIVE
ON RIGHT.
RECEIVED
DIV. OF WATER QUALITY
OCT 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
CO UCTING THE WELL DATE
Submit original to Division of W : , Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Depmhuent of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
33570E
1. WELL USE (Check Applicable Box): ® Residential U Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
BREEZY HILL LANE DRILLING LOG DF�,P-TH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation nescription
3. OWNER HUBERT METCALF T
Address BREEZY HILL LANE
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 11/13/06
5. TOTAL DEPTH 59
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 39 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface°
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
Depth Diameter
From 0 To 59 Ft. 24
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Wall Thickness
or Weight/Ft Material
CEMENT
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size
From 39 To 59 Ft. 78M
From To Ft.
17. REMARKS:
Material
GRAVEL
35° (4' 4i• I" IQ
14430401
-
I c5 o LE' S 47"'.)
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON SANDY PLAINS
RD. RT. ON FLOYD BLACKWELL. LEFT ON BREEZY HILL
LANE. 1ST HOUSE ON LEFT
DECEF ED )at.)N
IV nF
h G z 70
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG ATL RE pF p
Submit original to Division of Wa
CON CTING WELL DATE
ty, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLE
COUNTY LINE RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER GEOFFREY ROSE
Address COUNTY LINE RD.
(Street or Route No.) A/
COLUMBUS NC 28722 k4. 35 ° ! 9 ' 2 '
City or Town State Zip rode h, g Z° Z' S2" "�
4. DATE DRILLED 10/11/06
5. TOTAL DEPTH 405
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ►Z NO
8. STATIC WATER LEVEL Below Top of Casing: 60. FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 10.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 85 Ft. 6-1/4" SDR.21 PVC
From To Ft,
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in.in.___,
From To Ft. in. in.
From To Ft. ___ in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. _
17. REMARKS:
If additional space is needed use back of form
t 344 21
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY, #108 E. FROM MILL SPRING. RIGHT ON COUNTY LINE
RD. 2/10 MILE ON RIGHT, GRAVEL DRIVE. (STEEL CABLE)
oN.
ORWAEE eD imir(
�CtiB @ E 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
eubmi,,1 �i�, ,r 1�ir%t3 // —
SIG�NA OF ERSONCONSTRUCTING L DATE
/t original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELLUSE (Check Applicable Boa): ® Residential ❑ Municipal
0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use: ___
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK DRILLING LOG DEPTH
NORTH HIGHLAND DR.
(Road Nam
e and Numbers,
CNDSTADTER, or �vision and Lot No.) From To Formation Description
OWNER3. MICHAEL
Address NORTH HIGHLAND DR.
(Street or Route No.) 28756
MILL SPRING
City or Town State Zip Code
4. DATE DRILLED 10/06/06
5. TOTAL DEPTH 645
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ►. NO
8. STATIC WATER LEVEL Below Top of Casing:_F f.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 20+ METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 18
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 95 Ft. 6-1/4" SDR.21 PVC
From To Ft
From To Ft.14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft _
15. SCREEN:
Depth Diameter Slot Size Material
From _ To Ft. in. in.
From _ To___ _ Ft.
From _ To Pt.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: ___
in. iht
in. in
lad. 35"10 I.yq" A%
lot) x 2"
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. LEFT ON SILVER CREEK
RD. LEFT ON NORTH HIGHLAND DR (LAKE ADGER) 1sr DR.
ON LEFT.
RECEIVED
DN. OF WATER QUALITY
NOV 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
« - /1)- ,9 G
SIGNA OF Yn CONSTRUCTING THE WELL DATE
ubmit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

orth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
i36 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
fewest Town: TRYON County: POLK
DHN SMITH RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
• 0-
0
. OWNER RICHARD HAGAN
.ddress JOHN SMITH RD.
itreet or Route No.)
RYON NC 28782
'ity or Town State
. DATE DRILLED 06/06/06
Zip rMe
. TOTAL DEPTH 705
. CUTTING COLLECTED ❑ YES NO
. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
. STATIC WA 1ER LEVEL Below Top of Casing: 60 FT.
Jse "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 5 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount 19.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 40 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
4. GROUT:
Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From To Ft
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
in. in.
From To FL
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
il 3Vi3' 3Y" N
Iti^5 Sz 3' 5 . es" v./
m
r, i
:)
ry
m
0
rri
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RT. ON JOHN SMITH RD. 1
MILE ON RT.
c
r`-
I
G7)
ru
co
DO I.,'ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
cp� to -6 -
SIGNATUfcE O PERSON CONSTRUCTING THE WFJ.i DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

orth Carolina — Department of Environment and Natural Resources —Division of Water Quality — Groundwater Section
i36 Mail Service Center— Raleigh, N.C. 27699-1636 —Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
327703
. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
earest Town: TRYON County: POLK
ENRY THOMPSON RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER. MICHAEL BRIDGES
ddress HENRY THOMPSON RD.
itreet or Route No.)
RYON NC 28782 0
ity or Town State Zip Code li 3S i5 tO. 81r`. N
DATE DRILLED 059/06 140,, %Z ° S' "240.0 °1"'
. TOTAL DEPTH 64
. CUTTING COLLECTED ❑ YES ® NO
. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
. STATIC WATER LEVEL Below Top of Casing: 44 FT.
"se "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
:op of casing terminated at/or below land surface requires a variance in accor-
nce with 15A NCAC 2C.0118
). YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
1. WATER ZONES (depth):
Formation Description
2. CHLORINATION: Type: CHLORYTE Amount: 9.2
3. CASING:
Depth
From 0 To
From To
From To
4. GROUT:
Wall Thickness
Diameter or Weight/Ft Material
64 Ft. 24 CEMENT
Ft
Ft.
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
From To Ft. in. in.
6. SAND?GRAVEL PACK:
Depth Size Material
From 44 To 64 Ft. 78M GRAVEL
From To Ft.
7. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON SANDY PLAINS
RD. LEFT ON HENRY THOMPSON RD. LEFT @ FORKS. LOT
ON LEFT PAST GREY SINGLEWIDE.
y
0
:- C
DC)
r. - rt.
L
ry Of?
Cr.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF) COS WELL DATE
Submit original to Division of W Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
S-f 0

orth Carolina — Depaittu..at of Environment and Natural Resources — Division of Water Quality — Groundwater Section
536 Mail Service Center — Raleigh, N.C. 27699-1636 —Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION it: 2785
STATE WELL CONSTRUCTION PERMIT it:
WELL USE (Check Applicable Box): El Residential ❑ Mlmicipal ❑ Industrial ❑ Agricultural El Monitoring
❑ Recovery El Heat Pump Water Injection El Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
earest Town: COLUMBUS County: POLK
MITH WALDROP RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER MARK MAZZILLI
I
.ddress SMITH WALDROP RD.
itreet or Route No.)
OLUMBUS NC 28722
ity or Town State Zip Code
. DATE DRILLED 05/18/06
TOTAL DEPTH 225
. CUTTING COLLEC1hD DYES El NO
. DOES WELL REPLACE EXISTING WF.1.1 ? El YES ® NO
. STATIC WATER LEVEL Below Top of Casing: 60 FT.
"se "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
prop of casing terminated at/or below land surface requires a variance in accor-
ince with 1SANCAC 2C.0118
1YIELD (gpm): 100 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION:
3. CASING:
Depth
From 0 To 80
From _ To
From To
4. GROUT:
Depth
From 0 To 20
From To
5. SCREEN:
Type: CHLORYTE Amount: 5
Wall Thickness
Diameter or Weight/Ft Material
Ft.6-1/4" SDR21 PVC
Ft.
Ft.
Material Method
Ft.OUILKRETE POURED
Ft
Depth Diameter Slot Size
From To Ft in. • in.
From To Ft. in. in.
From To Ft. in. in.
6. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
7. REMARKS:
Material
Material
(a+ 3g' i7' i.(c4"
82` $` ta,lq"vI
(aim
If additional space is needed use back of form
32730.4
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RIGHT ON SMITH
WALDROP RD. 3/4 MILE ON RIGHT.
c
c
N
0
0
Q,
DO CERTIFY THAT THIS WELL WAS CONSTRUL lt.D IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNAT[ PrFR ESON UCTI G THE WELL �"(1/40 DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

From: Scott Gantt 7044347212 To: Stephenie Wilson
Date: 7/10/2006 Time: 6:06:44 PM Page 4 of 7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential © Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest town: FLAT ROCK
ENGLISH HEIFER RD
County POLK
(Street Name. Numbers. Community, Subdivision, Lot No,. Zip Code)
5. OWNER
ADDRESS
JEREMY RILEY
404 ENGLISH HEIFER RD
(Street or Route No.)
FLAT ROCK NC
City or Town State
Area Code - Phone Number
4. DATE DRILLED 6/8/06
5. TOTAL DEPTH 200
6- DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28731
Zip Code
YES ❑ NO 0
65 FT.
Ouse `a" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated atfor below Lind surface regimes a variance m
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 15 METHOD OF TEST ARDM
ta. WATER ZONES (depth): 200
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.17. 3 17 / 82.20.072
(degrees/minutesiseconds)
Latitude/longitude source: © GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Foliation Description
0 40 Clay
40 200 Consolidated Rock
it. DISINFECTION: TYPE HYPOCPLORI I Amount 7 Oz LOCATION SKETCH
12. CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or Weight/Ft. Material two State Roads or County Roads. Include the road
From 0 To 47 Ft 6 1/4 " SDR 21 PVC numbers and common road names. O
13. GROUT: C
Depth Material Method C "�j T,
From 0 To 20 Ft. GRAVEL MIX GRAVITY I'
y rt
14. SCREEN y
TV
Depth Diameter Slot Size Material �l
From NA To PC in. in. 0 • ▪ Or-;
On L�
15. SAND'GRAVEL PACK:
Depth Size Material
From NA To Ft, _':G.t
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

From: Scott Gantt 7044347212 To: Stephenie Wlson
Date: 7/10/2006 Time: 6:06:44 PM
Page 1 of 7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1- WELL USE (Check Applicable Box): Residential © Municipal ❑ Industrial D Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: COLUMBUS
132 UPPER RIDGE VIEW RD
County POLK
(Street Name, Numbers, Community. Subdivision, Lot No,. Zip Code)
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley fl Flat
Latitude/Longitude of well location
35-14.408 / 82.09.641
3. OWNER LUDWIG RITTER (degrees/minutes/seconds)
ADDRESS 132 UPPER RIDGE VIEW RD Latitude/longitude source: S GPS ❑ Topographic map
(Street or Route No.) DEPTH DRILLING LOG
COLUMBUS NC From To Formation Description
City or Town State Zip Code 0 50 Clay
Area Code - Phone Number
4. DATE DRILLED 7/8/06
5. TOTAL DEPTH 640
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES Q NO 0
300 Fr.
(Use "+- If Above Top of Casmgl
a. TOP OF CASING IS 2 Fr. Above Land Surface'
*Top of casing tenninaad at/or below hind surface requires a variance in
accordance with I5ANCAC 2C.0118
9_ YIELD (gpm): 1 METHOD OF TEST ARDM
to WATER ZONES (depth): 420
II. DISINFECTION: TYPE HYPOCHLORITE Amount 16
57 640 Consolidated Rock
L. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 57 FL 6 1/4 n SDR 21 PVC
13. GROUT:
oar
Depth Material Method
From 0 To 20 FL GRAVEL MIX GRAVITY
14. SCREEN
Depth Diameter Slot Size Material
From NA To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft,
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
t_
r
0,6
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7/8106
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

From: Scott Gantt 7044347212 io_ Stepneme Wilson
Date: 9/14/2006 Time: 8:57.34 PM Page 4 of 9
293 'i W fh
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDU AL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1- WELL USE (Check Applicable Boor Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use-
,_ WELL LOCATION:
Nearest town, LAKE LURE County POLK
TURNING LEAF LANE, OFF GRASSES KNOB RD
(Street Name, Number, Community, Subdivision. Lot No,. Zip Codel
S. OWNER
ADDRESS
JACKIE FOX
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley 0 Flat
Latitude/Longitude of well location
35.38.942 / 81.17.155
(degrees(minutes/seconds)
2006 HINES CIRCLE Latitude/longitude source: ❑ GPS ❑ Topographic map
(Shutt or Route No.)
STANLEY NC
City or Town State
'04-236-5089
Area Code - Phone Number
4. DATE DRILLED 8/3,06
5. TOTAL DEPTH 120
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28164
Zip Code
YES 0 NO E
20 FT.
ruse If Above Top of Casing)
8. TOP OF CASING IS e FT. Above Land Surfaces
`Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm):
30 METHOD OF TEST ARDM
10_ WATER ZONES (depth): 50 80 110
DEPTH DRILLING LOG
From To Formation Description
0 35 Clay
35 120 Consohdated Rock
it. DISINFECTION: TYPE HYPOCHLORITE Amount 5
Oz
LOCATION SKETCH
v. CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or WeighlFt. Material two State Roads or County Roads. Include the road
From 0 To 43 FL 6 1 14 " SDR 21 PVC numbers and common road names.
U. GROUT:
Depth Material Method
From 0 To 20 FL GRAVEL MIX GRAVITY
1d. SCREEN
Depth Diameter Slot Size Material
From NA To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft,
16. REMARKS:
SEE 2 y 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
8/3/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone]. within 30 days.
GW-I REV. 07/2001

From: Scott Gantt To: Stephenie Wilson Date: 6/21/2006 Time
:07:36 PM Page 3 of 5
WELL CONSTRUCTION RECORD 3 2 I U 4
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
Of applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: COLUMBUS
HOOPER CREEK FARMS , LOT 2 ARLYS RD.
County POLK
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER LUDWIG RITTER
ADDRESS 132 UPPER RIDGE VIEW RD
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.13.214 / 82.08.909
(degrees/minutesrseconds)
Latitude/longimde source: 0 GPS ❑ Topographic map
(street or Rowe No.) DEPTH DRILLING LOG
COLUMBUS NC 28722 From To Formation Description
City or Town Stale Zip Code 0 125 Clay
828-808-0394 125 460 Consolidated Rock
Area Code - Phone Number
4. DATE DRILLED 5/16/06
5. TOTAL DEPTH 460
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO El
95 FT.
rust "*" If Above Top of Casing)
8. TOP OF CASING IS 2 Fr. Above Land Surfaces
'Top of casing tcnninated at/or below land surface requires a variance in
accordance with I5A NCAC 2C.01I8
9. YIELD (wm): 5 METHOD OF TEST ARDM
10. WATER ZONES (depth): 420
u. DISINFECTION: TYPE HIPOCHLORITE Amount 18 met LOCATION SKETCH
12. CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or Weight/FL Material two State Roads or County Roads. Include the road
From 0 To 130 FL 6 1/4 " SDR 21 PVC numbers and common road names.
13. GROUT:
Depth Material Method
From 0 To 20 Ft. GRAVEL MIX GRAVITY
14. SCREEN
Depth Diameter Slot Size Material
From NA To FL in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To FI,
16. REMARKS:
o6
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.
6/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

From: Scott Gantt To: Stephenie Wilson
Date: 621/2006 Time: 11.07:36 PM Page 2 of 5
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT If
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: COLUMBUS
BILL COLLINS RD
County POLK
(Street Name. Numbers, Community, Subdivision. Lot No,. Zip Code)
3?u153
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.15.986 / 82.077.888
3. OWNER CHUCK HOBART (degrees/minutes/seconds)
ADDRESS 2220 EDGEFIELD RD Latltude'ongitude source: ❑ GPS ❑ Topographic map
(Street or Route No.) DEPTH DRILLING LOG
SPARTANBURG SC 29302 From To Formation Description
City or Town State Zip Code 0 85 Clay
864-590-4466 85 200 Consolidated Rock
Area Code - Phone Number
4. DATE DRILLED 5/10/06
5. TOTAL DEPTH 200
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO El
45 FT.
(Use "+- If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of casing tmnimted at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 15 METHOD OF TEST ARDM
to. WA 1tR ZONES tdepth): 110 180
11. DISINFECTION: TYPE HYPOCHLORITE Amount 8
12. CASING: Wall 'Thickness
Depth Diameter or Weieht/Ft Material
From 0 To 94 FL 6 1 /4 " SDR 21 PVC
13. GROUT:
Oz
Depth Material Method
From 0 To 20 FL GRAVEL MIX GRAVITY
14. SCREEN
From
Depth
NA To
Diameter
Ft. in
Slot Size. Material
m
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To FL
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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.
6./ 1 /06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

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:
9 'i ri r,
i iJ I
ri alte/>/'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
aroPeP
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural C, Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 12-If Other, List Use: tine .or . /
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ere.t t/ ce-2-'tit i1'/C County / L/e.
eitec Ate9
(Road Name and Ntenbers. Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER
Address
�t ..1.,Vcr Ile.26 /S I%,ihwt
�S�tMeet or Houle No.)
fi
O7- .off fG .1974/.i^/
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH -N
6. CUTTINGS COLLECTED YES R". NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO0.
8. STATIC WATER LEVEL Below Top of Casing: 7/ FT.
(Use if Above Top of Casing)
9. TOP OF CASING 15 t / FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (pm)* 34 METHOD OF TEST AS.t'
/CO
11. WATER ZONES (depth)- So
12. CHLORINATION: Type /ei/ /d!F Amount .pr
13. CASING:
Wall Thickness
Depth , Diameter or Weight/Ft. Material
From To Sre Ft eL* 'o 512112/ /C//G
From To Ft
From To Ft
14. GROUT:
From,
arc% '
r7'
To
aaf
_Coe'
yyo
DEPTH
Formation Description
4,?.>7,t , zr eta'
4,01 etle.t0r,vcs
N 3r° /.5 . 3l ' Zood'g° at 4;19
If additional space is needed use back of form
, Depth Material Method
From 6 To 20 Ft ,dE.ucb0/-elf, 16 if F
From To Ft
15. SCREEN:
e th Diameter Slot Size Material
From o Ft in in
From _ To Ft. in _ in
From To Ft in in
16. SAND/GRAVEL PACK:
De th Size Material
From /t/ o Ft
From ,��T/oo Ft. �1
17. REMARKS: 1014: 4'/4tf5 4/�'//Pl4V'f d .G 7;er,t/ We/J eXece
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.
LOCATION SKETCH
(Show direction and distance from at least two State 17
O_
rG
o-..
/9r
Roads, or other map reference points)
470,
r
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # c 13 8
3 312 4 a
1. WELL CONTRACTOR:
1 ((��
JAMes I.(), Czimp
Well ontractor (Individual) Name 11
am 5 jA)e 11 Pimp Co.) Inc.
Well Contractor Company Name Q, / �
STREET ADDRESS I" D Box x `T a
/[ekthora NiC a2$04D
City or Town State Zip Cale
(S-1.8 } I453- 932,-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED '7 2 m — D (
TIME COMPLETED J£S AM'PM❑
3. WELL LOCATION:
CITY:
�Allti�a
COUNTY ('O l K.
J') yl
(Street Name, Num , Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope alley ❑Flat ORidge ❑Other
(check appropriate box)r
LATITUDE �_ 2ryf' 1 !. 44 3
LONGITUDE 2` c l7r.// 70 el
Latitude/longitude source: '[dGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this forrn 7not using GPS)
4. WELL OWNER L,l I` Y l r rAd rs
OWNER'S NAME Y � 1V16. / ILK, ,71T" E
STREET ADDRESS Ti B D x 1 D a 13
Sal N� ;W7'13
City a Town State Zip Cale
Area code - Phone number
May be in degrees,
minutes, seconds Or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: 2,0
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO �I
c. WATER LEVEL Below Top of Casing: 2, 5 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Tap of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)
): 7 D METHOD OF TEST A 1 r
f. DISINFECTION: Type CAA 10 Y iyi e
g. WATER ZONES (depth):
From
From
Fran
6. CASING:
To
To
To
From
From
From
Amount / C up
Depth /.II Diameter
Fran o To Y G Ft h ,9
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
SOX�1 P ✓c.
7. GROUT: Depth Material Method
From D To ao Ft. 5acHA- / A -A et
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
To
From •
From
Ft.
Ft.
To Ft.
10. DRILLING LOG
From To
D 4to
io °LD5
11. REMARKS:
Size
Material
Formation Description
rlirt) 5Ya✓e Ir sand
Caki5611 late 1 ro.1( o
42.?
N
0
I DO HEREBY CERTIFY THAT TMS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THR
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG
RE OF CERTIFIED WELL C
—v'
cc.JAfines jJ.
PRINTED NAME O PERS
NTRACTOR DATE
W1
N CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC-27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 13 g
33 258
1. WELL CONTRACTOR:
wv(es fit. , �tm�
Well Contr�4.-mor(Ind 1, N. ftt ail CC . )Tn7 T.
Well Contractor Company Name /YJ
P D box i1
STREET ADDRESS
!eKboro is ago 0
City or Town State Zip Code
(/2•9 )- 453-'73;g-
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 Applicable Box): Residential Water Supply [�
DATE DRILLED ZS ' I' — /D 6
TIME COMPLETED ) I . q 7 AM (V'PM ❑
3. WELL LOCATION:
CITY: 1 II 510 r) yl gg COUNTY_BA____
,2b5trliknoA Rd.
(Street Name, Numb". Community. Subdivision, Lot No., Parcel, Zip Code)
VT POGRAPHIC / LAND SETTING:
Slope °Valley ❑Fiat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 ^' II, 36C
LONGITUDE) 2-e /0, 03r-
Latitude/longitude source: I2GPS °Topographic map
fixation of wel must be shown on a USGS topo map and
attached to this form %not using GPS)
4. WELL OWNER
OWNER'S NAME ��) G IA vie K(?✓�N`16Y(h
STREET ADDRESS (240 Don y Knto 11 Kd.
5 City orT� 1 I �� State to -Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS: d,�(l ^ 5-
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO,
c. WATER LEVEL Below Top of Casing: 55 FT.
(Use if Above Top of Casing)
d. TOP OF CASING 15 FT. Above Land Surface•
'Top of casing terminated aVor belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): D�U METHOD OF TEST Lr{
f. DISINFECTION: Type C k)a ✓l Vie Amount I Cap
g. WATER ZONES (depth):
From To From To
From To Fran To
From To From To
6. CASING: Thickness/
Depth Qiameter Weight Material
Fran0 To '/ FL (n I/U SDRE PVC -
Fran To Ft.
From To Ft.
7. GROUT: Depth �1 Material M- od
.y From 0 To -0 Ft. Cs( Lkytic Picot
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 •7o sek.A )0t1 It
11. REMARKS:
�)45oli/14fl re (.-1( C-3
7 _ _
1V
CFI r'
0
p. 7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGN
TUR OF CERT FIED WELL CO RACTOR DATE
PRINTED NAME OF PERSON CONSTRICTING THE WELL
Submit tha original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1 .i11 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form SW -la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 138
1. WELL CONTRACTOR:
James I,t)r CHIP
Well CFtractor (Individual) Name
LAWNps lt)e it +- PLmp C .
Well Contractbr Company (Name
STREET ADDRESS b 130k 419
El-ilel(bore
TnL.
City or Town State Zip Code
(2 8 } 14 53 —)3 as
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED Q g d �o
TIME COMPLETED
�}:3D
AM ID PM
3. WELL LOCATION: pn, /
CITY: L—o l ITstLa.5 COUNTY 1" D I K
La mkt;Yt4 wrn2r. Dff Pen;e( RJ.
(Street Name. Numbers, munity, Subdivision, Lot No.. Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope alley ❑Flat ()Ridge ❑Other
(check Y
appropriate box) , r
LATITUDE 3 ° /4. �o
LONGITUDE I at if, 6, 0/
Latitude/longitude source: MGPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form snot using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER (�
OWNER'S NAME '7 &a of Coiaw� t5
STREET ADDRESS I P. bo7f iLLb
Colu-Jnl7u5 IJC_ 2R7aR
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: JY /-
b. DOES WELL REPLACE EXISTING WELL?, YES ID NOX
L
c. WATER LEVEL Below Top of Casing: '"I b FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing tmninated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 50 METHOD OF TEST A I r
L'l
lvS '�>ac reK601ida1ed vecic)
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC PC. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEJ,L OWNER
SIGNAA''4IRE OF CERTIFIED1WELL CONTRACTOR DATE
00. /
YVLE5 W • rQ
PRINTED NAME OF PERSON COttTRUCTING THE WELL
33
255
e.
f. DISINFECTION: Type C hit), P e
Amount I yz o f�
g. WATER ZONES (depth):
From To From To
From
From
To
To
From To
From To
6. CASING: Thickness/
Depth 2 Diameter Weight Material
From 0 To i0.D Ft. )' " 3 n (ir. i •
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 63 Ft &•7- Seal Orl
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From• To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
c
r 4- rtlrt.5avd c u_
i
o V--:
rr
73
C'r
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1697 Mail Service Center— Raleigh, NC276991617 Phone No. [phone] ext 568.
Form GW-i a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
331252
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & _Pump fn Tnr
Well Contractor Company Name
STREET ADDRESS P 0 Box 429
Ellenboro NC 28040
City or Town State Zip Code
( 828) 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
_WELL USE (Check Applicable Box): Residential Water Supply V
DATE DRILLED /
TIME COMPLETED a : 3 C AM ID PM 03
3. WELL LOCH 10 :
CITY: I )1 •�� Y I tl COUNTY 0
9Yeeh K i Vey gA )avtci— Lot lei,
(Street Name. Numbers. Community. Sub ivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND S NG:
-Slope oValley ❑Flat E Ridge ❑Other
(check appropriate box) (,
LATITUDE 3 ) • S1 7f
LONGITUDE 4i`.
Latitude/longitude source: eaths ❑Topographic map
(locabon of well must be shown on a USGS topo map and
attached to this form ? not using GPS)
4. WELL OWNER /11 .�
OWNER'S NAME J(�; e] Cie CC' •,U Yl6!YIA([hh
STREET ADDRESS 0 14
R 66-n. c N 6- 2g
State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
City or Town
( /-
Area code - Phone number
5. WELL DETAILS: r ir ,--
a. TOTAL DEPTH: `t L 7
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA Q
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): lOO METHOD OF TEST a 1 r
f. DISINFECTION: Type ChlOrlIle Amount IA-. CY,1S
g. WATER ZONES (depth):
From To From To
From To Fran, To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To .V( Ft. 6 j- SDR21 PVC
Fran, To Ft.
From To Ft.
7. GROUT: Depth
Material Method
From 0 To 20 Ft sackrete hand
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. _ in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
7
.94 L105
11. ' REMARKS:
Formation Description
sand i c lath .
Cbnsv1) dateA Eck',
c-
V
r—•1
0
C
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
I SA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD.HAS BEEN PROVIDED TO THE WELL OWNER
SIG UR OF CERTIFIED WELL C NTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
uhrnit the original to the Division of Watfr Quality, within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC276994617 • 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 # 138
331242
1. WELL CONTRACTOR:
dames Li • Ca.wy
Well Contractor (Individual) Name
�0.05 k )•
� T mtm Lc. L c.
Well Contractor Company Name
STREET ADDRESS 1) C Bon T °I
G-) CKNC a��LYD
City or Town State Zip Code
fi> 1-15-3-')3dQ
Area code- Phone number
2. WELL INFORMATION: q
SITE WELL ID #(irapplicable) Vo (t C ° CC, 0 1
STATE WELL PERMIT#(° applicable)
DWQ or OTHER PERMIT #(if applicable) /
ic
WELL USE (Check Applicable Box): Residential Water Supply H
DATE DRILLED / - j 7- oz /
TIME COMPLETED 3 45 AM 0 PM (Q'
3. WELL LOCATION:
CITY: NI; 11 I ) •) i') 1'(G COUNTY
Ne I I);n )) j(00,1wt.
(Street Name, Numbers. Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC/ SETTING:
❑Slope °Valley tat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3 CI " )1. 5 13
LONGITUDE %, a OU. L l7
Latitude/longitude source: »dPS 0 Topographic map
(bcatbn of well must be shown on a USGS topo map and
attached to this form IInot using GPS)
4. WELL OWNER }
OWNER'S NAME L 1 Eyr'L EO. ek lt_
STREET ADDRESS I I- I S. C W N I 51-
.
Pr-. Ye51- L-I NC a c4-3
Ci(y or Town tate Zip Code
00
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
r i
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO yy
/
c. WATER LEVEL Below Top of Casing: d' J FT.`'
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 4 METHOD OF TEST A l r
t. DISINFECTION: Type C k I o r l vie Amount C IN 5
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Wei ht Material
Fran (3 To IDa- FL LY'-1 SDg ZI PVC
From To Ft.
Fran To Ft.
7. GROUT: Depth Material Method
From 0 To ,...-0 Ft. Sa-C Creie licit yl 41
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
U IDn riirt. r
,oa ¶o5
11. REMARKS:
wy
Consoler
A
P C
roc t
L.
n
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- A
SIGMAE OF CERTIFIED WELL CONTACTOR DATE
A-yyl e 5 W r ('d
PRINTED NAME OF PERSON CONST�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

From: Scott Gantt To: Stephenie Wilson Date: 3/8/2006 Time: 9:42:44 PM
Page 3 of 4
From
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1_ WELL USE (Check Applicable Box) : Residential C Municipal
RecoveryI ❑ r, LiIndustrialt❑ Agricultural ❑ Monitoring ❑
❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: MILL SPRING
STANLEY DR, OFF LAUGHTER RD LOT 4 & 5
County POLK
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER SCOTT MARSH
ADDRESS 5965 Hwy 9
(Street or Route No.)
MILL SPRING
City or Town
828-625-2904
NC
State
Area Code - Phone Number
4 DATE DRILLED 2/3/06
5. TOTAL DEPTH 400
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28756
Zip Code
YES ❑ NO
0 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface`
'Top of casing terminated at/or below land surface requires 2 valance in
accorda ere with 15A NCAC 2C.0118
9. YIELD (gpm): 0 METHOD OF TEST ARDM
10. WATER ZONES (depth): NA
if DISINFECTION: TYPE HYPOCHLORITE Amount l2
%op
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.23.019 / 82.11938
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
From
0
DEPTH
To
55 Clay
DRILLING LOG
Formation Description
55 400 Consolidated Rock
12. CASING: Wall Thickness
Depth Diameter or WeightPt. Material
From 0 To 62 Ft 6 1/4 " SDR 21 PVC
13. GROUT:
From 0
14. SCREEN
Depth
To
Depth
From NA To
Oz
Material Method
20 Ft GRAVEL MIX GRAVITY
15. SAND/GRAVEL PACK:
Depth
NA To
16. REMARKS: DRY WELL
Diameter
Ft. in
Size
Ft,
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
3/1/06
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
RECEIVED
MAR 2 7 2006
GW-1 REV. 07/2001
Asheville Regional Office
Agyffer Protection

rrom: Scott Gantt To: Stephenie Wlson
Date: 3/8/2006 Time. 9:42:44 PM Page 4 of 4
WELL CONSTRUCTION RECORD 1
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ❑ Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use: 0
2. WELL LOCATION:
Nearest town: MILL SPRING
STANLEY DR, OFF LAUGHTER RD LOT 4 & 5
County POLK
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER SCOTT MARSH
ADDRESS 5965 Hwy 9
(Street or Route No.)
MILL SPRING
City or Town
NC
State
28756
Zip Code
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude%Longitude of well location
35.23.001 / 82.11.945
(degrees:minutes/seconds)
Latitude,ongitude source. ❑ GPS ❑ Topographic map
DEPTH DRILLING LOG
To Formation Description
50 Clay
From
0
828-625-2904 50
Area Code - Phone Number
4. DATE DRILLED 2/8/06
5. TOTAL DEPTH 400
6. DOES WELL REPLACE EXISTING WELL'
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO E
70 FT.
(Use "*" II -Above Top of Casing)
8. TOP OF CASING IS 2 F7. Above Land Surface*
*Top of casing tcnninated at/or below land surface requires a variance en
accordance with 15A NCAC 2C0118
9. YIELD (gpm): 2 METHOD OF TEST ARDM
10. WATER ZONES (depth): 250
580 Consolidated Rock
11. DISINFECTION: TYPE HYPOCHLORITE Amount 24
12. CASING:
Depth Diameter
From 0 To 59 Ft. 6 1 /4 "
13. GROUT:
From 0
14. SCREEN
Wall Thickness
or Weight/Ft. Material
SDR2I PVC
Oz
Depth Material Method
To 20 Ft. GRAVEL MIX GRAVITY
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS: DRY WELL
Diameter
FL in.
Size
Ft,
Slot Size
in
Material
Material
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
O
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.
3/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater
27699-1636 Phone No. [phone], within 30 days.
S�.L.,.., 1636 Mali Set ore center - Haterght
RECEIVED
MAR 27 2006
Asheville Regional Office
Aquifer Protection
Date
NC
GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Wee Contractor.(IndMdual) Name
Camp's Well & Pumo
Co. Inc
Well Contractor Canpany Name
STREET ADDRESS P O Doi 429
Ellenboro NC 28040
City or Town State ZIP bale
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Ot applicable) •
STATE WELL PERMIT#(aappliceble)
DWQ or OTHER PERMIT #(S applicable) /
WELL USE (Check Applicable Box): Residential Water Supply is
DATE DRILLED if
7 ,I
TIME COMPLETED Go
3. WELL LOCATION:
t '
CITY: 1 ) ✓) YL
�rc kla ni uLP_LJ
(Street Pane. Numbers. CommuNty, Subdivision. Lot
TOPOGRAPHIC 1 LAND SETTING:
❑Slope DValey °Flat °Ridge ❑Other
(chock appropriate box)
LATITUDE _ e ca°• 6'6 61Z-
LONGITUDE 1 a_ D
i ! 3
Latitude/longitude source: GPS °Topographic map
(bcagon o/Wei must be shown on a USGS topo map and
attached to this fan Inot using GPS)
AM O(� PM
n
COUNTY 'Y O j K
hl 14;akin d ftirnl
Parcel. .21p Code)
Maybe )n degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
STREGT ADDRESS
ro Be ac k
City or Town State
ele-t idle(
✓di
L
Zip Code
Ansaa code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: .5 4 5 .,
b. DOES WELL REPLACE EXISTING WELL? VEESp NO
c. WATER LEVEL BelowTop d Casing: J FT,
(Use'+' If Above Top of Casing)
d. TOP OF CASING 1S 1 FT. Above Land Surface'
?op of casing terminated aUor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a METHOD OF TEST GU r
f. DISINFECTION: Type c)'ilOrine Amount _.VJ
g. WATER ZONES (depth): �� �� ��
From To
From To
From To
8. CASING:
Depth a/ Diameter
From 0 To "1 Ft 6•
From To Ft.
From To •Ft.
From To
From To
From To
Thlclmess/
Weight Material
SDR21 PVC
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
Front__ To Ft
8. SCREEN: Depth Diameter Slot Size .Materiel
From__ To Ft In. In.
From To_ Ft in. in.
From_ To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft.
From To Ft
From To Ft.,__'_
10. DRILLING LOG
From To.
0• qlt
ForrpmTatioq Description
SccPtdl clay
•
Coot o i (ice (.1 re r-K
RECLztqf
•
8sr1eVi11:. r�(. ,:
11. REMARKS:
cl
I DO HEREBY WIMPY MAIMS WELL WAS CONS1RUC1ED IN ACCORDANCE wins
15A NOAC20. WELL CONSTRUCTION STANDARDS, AND "MAT ACOPY OE THIS .
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
A CaEL� f404
kcERTID WELL CONTRACTOR CTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
SIG
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 end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELLCONTRACTOR:
James W Camp
Well Contractor (Individual) Name
Camp's Well & Pump Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tarn State Zip Cole
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #UI applicable)
STATE WELL PERMIT#(8applicable)
DWQ or OTHER PERMIT #(K applicable)
WELL USE -(Check Applicable Box): Residential Water Supply
DATE DRILLED 4 - - D t
TIME COMPLETED ' 02Viev N AM 0 PM (g'
3. WELL LOCA^TIO : 1I
CITY: t `' I1 )l Debt i Ai COUNTY PO l <
TOPOGRAPHIC / LAND SETTING
❑Slope °Valley Ci tat °Ridge Daher
(check appropriate box)
LATITUDE . 5` /g • if(LONGITUDE g a2° o2.3g5
Latitude/Iongitude source: V6PS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this faro not ushg GPS)
tieek R;ver lowl5 -Lot )31e
(Street Name Numbers. Community, Subdi Ion, Lot No., Pareel;2lp Code)
May be in degrees,
minutes, seconds or
in a decimal forma
f. DISINFECTION: Type chl Orine Amount I C 0.11
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From To
6. CASING:
TMcimese/
Depth Diameter We ht Material
From 0 To chh Ft. b t SD 21 ' PVC
From To Ft _
From To .Ft _
7. GROUT: Depth Materiel
From 0 To 20 Ft Sackrete
From To Ft.
Fran To Ft
8. SCREEN: Depth
From To
From To
From To
Method
Hand
Diameter . Slot Size .Material
Ft. In. In.
Ft. In. In.
Ft. In. In.
9. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft
Fran_TTo Ft
10. DRILLING LOG
From To . Fonnalion Description
0 55 cf; tl Send
Try- 930
Cp y(5 c l i d it e d r c c.K.
us+
WELL
ER
d. OWNER'S
ERNAME �21 1 I K) vms -l,' t o iv1101
STREET DRESS w l 5-0 J &ba-I N1Yt.t Ctrz I'
rDrfi Ora t rl_ 30alas
City or Tam Mate Zip Code
(�)
Area code - Phone number
5. WELL DETAILS: " r .
a. TOTAL DEPTH: J
b. DOES WELL REPLACE EXISTING WELL? YES p NOA
c. WATER LEVEL Below Top of Casing: 3 .S FT,
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Lend Surface'
'Tap d casing termNated at/or below land surface may require
a valiance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): 94, METHOD OF TEST AI P
11. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
isA NCAC 20. WELL CONSTRUCTION STANDARDS, AND THATACOPY OF. THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
P
SI T.0 E OF CERTIFIED WECk CO RACTOR
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality within;30. days. Attn: Information Mgt.,
1617 Mall Service Center - Raleigh, NC 27699.1617 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05

' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quarry
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & Pum.p Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 Bog 429
Ellenboro NC 28040
City or Tom State Zip Cetie
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID CO applicable)
STATE WELL FERMIUM applicable)
DWQ or OTHER PERMIT #(If applicable) /
WELL USE (Check Applicable Bea): Residential Water Supply Qy
DATE DRILLED 7 " Al -_0
TIME COMPLETED 3: 1-} 5 AM ❑
3. WELL LOCATION:
-Tie I r o Yt
PMbi
comity Polk
G nik PVI
(Street Name, Numbers. malty, Subdivision, Lot No., Parcel Code)
TOPOGRAPHIC 1 LAND SETTING:
OSlope OValey DFWt ORidge ❑Otter
(Chadic eppropdatabc90
LATITUDE S ,.0 i3 3 16
LONGITUDES ac )3' 65
Latitudc/Iongitude source: rpirPS OTopographic map
(bcatbn of
must
be shown
fA usion ng a U GS � map and
toattached this
4.WELLOWNER {-
OWNER'S NAME )fI1 5L.} 7)&Ie LokttStrUc AoYt
STREplf ADDRESS elk i5 %AKcets eme
9(eer S C o29G �c
City orTam State Zip Code
May be. In demos,
minutes, seconds or
in a decimal rennet
Area code Phone number
5. WELL DETAILS: 6J
S. TOTAL DEPTH: ,�,/ /
b. DOES WELL REPLACE EXISTING WELL? I YES p NO Y'
c. WATER LEVEL Belau Top of Casing: 4 0 FT,
(Use se 0 Above Top of Casing)
d. TOP OF CASINO 13 1 . FT. Above Land Surface*
:Top el easing terminated et/or belay land surface ni@y require
a variance In accordance With 15A NCAC 2C .0118.
e. YIELD (gpm):..22._METHOD OFTEST a.i Y
f. DISINFECTION: Type Chlori.ne Amount I/x c+.(
g. WATER ZONES (depth):
Rom To
Ran To
From To
6. CASING:
From 0DTom rP5 Ft. 67ter
Ran To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 70 20 Ft Sackrete Hand
From To FL
From To Ft
From To
From To
From To
Thickness/
Weight Material
SDR21 'PVC
8. SCREEN: Depth Diameter Slot Size .Material
Rom_ To Ft. In. M.
From ToFt. in. in.
From_____ To Ft in. In.
9. SANDIGRAVEL PACK:
Depth Size MaterialFrom To FL
From To Ft.
Fran To FL
10. DRILLING LOG
From .To_.
0•
/e5 '3011
Formation Desnriptbn
Sarid 15 ra✓ e l ( lay
rottsoli(late() rocK
10'
11. REMARKS:
"LT
0i
I DO HEREBY CERTIFYTNATTHIS WELL WAS CONSTRUCTED NACCORDANCE WITH
16A NCAC 20, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THI$ •
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG U E OF CERTIFIED'W WELL CONTRA DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within ;30. days. Attn: information Mgt.,
1617 Mali Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
James W. Cann
W dl C.onhaeta.(NdMdual) Name
Camp= e?1 R Pmn. Inc_
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City a Town State Zip Code
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SHE WELL ID Of eppendie)
STATE WELL PERMITO(eepPileable)
DWQ or OTHER PERMIT #(0 applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED/' Rj ..()C'
TIME COMPLETEDAMO PMad
_—
3. WELL LOCH ON' 3
CITY: I f II �:9r'i Arti_ COUNTY i 0 I TK
cLylcl yte
(Street Name. Numbers, .onununity, uIMMsbn, Ld No., Parcel, Zi9 Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVaOey OFIat Tdttidge CI Other
trams eppropdataba0
LATITUDE _1-- � , ), 4 94
LONGITUDE 2- f 3' q.0 &A%
Latitude/longitude source: OOPS DTopogaphic map
a(catbnoro fomt # shown g p j GStopOmapand
4.WELLOWNER �^(
OWNER'S NAME po, i 't%we L-iJ
IMay to in aepea,
minutes, seconds or
in a decimal knot
STREPDDRESS
City or Two I State Zip Code
T
Aroacodee phone number S. WELL DETAILS: �7
a. TOTAL DEPTH: ~/) y
b. DOES WELL REPLACE EXISTING WELL?� YES p NO (D,
c. WATER LEVEL Below Top d Casing �' 1
(Use '+'.8 Above Top of Casing)
d. TOP OF CASINO IS 1 FT. Above Lend Surface'
:Top of casing terminated allot belay land surface may require
a variance in accordance with 15A NCAC 2C .0118..
e. YIELD (gpm): 2(2.— METHOD OF TEST /LJ (
$ESIDENTIAL WELL CONSTRUCTION'RWORD
North Carolina Department of Environment and Natural Resources- Division of Water Quarry
2138'
r. DISINFECTION: Type Chlorine Amount (�9. ["`t(
g. WATER ZONES (((gdth`,):
From Too From To
From To From To
From To From _ To
S. CASING:
Thickness/
Depth - D]ametof Wo�p� Materiel
Fran O To i l Ft 6# SDR21 PVC
From To Ft.
From To .Ft
7. GROUT: Depth - Material Method
From 0 To 20 Ft Sackrete Hand
Fran To Ft
Front . To Ft.
8. SCREEN: Depth Diameter ID. Slot Sim In..Material
From To Ft
From To Ft In In.
From_ To Ft In. ^ in.
9. SAND/GRAVEL PACK: Depth Size Material
From To_ FL
From To Ft �--
From To Ft. •-
10. DRILLING LOG
From
0•
ormationset'tption
,t,A lglm /
RFCIEIVE
-2D2M06
Asheviele Regional Office
--CritenTblecti
11. REMARKS:
CJ
I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA HOA BEEN PROVIDED 2C.UOSWELL WELL TION STANDARDS, AND
AT IHACOPPYY OFN
RECORDTis •h rn
Sjc T RE OF CERTIFIED W
James W. Cam
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit 16 7 Mall Seroriginal to the vicce Center - Rallvision of Watereigh, NC 27 99.1617 ucliP- Phone No. 919) 733 7 5 ext 568.Information Mgt.,
NTRACTOR BATE
Form GW-la
Rev. 7105

RESIDENTIAL WELL coNSTRU.c11ONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION II 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor . (IndhAdual) Name
Camp's Well & PUnD Co. Inc
Well Contractor Company Name
STREET ADDRESS P O Bok 429
Ellenboro NC 28040
City or Town State Zip bode
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID aril applicable)
STATE WELL PERMIT#N applicable)
DWQ or OTHER PERMIT a(If applicable)
WELL USE {Check Applicable
>B>ox): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED • I5— AM O PMI
S, CITYELL LOCY OIft: S COUNTY P61 K
F lett gRtrkCk Tr-K`l l
(Street Name, Numbers, Community. SubdMsion, idNo., Parcel;.21P Code)
.TOPOGRAPHIC 1 LAND SETTING:
12
1Siope OValey tonal CI Ridge ❑Other
(check epproCCPlataa?x) I,
LATITUDE S 2/ . '' `Y(o
LONGITUDE_ 1.JJ
I I . 1-57
Latitude/longitude source: ❑CPS oTopographic map
attached of wel
el must be shown on a USGS topo map and
not ho CPS)
4.WELLOWNER �NC
/7 ( /
OWNER'S NAME N CIbfv )&Arc' f
STREET ADDRESS nI
City or�S o F l cd 7Yti p1 C A� 7 f,
J Slate Lp Code
May be in degrees,
minute, seconds or
in a decimal format
Area codes Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NO 0
c. WATER LEVEL BelowTop of�0 Casing: V FT,
(Use se 8 Above Top of Casing)
d. TOP OF CASING IS 1 F7. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
305"
e. YIELD (gpm): METHOD OF TEST
r. DISINFECTION: Type chlorine Amoud
g. WATER ZONES (AT th):
From To It l)
From To
From To
6. CASING:
Depth
From L To /0. _Ft.
Fran To Ft
Fran To FL
7. GROUT: Depth
From 0 To 20
From To
From__ To
8. SCREEN:
From
From
From_
Depth
To
To
To
9. SANDIGRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To.
0• i`n\
From To
From To
From To
D)apreter
TMcbussl
SDR21
VC
Material Method
Ft Sackrete Hand
FL
FL
Diameter - Slot Size Matettal
FL in In.
Ft. in in.
FL In. In.
Size Material
Ft
Ft.
FL..
ormationpp scriptin
JAA . (1_ NA
(r\.0.rA JF1
RECEIVFn
MAR 2 7 2006
ca
C5
-Asheville-Regional-Office
AGUlter Protection
11. REMARKS:
1 DO HEREBY CERTIYTHATTHIS WELL WAS OONSrRUC1EDNA000RDANCE wnH
ISA NCA020. WELL CONSTRUCTION STANDARDS. AND TH&TA COPY OF THIS
RECORD HHA,SS_BEE'NDPROVIDED 701HEE�W,E,LI. OWNER.
SI9NIC•URE OF CERTIFIED WELL CONTRACTOR �.�TE G
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617mit Mall the
9inal to e Center- Raleigh, NC 27 99- 6117 Qualitye Division of Water Ph ne No. (9 9) 733 7Attn: ext 68.gon Mgt.,
Form GW1a
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
We Contractor.(1ndK 131) Name
Camp's Well & B]1mn Co.
Well Contractor Company Name
STREET ADDRESS P 0 BoX 429
EllenborO NC 28040
City or Town State Zip Code
(828)- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #8f applicable) '
STATE WELL PERMITA(It applkable)
DWQ or OTHER PERMIT #(S applicable) ,,/
WELL USE (Check Applicable Bat): RBsidenual Water Supply Q
DATE DRILLS
TIME COMPLETED ( 3 C'+ AM O PM di
3, WELL LOCAT,
CITY: • I 5; Yr1 COUNTY PC 17C
Inc
Lelia
(Street Name. N _ n. Community. SubdMsior2 Lot No .
rce
TOPOGRAPHIC/(ANDS ING:
OSlope OVaeey Wit ISCIOther
mr (ah appropriate box)
LATITUDE •i,1`=�`'
LONGITUDE,. & I D ' a44 It!
latitude/longitudesource: OOPS OTopogtaphicmap
�ch d to #r loam tnot uses; GPS)GS rope map and
4.WELL OWNER _ e
OWNERS NAME t C
STREET ADDRESS
Pa
l Zb Code)
City or Tam
Area code - Phone number
IMay be In degas,
m%nutes, seconds or
in a decimal form
State Zip Code
S. WELL DETAILS: 305
a. TOTAL DEPTH:_.
b. DOES WELL REPLACE EXISTING WELL.? ? IS p NOA
c. WATERLEVEL
11AboveTopofC
(U" Casing'.
d. TOP OF CASING IS 1 FT. Above Land Surface
'Top el casing terminated atIor belay land surface may require
a variance In with 15A NCAC 2C .0118.,
O`-� METHOD OF TEST A ite. YIELD(9Pm1��---
1, DISINFECTION: Type chlorine Amount / ?.'t Cdi/)S
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
8. CASING: kyneter
Fran 0To i 7r Ft 6#
From To Ft
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
Fran To Ft
Roma-- To Ft.
Thickest
Weight Material
SDR21 PVC
8. SCREEN: Depth
From To
From To
Fran T
9. SANDIGRAVEL PACK:
Depth
Fran To Ft.
From To Ft.
From To Ft
Diameter Slot Size
FL In. III.
Ft In. __ M.
Ft In. _ In.
Material
Slur Material
10. DRILLING LOG From To.
Formation DescripDescription.
S_Atl PO-
r
w
11. REMARKS:
I DO HEREBY CERTIFY T ATTHtS WELL WAS CONSTRUCTED N ACCORDANCE wrni
16A Nat 20, WELL RECORD HBEEN OVIDEDTOR STANDARDS. AND MAT AWRY OF. THIS
THE WELL OWNER
AS
S
I RE OF CERTIFIED WELL C
JameS W. C s—
RINTED NAME OF PE R ON CO
; cDATE
NTRACTOR DATE
am GW-ta
Submfthe original to the Division of Water Quality with n;30.days. Attn:Inform don Mgt 2 2�O�eY 7I05
1617 Mali Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 56 MAR
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
Noah Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camn
Well C.an.ractar.(IndMNdual) Name
Camp's Well & P_umD Co. Inc'
Well Contractor Company Name
STREET ADDRESS P 0 BoX 429
Ellenboro NC 28040
City or Town State Zip Oode
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tat applicable)
STATE WELL PERMIT8lif apPlicabit0
DWQ or OTHER PERMIT #Of applicable) J
WELL USE(Check Applicable Box): Residential Water Supply 11
DATE DRILLED _ GG• 0 C
TIME COMPLETED el 3 V AM ° PM ❑
3. WELL LOCON:
CITY:
COUNTY tl�Jl�
C
Moot Name, N rl Fs, Subdivision. Lot No., Perot Code)
TOPOGRAPHIC 1 LAND SETTING:
°Slope DVafey °Flat \@Ridge °Other
(caeca ppmpdatebox)
LATITUDE JL --!' :-.l.{ —IN
LONGITUDE fl , .tab
Latitude longitude source: OOPS °Topographic map
(bcetbn of we/must be shown on a USGS topo map and
seethed lades form lnot using GPS)
4. WELL N OWNERcc
Qku I (�•,
OWNER'S NAME �.L1�•� kit),
ST,itEET ADDRESS
,Yn tWyN�v DD
City or Town State
Ln(e
Area
code. Phone number 5. WELL DETAILS: �
a. TOTAL DEPTH: 0 0
b. DOES WELL REPLACE EXISTING WELL? YES p NO
cr.
f
WATER LEVEL Below Top of Casing: t0 FT'
(Use '4" 8 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated Woe below land surface may require
a variance It accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST Q
IMay be. in degas,
minutes, seconds a
in a dedanl format
f. DISINFECTION: Type chlorine Amount /7/g raps
g. WATER ZONES ((depth):
From To 140 From To
Fran To
Fran To
From To From To
8. CASING: - D)apt7aln Thy
Fran 0 DTepDepthFt eter SDR21 PWeigle VC
From To Ft 6t _
From To .Ft
7. GROUT: Depth Material
Fran 0 To 20 Ft Sackrete
Front_ To Ft
Fran . To Ft
8. SCREEN: Depth Diameter Slot Size .Material
Fran To Ft. In. In.
From To Ft In.
Fran To Ft in.
Method
Hand
In.
dr.
9. SAND/GRAVEL PACK: Depth Sim Materiel
From To Ft
From To Ft.
From To Ft^---
10. DRILLING LOG
From To
0• .104
•
11. REMARKS:
^ Fortrt@9On Description
I DO HEREBY CERWYTHATTHIS WELL WAS DONS1RUC1ED N ACCORDANCE WIM
RECDRD HAS BEEN PEDTOTHE WELL OWNER.niaACOPY OF. THIS
10
V
SI RE OF ERT ED WELLtONDATE
bA
TU
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ty within 30 days. Attn:
11617mMai Servlee Center - Raleigh, NC 2 699- 6117 ft the oriinal to the Division of VVater atlPh ne No. (9 9) 733 7015 eat 68.Oon Mgt.,
Form GW1a
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Ca
Weil Contracta.(IndMduaq Name
Camp's Well & Pump Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 Bo* 429
Ellenboro NC 28040
City «Tame ' State Zip Cade
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Ot applicable)
STATE WELL PERMIT#(lapp1Ieabie)
DWQ or OTHER PERMIT #(H applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED / - ✓� - (14
TIME COMPLETED ,%Z . Ilc AMC PMO
3.WELL LOCATJ� s
CITY:
lt'/Ce ./-iidgrr�Jr I4i)k/7i)�
(Street Name, Numbers. CaginunIty, SubdMsion, LotNo., PlUtelt BF Code
TpPOGRAPHIC / LAND SETTING:
bla Slope OVaDey [Mat ['Ridge Daher
(deck appropriate box).
LATITUDE _ 5 iq•9-84 k
LONGITUDE g Z ) Z• -? i W
IatitudeAongitude source: 0 GPS iTopographic map
attach attached to this lam l not shown USGS on a topo map and
using GPS)
4. WELLOWNER 1 +}-
OWNER'S NAME II1'1 3YI'111 V . SSOG.
STRE ADDRESS P D Bo X q I zs
Df(5a.r±/t blAtrq 5 G 45aS
City dr Town Slate Zip Code
May be In degrees,
minutes, seconds or
in a decimal brnmt
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: <5 111
b. DOES WELL REPLACE EXISTING WELL? YES NO 0
c. WATER LEVEL Below Top of Casing: :'I) FT.
(Use'+' 8 Abo a Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Tap of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118. ,
e.YIELD (gpm):Jn METHOD OF TEST air
6. CASING:
f. DISINFECTION:Type chlorine Amount 0 cat
g, WATER ZONES Me):I
From To 1 AV From To
From To From To
From To From To
Thickness/
Depth DWlneter Weight Material
0 FrOn To �6 FL 6# SDR21 PVC
From To FL
Fran To FL
7. GROUT: Depth Materiel Method
Fran 0 To 20 FL Sackrete Hand
From To Ft.
From . To Ft.
8. SCREEN: Depth Diameter Slot Sim .Material
From To Ft. In. N.
From To Ft. In. In.
From_____. To Ft. In. In.
9. SANDIGRAVEL PACK:
Depth Sim Material
Fran To Ft.
From To FL
Fro n To Ft.
10. DRILLING LOG
From lTo
0' t)
1-I.0 bb• •
V
aFoomronMn
7 2uu6
gio
0
Ant far rote Ion
11. REMARKS:
u
I COHEREBY CERTIFY SMITHS WELL WAS CONSIRUCIEDN ACCORDANCE WRH
i5A NCAC 2C, WELL CONS1RUC11ON STANDARD$, AND 1HATACOPY OF INS
R CORD HAS BEEN PROVIDED TO THE WELL OWNER.
� I� u1 lEL �•�1U1Ie
SIG OF CERTIFIEDWELL 'CO RACTOR DATE
ames W. Camp
i'RINTED NAME OF PERSON CONSTRUCTING THE WELL
11 17 Mall he
9e Center- Raleigh, NC 27699-1617 al Phone No. (9 9) 733 7015 exit 68.g Mgt.,
Form GW-la
Rev. 7/05

From: Scott Gantt To: Slephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM Page 11 of 12
326890
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE
ONE WQ PERMIT #
STATE WELL CONSTRUCTION PERMIT # (ifAapplicable)
(if applicable) ❑
I. WELL USE (Check Applicable Box) : Residential ® Municipal 0 Industrial El Agricultural ❑ Monitoring
Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATION: Topographic/Land setting
Nearest town: DANNY WOOTON County POLK ❑ Ridge 0 Slope ❑ Valley 0 Flat
625 ABRAHMS MOORE RD Latitude/Longitude of well location
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
35.18.850 / 82.03.357
(degrees/minutes/seconds)
3. OWNER DANNY WOOTON
ADDRESS 625 ABRAHMS MOORE RD Latitude/longitude source: 0 GPS 0 Topographic map
(Street or Route No.) DEPTH DRILLING LOG
MILL SPRING NC From To Formation Description
City or Towo State Zip Code 0 47 Clay
47 280 Consolidated Rock
828-863-2990
Area Code - Phone Number
4. DATE DRILLED 5/5/06
S. TOTAL DEPTH 280
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO El
60 FT.
(Use "a" IfAbove Top of Casing)
8. TOP OF CASING IS 2 F. Above Land Surface*
°Top of casing terminated at/or below laid surface requires a variance in
accordance with 15A NCAC 2C 0118
9. YIELD (Wm): 20 METHOD OF TEST ARDM
O
10. WATER ZONES (depth): 275 T "*7
11. DISINFECTION: TYPE HYPOCHLORITE Amount 10
or LOCATION SKETCH a !U`+
—G
12. CASING: Wall Thickness Show direction and distance in miles from at least J -.- l
Depth Diameter or Weight/Ft. Material two State Roads or County Roads. Include the road P
From 0 To 54 Ft 6 1/4 " SDR 21 PVC numbers and common road names. o CDtii
r
13. GROUT: cmf�
Depth Material Method --i
From 0 To 20 Ft GRAVEL MIX GRAVITY -<
19. SCREEN
Depth Diameter Slot Size Material
From NA To Ft in iu
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
5/6/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
JUN 06 2006

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM Page 10 of 12
326Q tl
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTF CANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE
ASSOCIATED WQ PERMIT #
STATE WELL CONSTRUCTION PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County POLK
PINNACLE SUBDIVISION , GRASSEY KNOB RD, WELL FOR WATERFALL
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER BOB ROWELL LAND AND TIMBER (degrees/minutes/seconds)
ADDRESS 260 Amanda Ct Latitude/longitude source: 0 GPS 0 Topographic map
(Street or Route No.) DEPTH DRILLING LOG
MOORE SC 29369 From To Formation Description
0 20 Clay
Topographic/Land setting
❑ Ridge ® Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.24.143 / 82.10 780
City or Town State
864-595-4360
Area Code - Phone Number
4. DATE DRILLED 5/3/06
5. TOTAL DEPTH 93
6. DOES WELL REPLACE EXISTING WELL'
7. STATIC WATER LEVEL Below Top of Casing:
Zip Code
YES 0 NO El
45 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
'Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.01I8
9. YIELD (gpm): 20 METHOD OF TEST ARDM
10. WATER ZONES (depth): 90
20
93 Consolidated Rock
it DISINFECTION: TYPE HYPOCHLORITE Amount 3 oe LOCATION SKETCH
12. CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or Weight/FL Material two State Roads or County Roads. Include the road
From 0 To 27 FL 6 1/4 " SDR 21 PVC numbers and common road names.
13. GROUT:
From 0
Depth Material Method
To 20 FL GRAVEL MIX GRAVITY
4. SCREEN
Depth Diameter Slot Size Material
From NA To Ft in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-lYv� 5/4/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
JUN 0 6 2006

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM Page 9 of 12
32688
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - GroundCERTIater FICATction
ION # 2554
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC.
SSOCIAPHONE
ONE WQ PERMIT #
STATE WELL CONSTRUCTION PERMIT #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County POLK
PINNACLE SUBDIVISION , GRASSEY KNOB RD, WELL FOR WATERFALL
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
3. OWNER BOB ROWELL LAND AND TIMBER
Topographic/Land setting
❑ Ridge © Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.24.1 / 82.10.756
(degrees/minutes/seconds)
ADDRESS 260 Amanda Ct Latitude/longitude source: 0 GPS ❑ Topographic map
(Street or Rout< No.) DEPTH DRILLING LOG
MOORE SC 29369 From To Formation Description
City or Town State Zip Code 0 65 Clay
864-595-4360
Area Code - Phone Number
4. DATE DRILLED 4/30/06
5. TOTAL DEPTH 540
6. DOES WELL REPLACE EXISTING WELL? YES El NO El
7. STATIC WATER LEVEL Below Top of Casing: 420 FL
(Use "*" ItAbove Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
'Top of casing terminated at/or blow land surface requbcs a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gym): <l METHOD OF TEST ARDM
lo. WATER ZONES (depth): 460
65
540 Consolidated Rock
n. DISINFECTION: TYPE HYPOCHLORITE Amount 6
12. CASING:
From 0
13. GROUT:
From 0
Depth Diameter
To 74 FL 61/4"
Depth
To 20 Ft.
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Wall Thickness
or Weight/Ft. Material
SDR21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in
Ft,
Slot Size Material
in.
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Iv
0
Cr.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
5/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
IGW-1 REV. 07/2001
JUN 06 2006
0
O
�i)
Fry
pet
rytfTl
<
Carl
C
r

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Cam
We Contractor.(atdMMual) Name
Camp's We11 & PUMA Co. Inc
Well Contractor Company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City or Town State ZIP bode
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mir applicable)
STATE WELL PERMIT#(vappneabla)
DWQ or OTHER PERMIT S(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATEDRILLED ✓.I 5-06
TIME COMPLETED T ' t S AM iV'PM
3.WELLL• - TION:
CITY: G ... d t,15 COUNTY
Reiaax '"Red tax
(Street Name. Numben, unity. Subdivision. Let No., Parce4 Op Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVasey 'emi [Midge ['Other
(G M& approprete box)
LATITUDE •..2_ 52 ) 3
LONGITUDE 0'2'c 0g• /37
Latitudelongitude source: ❑GPS °Topographic map
(bcatbn of wee must be shop on a USGS topo map and
attached to this form blot using GPS)
4.WELLOWNER ((�� 11 �
OWNER'S NAME CrAi t itt rie �Yi\e5 LI-l_
STREET ADpDRESS / 3 . gttpau. e Rd . .
ndersonll II �
May be. in degrees,
Stubs, seconds or
In a decimal forma
i e NC_ ?39
ity or Tam S Zip Code
Area code Phone numbs
5. WELL DETAILS: �\ 0 r
a. TOTAL DEPTH: J ���yyy
b. DOES WELL REPLACE EXISTING WELL? YES p NO p�
c. WATER LEVEL BelowTop of Casing: 3 0 FT,
(use '+•.HAbo✓e Top of casing)
d. TOP OF CASING IS 1 _— FT. Above Land Surface*
lop d casing tembietad atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): 1. METHOD OF TEST Cia
569? 6
f. DISINFECTION: Type chlorine Amount / %a cur
g. WATER ZONES (depth):
From To From To
Fran To From To.
Fran To From To
8. CASING: TT'
Thickness/
Fran 0 of Ft. Ds,i or SDR21
Depth From To Ft __
Fran To -FL
7. GROUT: Depth Material
Method
From 0 To 20 FL Sackrete Hand
From To FL
From__ To Ft
PVC
8. SCREEN:
From
From_•
From
Depth
To
To
To
Diameter - Slot Sim .Material
Ft. In. In.
Ft in. In.
Ft in In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Fran To Ft.
From To FL
10. DRILLING LOG
Rom .To.
0 103
103 • 465
11. REMARKS:
*nation Description
Cm t)+, ,awl
v
6 sAn6
I DO HERESY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE
ISA NCAC 2C. WELLCONSTRUC ION STANDARDS. AND7laTACOPY 9E mis WRN
RECORD HAS BEEN PRWIDEDTOTNE WELL OWNER.
A0W 90
$�I"C�{TURE OF CERTIFIED WELL CONTRACTOR BATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Mall Servi icoriinal to the Division of Water al e Center — Raleigh, NC 276994617 Phone No.(9 9) 733J 6 ext 68.ti. Mgt,617 Ma
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 21 38
ter. 2 aF 9.. 7
1. WELL CONTRACTOR:
James W. Came
Well C.ontractor (IndhAdual) Name
Camp' s Well & Pimp Co. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tom • State ZIP code
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 0(0 apdiceble)
STATE WELL PERMIT#(Bappncable)
D W Q or OTHER PERMIT Slit applicable) `t El
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED -1 - C b
TIME COMPLETED
AMe PMo
3. WELL LOCH O : ,/
CITY: I/ SA) )r) N COUNT' U4k
Itto
(Streak Name. NuBibet.s. Community. Subdivision, Lot No.. Porcelain Code)
TOPOGRAPHIC / SETTING:
❑Slope OVatley CI Ridge CI Other
(creak .pprcpd.te bm0
LATITUDE j_ S ° rpi . 41) I r
LONGITUDE g Z a O i• D y `( W
Latitude/longitude source: OAPS OTopogaphic map
(locatboo of we/ must be shown on a USGS topo map and
attached to this tam I nor using GPS)
May be in deptes,
minute; seconds or
in a decimal tame
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS,.
[�Y/�J II JPriri IVC
cityor Twvn Site Zip Code
kentiv Bade/
5-Me !thee Rid
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
�D S
b. DOES WELL REPLACE EXISTING WELL? // YES p NO (�
Y
c. WATER LEVEL Below Top of Casing: - 0 Fr, )
(Use '+'. S Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surfacer
'Top of casing terminated at/or beiow land surface mey require
a variance In accordance with 15A NCAC 2C .0118. ,
e. YIELD (gpm): lb METHOD OF TEST al r
f. DISINFECTION: Type Chlorine Amount / cL/
e. WATER ZONES (depth
From To I q.S From To
From To From To
From To From To
6. CASING: Thlolmassl
Depth W-Lett Material
Frmt 0 _ �8 Ft. D etaz SDR21 PVC
From To Ft
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
Front_ To FL
a. SCREEN: Depth
From To
From To
From To
Diameter Slot Size .Material
Ft. In. h.
Ft in. In.
Ft In. In.
S. SAND/GRAVELPACK:
Depth Size Material
From To FL
From To Ft,
Fran. To Ft
10. DRILLING LOG
From To. Formation Description
.0 • of Sand /o nick
•
_as* cps Censoiidate d rock
36 2006
11. REMARKS:
c-)
II
cm
Cr. y`-I
r—
RDANCE VCR
ISA WC 2C. WELLCON TTRUCTOONLLSTANDARDS DN TACOPWAS CONSTRUCTED IN Y QFF PIS •
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
,h \ Al Gayer �/A
URE OF CERTIFIED WELL ONTRACTOR BATEE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699.1617 ' Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

CltyorToym Stale
( 828. 453-7322
Area code• Phone number
• RESIDENTIAL WELL CONSTRUCTION RWORD
North Carolina Deparonent or Environment and Natal Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ffi 21 3 8 '
1. WELL CONTRACTOR:
James W. Camp
Well Ca lrscta.(indMduaq Name
Camp's Well & RUM) Co_ inc_
Well Contractor Company Nana
STREET ADDRESS P 0 BOX
429
E1lenboro NC 28040
Zip Code
2. WELL INFORMATION:
SITE WELL IDt#(ilapplicable) STATE WELL PERMIT/(1 W nicable) P6 I K tacit'
DWQ or OTHER PERMIT Sot applicable)
WELL USE (Cheek AppOcable Baq: Residential Water Supply 0
DATE DRILLED .5 I I --& 6 ` �
TIME COMPLETED I '.3U AM PMp
3. WELL
cry: LOCATION: r y, n couiiTY Pb) 1 .
CITY: I�u 7h eY7DY la I �
a9 1J&9 0 K
(Street Muria, NmabeLI,.Calvamity. SubdMslon, I.d No., Pareel:2l Code)
TOPOGRAP IC / LAND SETTING:
°Slope slay OFlel ORIdge Daher
laws Man"
LATITUDE � :Le LT
LONGITUDE g L '511.LL4-32
Latitude/longitude source: POPS °Topographic map
(bcatbn o(wel must be shown on a USGS topo map and
attached to this ram If not using GPS)
May la in degas,
minutes, seconds or
in a decant format
4. WELL OWNER
OWNER'S NAME (' ct
STREET ADDRESS I
L n.. .
R`}'yter-o r (Hoy, K 2 S t 3 9
µ
eve eut)PK
City or Tam State 1 Zip Cede
( }
ACea code• Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
23 0 `/
b. DOES WELL REPLACE EXISTING WELL? YES p NO {p
a. WATER LEVEL Wow Top dCasing 6 Fr,
'
(Use w II Above Top d Casing)
d. TOP OF CASING IS 1 . FT. Above Lend Surface•
:Tap of wing terminated at/cr belay land surface my requUe
a variance In accordance wt h 15A NCAC 2C.01ie.
e. YIELD (gpm):/ _METHOD OF TEST £t.(✓
From
6. CASING: , r J�ne�t
• Depth
Frem 0 To -rd2 Ft• D
Fran To FL
Fran To .Ft
2EC9'7'�
r. DISINFECTION: Type oh1orine Amount
g. WATER ZONES (depth):
Frain To From To
Fran To From To
To From To
73- cut
T lctaienl
Salteriai
DR21 PVC
7. GROUT: Depth Matelel Method
Fran 0 _To 20 FL Sackrete Hand
Front_ To Ft.
From_s___To FL
I. scREEN: Depth Diameter • Slot Sloe .Material
From To Ft._In. In.
Fran_____ To Ft. in. In.
Fran _To Ft. In. In.
B. SANDIGRAVEL PACK: SW
Depth Material
F _To__ FL
Fran To Ft.
Frain To _ Ft.
Y10. DRILLING LOG Formation DescriptionFrom To .
.0' #a
c6D •
J!Tni_ ii R ?nos
11. REMARKS:
idIfearlitanni.
>r
cr,
m
IDOHEREBY mart TUTTW6 WELL WAS 00NsTrai ED 1 ACCOPDANCE Wml
SANCAC2C. WELL CONSTRUCTION
RECORD HAS BEEN PROVIDE:TOME WELL OWNER
11�� , 5�19-a6
SIC R OF CERTIFIED WE "CO RACTOR DATE
James W. Camp •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submit the original to the D1%9161611 of Water
Mall Service Center— Raleigh, NC 27 99-1617 Quality Phone No. (9 91733 Y 5 eon 568.8 . Mgt.,
Form GW-la
Rev. 7105

North Carolina • Dnpmhrronl of E..vimmm�nl I rl I I I
n nl Binb•r quality - C3rtu,d�:ra lnr
1636 Mail Service Center - - anti
3 I n h"'o'r„n - 3-322I
Ftainigl,, N.C. 27699-1636 Phone (919) 7:l3.3721
WELL CONSTRUCTION RECORD
li m
33740
WELL CONTNnC 1011: W1N._pe )J l ds,SQ, e_
WELL CO1Lr11AC 1011 C1:11 IIricA'NOII It: S31 J-1
S I ATE WELL CONS ?BBC I ion I'EnMi 1 rt: - -
1, WELL USE (Check Applicable Pot), flesklnnlial
11 municipal 1.11
1 hnl Aglcullurd 1.__RecoverY Heal Pump Walnr J II Wee, L^Use:
2. WELL LOCATION: (Show skolrh of Ihn lacaliun bolew)
Nearest Town:. C�+ �k�-_--._-__ c eel
(Road Name' ``end Numbers, Conxuunll Y•l eSuh,- - ._ _-..mnl Nil
.._l
3. OWNER 1�1 ;lcinn rot
Address --- 3�Ular r15
($liecl of Iloiila 116.)
IH1111.111tiI.OI__
hum to
a0
City —_—fir �oW^ lain Zlp Coda--__LD-r! _71
4. DATE MILLED —
5. TOTAL bEPT- — ------ - '1 - - GO j�
B. CUTTINGS COLLECTED YES 1)r)
—
7. DOES WELL REPLACE EXISTING;WrL,i YES r;pI—I �Qo _---- �c7°
R. STATIC WATER LEVEL Below lop DI Casing; La I Fr.
va nlr o .aahrp
9, TOP OF CASING IS -% r F. Above Land Sutlnco•
'Top of eash,p laminated •Uor below land nu, Inca Ipipit ,n n vnrinnen In nccor- —
dines wills ISA !ICAO 2C .0110
10. YIELD (goal): _a_ MEN IOD Or TES I
11. WATER ZONES (depth):
LI•.nuL>rinq 1_1
U(:I•III
I ruranorr 1`•�-dl•5.0
12, CNLORINA'rION: Type - 1��
YI SL Amount I[,
13. CASING: O II nrblilipllai Spare lc Moody(' rpm Mick of I•am
Depth Dimneler
Rom -b 1 To `1 1 rt __(elma
From To rt.
From To ri
14. GROUT:
Wall NII^I•nrls
or wciphVrl, I.laletlal
PVL
Depth Malorlal
From � To
.1-1. P.J4r1...__
From To
15. SCfEEN:
Flom
Rom
Fwrn
Opp Diainolor SIOI 1117o
o rt
El. In. -- —_
To _
10. SAND/GRAVEL PACK:
Frorn
F-fom
17. REMARKS:
Depth Size
To rt
To rt.
Method
Malachi
(Siva
LC)CA;IIOII-;tl;l 11:11
'/ dirmalOn and tlialanco horn al I„a-1
Inadn, Or oilier reap rn Inrp'cr p•,inl;)
NC
SG
I DO IIEnEBY crnl iry 711AT 11IIS Wr-1.1. YA5 CONS MUM ro IN ACCviir rlcE wI III ISA IICAC 21:. Val I
cONstfUctlON STANDARDS, AND 11IA7 A Corr Or 7 rlECOrib 11 Ell PnOVIDEO 70 711E WELL UWNEI I.
FOn OFFICE USE ONLY
Ouad No:
!:IOIIAIURE or run Sofl COMIIMIC 1^.rli _12.
SubnA1 Rndnl th, tnlp4,ai la Division of Water Oualily. CNnndwalor Seclien lrhhin yl dap
DA IE
Q77 111[7. I7011

firth Carolina —Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
36 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
/ELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
327691
WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
=rest Town: COLUMBUS County: POLK
UNTVIEW LANE DRILLING LOG DEPTH
.oad Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER DAVID & LUCRETIA FADEN
ddress HUNTVIEW LANE
treet or Route No.)
OLUMBUS NC 28722
ity or Town State Zip Code
DATE DRILLED 05/24/06
TOTAL DEPTH 605
CUTTING COLLECTED ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 60 FT.
se "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'op of casing terminated at/or below land surface requires a variance in accor-
nce with 15A NCAC 2C.0118
). YIELD (gpm): 7 METHOD OF TEST: ARD
i. WATER ZONES (depth):
Formation Description
If additional space is needed use back of form
'.. CHLORINATION: Type: CHLORYTE Amount: 16.5
3. CASING: SKETCH
Wall Thickness "" s from at least two State
Depth Diameter or Weight/Ft Material =rice points)
From 0 To 60 Ft. 6-1/4" SDR21 PVC RT. ON PENIEL RD. LEFT
From To Ft. HUNTVIEW SUBDV. ON
From To Ft. 'PAST TALLY HO LANE.
4. GROUT: C
Depth Material Method LD
ckL-
From 0 To 20 Ft. QUILKRETE POURED
From To Ft. kk6"te-
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
5. SAND?GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft.
7. REMARKS:
DO CERTIFY THAT THIS WF7.I WAS CONSTRUCTED IN A ..,NCE WITH 15A NCAC 2C, WTI
ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit
TRUC11NG THE WELL - DATE
Groundwater Section within 30 days
GW-1 REV. 12/99

lorth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
[636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
r.
<, U J
1. WELL USE (Check Applicable Box): 0 Residential ❑ Municipal 0 Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
LITTLE MTN. RD. DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER IIATCREEK TIMBER
Address LITTLE MTN. RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip ('rile
4.DATEDRILLED 07/15/06
5. TOTAL DEPTH 505
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER. LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 13.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 50 Ft.6-1/4" SDR21 PVC
From _ To FL _
From To FL
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUILKRETE POURED
From To FL
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 FL
From To Ft.
17. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
11
LOCATION SKETCH
' (Show direction and distance from at least two State
Roads, or other reference points)
WLAKER ST. FROM COLUMBUS. RT. ON PENIEL RD. RT. ON
LITTLE MTN. RD. GO 1 MILE & LEFT INTO HIGES CRK.
SUBDV. WELL SIT ON LEFT . ENTRANCE.
0
c
c)
J ry
n
0' �J
o r
I DO CERTIFY THAT THIS WELL WAS CONSTRULI7_,D IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
IGNATI!RE OF PERSON C NS CTING THE WELL l DATE
Submit (>eltginal to Division of Water Quality, Gromrdwater Section within 30 days
GW-1 REV. 12/99

Borth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
JVELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
67 "',4i0.
�;3'v
I. WELL USE (Check Applics)* Box): ❑ Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
0 Recovery ❑ Heat Pomp Water Injection ® Other If Other, List Use: CONSTRUCTION
>_. WELL LOCATION: (Show sketch of the location below)
nearest Town: TRYON County: POLK
'EA RIDGE RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER WHITE OAK PLANTATION
Address PEA RIDGE RD.
;Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
4. DATE DRILLED 07/13/06
5. TOTAL DEPTH 405
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated ear below kind ncface requires a variance in accor-
dance with 15A NCAC 2C.01I8
10. YIELD (gpm): 20 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 10.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 30 Ft 6-1/4" SDR21 PVC
From To Ft
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft QUILKRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
,(Show direction and di sauce from at least two State
Roads, or other reference points)
HWY. #74 E. FROM COLUMBUS. RIGHT ON PEA RIDGE RD.
1.2 MILES ON RIGHT. 2L1D SET OF GATES.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCtED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
c
c)
0
r^,
0
r V
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit
IGNAT[JRE OF PERSON CONSTRUCTING THE War DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELT LOCATION: (Show sketch of the location below)
Nearest Town: SALUDA Cotmty: POLK
LITTLE COVE CREEK DR
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER ALLEN DILLMAN
Address LITTLE COVE CREEK DR
(Street or Route No.)
SALUDA NC 28773
City or Town State Zip Code
4. DATE DRILLED 07/04/06
5. TOTAL DEPTH 205
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WAlE1t LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing Laminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 110 Ft.6-1/4" SDR.21 PVC
From To Ft.
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft QUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. _ in. in.
From To Ft. in._ in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
DRILLING LOG DEPTH
If additional space is needed use back of form
,, r
'
LOCATION SKETCH
(Show direction and diaanrP from at least two State
Roads, or other reference points)
FROM COLUMBUS. I-26 W. TO SALUDA EXIT. LEFT ON
OZONE RD. LEI.1 ON HOWARD GAP RD. GO 3 MILES. LEFT
LITTLE COVE CREEK DR LEFT AT FORK. 1/10 MILE ON
RIGHT. NEW DRIVE.
c�
�.t
N_
0
I DO CERTIFY THAT THIS WFT.I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WET 1
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
—URE () )/�C I✓C tom, 4""P/EI,L `f%Qitp / — S� 4 l
SIGNA_ F PERSO CONSTRUCTING THE DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources —Division of Water Quality — Groundwater Section
1636 Mail Service Cater — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #: _
n ' VA ry
} !c,l
1. WELL USE (Check Applicable Bos): N Residential ❑ Municipal
❑ Recovery ❑ Heat Pump Water Injection ❑ Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: FOLIC
LITTLE MTN. RD.
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER HATCREEK TIMBER & CATTLE
Address LITTLE MTN. RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Cade
4. DATE DRILLED 07/20/06
5. TOTAL DEPTH 545
6. CUTTING COLLECTED ❑ YES N NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES N NO
8. STATIC WA1ER LEVEL Below Top of Casing. 200 FT.
(use "+" if Above Top of rasing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of rasing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 100 METHOD OF TEST: ARD
11. WAILKZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To
From
From
14. GROUT:
Type: CHLORYTE Amount: 15
Wall Thickness
Diameter or Weight/Ft Material
50 FL 6-1/4" SDR21 PVC
To Ft
To Ft
Depth Material Method
From 0 To 20 FtOUIICREFE POURED
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 FL
17. REMARKS:
❑ Industrial ❑ Agricultural U Monitoring
If Other, List Use:
DRILLING LOG
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
WALKER ST. FROM COLUMBUS. RT. ON PENIEL RD. RT.
ON LITTLE MTN. RD. GO 1 MILE & LEFT INTO HUGHES
CRK. SUBDV. WELL TOP OF HILL TO RT. ON LOT #15>
r-i
r— C,",7,
0
c= -v
0'
I DO CERTIFY THAT THIS WELL WAS CONSTRUC TED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
-2- a 0 mil,
SIGNATURF'OF PERSON CONSTRUCTIN_erica ELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] Quality —Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Bony. ® 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: COLUMBUS County: POLK
MLOCK DR DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
I. OWNER MATTHEW FARISS
Address HEMLOCK DR
Street or Route No.)
OLUMBUS NC 28722
:illy or Town State Zip Code -
DATE DRILLED 06/23/06
TOTAL DEPTH 385
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WFI J ? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 60 FT.
Jse "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 40 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION:
3. CASING:
Depth
From 0 To
From To
From To
1. GROUT:
Depth
From 0 To
From To
i. SCREEN:
Type: CHLORYTE Amount: 9.5
Wall Thickness
Diameter or Weight/Ft. Material
60 Ft. 6-1/4" SDR21 PVC
Ft.
Ft.
Material Method
20 Ft. QUILKRETE POURED
Ft.
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Fmm To Ft.
. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
. REMARKS:
in in
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HOUSTON RD. FROM COLUMBUS. LEFT INTO WHITE OAK
MTN. SUBDV.LEFT ON HEMLOCK DR 1' DRIVE ON LEFT..
t0 CERTIFY THAT THIS WFI i WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
INSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
OR OFFICE USE ONLY
goad No:
.ria1 No.
07a
.i'O _
R dCONSTRUCTI CONSTRUCTING WWELL Ana- /n - .3 �% (n
SIGNATURE OF P ON CONSTRUCTING THE W�Iy DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
AUG
ZUL

North Carolina of
olina —WELL CONSTRUCTION RECORD
WELL CO Environment And Natural Resources — Division of Water
NTRACTOR (INDIVIDUAL) NAME (print) ,pEFF M LTON
WELL CONTRACTOR COMPANY NAME PITTMAN Quality Groundwater Section
WE OLL H—R1NG LLC CERTIFICATION # 3417
STATE WELL CONSTRUCTION PERMIT #
(if applicable) ASSOCIATED WQ PERT # PHONE # [phone] MI
1. WELL USE (Check Applicable Box): (if applicable) Monitoring 0 Recovery ) Residential MunicipavPubfic
0 Heat Pump Water in'Industrial Li Agricultural
2. WELL LOCATION: Injection 0 Other 0 if Other List Use _
Nearest Town: MIII PRING County POLK SOUTH COVE RD,
(Street N Topographic/Land setting3. OWNER: e, NumVID ROWE unity, Subdivision, Lot No., Zip Code) 0 Ridge 0 Slope 0 Valley 0 Flat
Address SO COVE (check appropriate box)
(Street o)bWd�longihtde of well location
MILL SPRING NC
City or Town State 28722 Latitude/longitude e source:
s mimrtes/seconds)
828 — 817-0388 Zip Code rtgitude source: ❑ k box) 0 Topographic map
Area Code Phone number DEPTH (check
4. DATE DRILLED 01/26/06 FromDRILLING LOG
5. TOTAL DEPTH: 505 To From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 80 FT.
8. TOP OF CASING IS 1-1/2 FT. (Use + if Above Top of Casing)
Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 3 METHOD OF TEST ,RD LOCATION
10. WATER ZONES (depth): Show direction and di
Two State distance in from at least
11. DIS Roads or County Roads. s. Include the road
INFECTION: Type CHLORYTE number and common names
12. CASING:WAmount 13,5 HWY. #9 N. FROM
Depth Diameter or all Thickness GARRETT RD. MILLSPRIN . LEFT ON
From 0 RIGHT ON GREEN HILL RD
To 80 Ft 6-1/4" SDR2 t Material LEFT ON SOUTH COVE RD. 6/10
From To Ft PVC RIGHT. MILE ON
From To Ft
13. GROUT: Depth Material
From 0 To 20 Ft Mood
UII�ETE POURED
From To Ft
14.SCREEN: Depth Diameter. Slot Size Material
From To Ft. in.
From To Ft. in.15. SAND/GRAVEL PACK: '� in.RECEIVED
From Depept Ft Size Material ra
From To FL _ MAR 08 2006
16. REMARKS:Asheville Regional Office `�
I DO HEREBY CERTIFYA • niter Protection
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CON TRUCTION STANDARDS AND THAT A COPY OF THIS RECORD PROVIDED THE
HAS BEEN PRO2C, WELL
WELL OWNER
SIGNA/ �.�� ♦ a
SIGNATURE 0 PERSON CONSTRUCTING THE WELL
Submit the original to the Division of WaterDATE
Submit the Phone l to (919) 733-32o1 Quality, Groundwater Section,1636 Mali within 30 days Service Center _Raleigh, NC
GW-1 REV. 07/2001
? '2()
6
3 Yt

North Carolina - Department WELL CONSTRUCTION RECORD
WELL aof Environment And Natural Resources - Division of Water
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS Groundwater Section
CONTRACTOR COMPANY NAME PIT �- CERTIFIFI CATION # 2785
STATE WELL CONSTRUCTION PERMIT # TMAN WELL BORING LLC
(if applicable) ASSOCIATED WQ PERMIT # PHONE # (828)_ 45� 2
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public
Monitoring 0 Recovery 0 Heat PumpOthe0 Other, Li 0 Agricultural
2. WELL LOCATION: Water Injection ❑ Other ❑ If Other Lis[ Use 0
Nearest Town: MILL SPRING County POLK A.R. THOMPSON RD. -LOT #24 Topographic/Land setting
(Street Name, 3. OWNER JOEum, Community, Subdivision, Lot Na,Zip Code) ❑ Ridge ❑ Slope Pe ❑Valley ❑Flat
Address A.R. THO (check Latitude/longitude
box)
MPSON RD. Latitude/loongitude of well location
(Street or Roue No.)
MILL SPRING NC (degrees/minutes/seconds)
Z'P CS
City or Town State ode Latitude/longitude itude so = 0 GPS 0Topographic map
708 - 301-3369
Area Code Phone number (check box)
4. DATE DRILLED 01/13/06 DEPTH
5. TOTAL DEPTH: 305 From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0 DRIL_ L�LOG
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
From To
8. TOP OF CASING IS 1- (Use "+" if Above Top of Casing)
*Top of 'n8 terminated 1/2 FT. Above Land Surface*
ated at/or below land surface requires a LOCATION SKETCH
variance in accordance with 15A NCAC 2C .0118. Show direction and distance in miles from least
9. YIELD (Rpm): 30 METHOD OF
10. WATER ZONES d TEST ARD Two State Roads or County Roads.t Include the road
(depth): number and common names
11. DISINFECTION: T HWY. #108 E. FROM MILL SPRING. Type CHL_ O_ RYTE Amount 7.5 A.R. THOMPSON RD, ILRIGHT ON
12. CASING: APPROX. 1 MILE ON RIGHT.
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0
To 70 Ft 6-V4" SDR21 From To Ft PVC
From To Ft
13. GROUT: Depth Material
From 0 To 20 Ft.
UIKRETE Method
From To POURED
14.SCREEN: Depth Diameter Slot Size
From To Ft. Material �`
From Ft.in. ,
15. SAND/GRAVEL PACK: in. _ RECEIVED 7
Depth Size Material in.
From To FL _ MAR 08 2006
From _ To - Ft cn
Asheville Regional Office
16. REMARKS: A. uifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STANDARDS A� THAT A COPY OF 1
S RECORD WITH PROVIDED
NCAC 2W WELL
n HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSO CO
NSTR f CTING t WELL -
G DATE
27699-1636 Phone No. [phone], within 30 days.
Submit the original to the Division of Water Quality, rou°dwater Section,1636 Mail Service Center -
Raleigh, NC
GW-1 REV. 07/2001
3 2
6 •"

North Carolina— WELL CONSTRUCTION
WELL CONTRACTOR
of Environment And Natural ResourcesCORD
NTRACTOR (INDIVIDUAL) NAME — Division of Water Quality — Groundwater Section
WELL CONTRACTOR COMPANY N (print) RODNEY ROBBINS
STATE WELL CONSTRUCTION PERMIT # PITTMAiV WELLpBRIN LG LC �RT�ICATIOH # 2785
(if applicable) ASSOCIATED WQ PERMIT # PONE ## 828 53-0662
1. WELL USE (Check Applicable (if applicable)
MOLL nPP cable Box): Residential ® Municipal/Public
2. WELL LOCATION: Recovery 0 Heat Pump Water InjectionOtherI the Li Agricultural
Nearest Town:0 Other 0 If Other, List Use
COS County POLK
GREEFI LDS
3, p (Street Name, Numbers, Community, Subdivision,❑Rid eocheek appropriate
Topographic/Land setting
OWNER: RICHARD WALLAHORA Lot No., Zip Code) g ❑Slope ❑ valley ❑ Flat
Address GREEN -FIELDS (chock i 01'w box)
(Street or Route No.)
hrdr✓Iongitude of well location
COLUMBUS NC
City or Town State
28722 (degrees/minutes/seconds)
828 — 894-0613 ZiP Code Latitude/longitude source: ❑ GPS 0 T
Area Code Phone number (check box) Topographic map
4. DATE DRILLED OU24/06 DEPTH
5. TOTAL DEPTH: 205 From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casin : DIALOG
g 40 FT. From To
8. TOP OF CASING IS 1-1/2 (Use + if Above Top of Casing) --
*Top ofFT. Above Land Surfaces
casing terminated Wor below land surface requires a
variance m accordance with 15A NCAC 2C .0118. LOCATION
9. YIELD (gpm): METHOD OF TEST ARD Show S direction and
10. WATER ZONES Two State Roads or County miles from at least
(depth): number Roads. Include the road
and common names
11. DISINFECTION: Type CHLORYTE H1 Y S. FROM MILL SPRING. RIGHT ON
12. CASING: �--� Amount 4.5 HWY. #14. LEFT ON GREENFIELDS
Depth Wall Thickness THE WAY TO THE SECOND ALL
From Diameter or Weight/Ft Material 11RIGHT
. CUL-DE-SAC. 4C NEW
Depth
0 To 110 Ft. 6-1/4" SDR21 From To Ft. PVC
From To Ft
13. GROUT: Depth Material
From 0 To 20 Ft. UHQtETE Method
From To Ft
�� POURED
14.SCREEN: Depth Diameter Slot Size Material
From To Ft.
From in.in.
15. SAND/GRAVEL PACK: '
From Depth Ft Size Material
From To Ft
16. REMARKS:
RECEIVED
MAR 08 2006
Asheville Regional Office
A. uifer Protection
r"1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONS ON ANDARDS
AND THAT A COPY OF THI RECORD WITH NCAC 2C, WELL
HAS BEEN PROVVIDEEDD TO THE WELL OVER
IGNA v OF PERSON raNS • _
' CTING THE + LL • Submit the original to the Division of Water DATE
27699-1636 Phone No. (919) 21, within 30 days., Groundwater Section,1636 Mali
Service Center— Raleigh NC
GW-1 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: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
326127
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2 WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
TAYLOR WATKINS RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER SANDRA TAYLOR
Address TAYLOR WATKINS RD.
(Street or Route No.)
MILL SPRING NC 28456
Zip Code
City or Town State
4. DATE DRILLED 04/25/06
5. TOTAL DEPTH 505
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing:41FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 1/2 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount:13.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 65 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9S. FROM MILL SPRING.LEFT ON WHITESIDES RD.
RIGHT ON WATKINS RD. STRAIGHT ON TAYLORA
WATKINS RD. 1/10 MILE ON RIGHT.
0
JUN 06 203
0
rri' 1
0 rat
r
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
GNATIJRE OF PERSON C NS UCTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

1. WELL USE (Check Applicable Box): Residential Municipal
0 Recovery 0 Heat Pump Water Injection 0 Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
WILKERSON HOLLOW LANE
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER JONATHAN & SHEn1Jr AN WOOTEN
Address WILKERSON HOLLOW I N
(Street or Route No.)—'�—
UMBJS NC 28722
City or Town State Zip Code
4. DATE DRILLED 0 /14/06
5. TOTAL DEPTH 405
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 }T
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 3 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: HLO yTE Amount: 10.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 100 Ft. 6-1/4" SDR21 PVC
From To FL
From To Ft.
14. GROUT: Depth Material Method
From 0 To 20 Ft. (JII,KRETE
From To Ft.
15. SCREEN: Depth Diameter Slot Size Material
From ToFt. in. in.
From To Ft. in. in.
From To Ft. in. is
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. 17. REMARKS:
North Carolina —Department of Environment and Natural Resources —
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]I vision of Water Quality _Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
Industrial Agricultural Monitoring
If Other, List Use: _
DRILL�LOG DEPTH
From To Formation Description
RECEIVED
OCT 1 ? 2G05
Asheville Regional Office
Aquifer Protection
If additional is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MIId, SPRING RIGHT ON COLLIN5vir LE
RD. LEFT ON WILKERSON H L W RD. SITE AT VERY END
AROUND TO RIGHT
DIV. O WA EIR QUALITY
OCT 0 6 200s
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit . :l1ti: to Division a Quality, Groundwater Section within 30 days
2
OF PERSON C • STRUCTING THE WELL
of Water r DATE
-/
GW-1 REV. 12/99
6

PAGE 01
Moth Grebes . Depw.e.m N Environment and Neural Nu.ouaeee • Division of Wets Dutily • OrouniwNer section
I17e ma Sete Corer • Rats N.C. I?Ne-tens Phwt. ISM 7334221
WELL CONSTRUCTION RECORD WELL CONTRACTOR* / _111fgJ,-/ /•`7/%may
WELL CONTRACTOR CERTIFICATION 1:
STATE WELL CONSTRUCTION PERMITS.
3 3 4.31;
1. WELL USES hSopilmt t Sash R1.Mordal Y MunldWi 0 Industrial CIAgvlcuhurd ❑ Monlimkg 0
fl.oevory ak Heat Pump Wales Intscion ❑ Other Cj 11 Other, Um Use:
2. WELL LOCATION: (Slaw,sk$ch of lies Walton below) /
He" Tian .7/r/' /t, r',�,✓7-440 Coe* -2( 1Z//dJ
CAt 4),e eLe_/— i/ 4 L tomIs /d -7/
Ron.wdNat Dewodty.or and tot Ma) DRILLINGLLING LOG
3. OWNER /j'/ /a! '/`)r,fti['d
lea art,. r- c __ 2
4, DATE DRILLED /0...,a Ito�o
5. TOTAL DEPTH 5" to '
6. CUTTSIGs COLLECTED YES rj NO�
F. DOES WELL REPLACE EXt$11NO WELL? YES 0 NOG--
S. STATIC WATER LEVEL bib, Top o1 G.kt1: g FT.
�f
Mint Te
grwleer erne C.ie
(tMs'.'1 Move T el CMtV)
S. TOP OF CASING 13 /' //a "'FT. Move Land Surface'
Res et e■.Mu lomensteil NW below Mai swiss* FMWwe .eerl.ee In *teen r.. bsGP.
fen e. S* .
ISA *CAC 2C.S11S p
'-
It YIELD (pond: „2 . METHOD OF TEST,. f . A n1•1 :)r 6�G
11. WATER ZONES (depth): 'CZ
e—
A&F WELL DRILLING
AND
91P Hwy. Business INC,UMP SERVICE,
74
Bostic, NC 28018
�Ptr2s-247.1773
F.nreietDesenise'
12. CHLORINATION: Type /..<.;.je Arnounita)deLaL
It CASING: Y /0 er
wee Rees nso
�f Depth / 01,110, w WMparFL MattelRom_ c Q4_Ta P ./ -Ye — L-- ,1LL
Rom To FL
From To FL
14. GROUT:
Depth MstMsl Method
From 1:;/3Totag_ R. 4tth' n.v- -jia� -f
From To FL
15. SCREEN:
Depth Dinh" Slot Ski Melsdul
From __ _ To . Ft ._..— In h
From ___ To FL _
From — To R. h. h.
1S. SAI4OIGRAYELPACK:
Dpi1 Slab MsIedW
From To FL
From To FL
17. REMARKS:
h DO HERHSY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH $SA 1C, WELL
CONSTRUCT ON STANDARDS, AND THAT A COPY OF NI RECORD HAS BEEN PROVIDEO'TOTNE Will OaSEF-_
f0 -02 S- oe
SIONATURE OP PERSON COh$TRUC11N01*E WILL o• : E
Mal S OWN Mew el Was O.de,.OsorOmMw Ncen 71.1.1701:sy$
cast yet. km
H addiloni specs M needed tea bask* Irtm
LOCATION SKETCH
IShe v direction and (Mina ban el limbo tube
Hoods. se other map nkaena;a porn?
FOR OFFICE USE ONLY
ors Na
Need tie.
A&F WELL DRILLING
AND PUMP ERVICE, INC.
911 Hw( u iness 74
S. 788018
828- 3
Lev
�r `f-
parr
24-2E03 MON 11:31RM ID:
PAGE: 1

Norm Carolina — Department of Environment and Natural Resources 1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone (733-32 2 of Water Quality — Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTJFI ON #: 2785
STATE WELL CONSTRUCTION PERMIT #:
I. WELL USE (Check Applicable Box): ® Residential
❑ Recovery Municipal El Industrial Agricultural ❑ Heat Pump Water Injection ElOther If Other, List Use: Monitoring
2 WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County
SOUTH PHILLIPS RD. POLK
(Road Name and Numbers, Community, or Subdivision and Lot No.) FromD�LING LOG
To
3. OWNER FRED & SUSAN HARTLEY
Address SOUTH PHILLIPS RD
(Street or Route No.)
COLUMBUS
City or Town NC 28722
4. DATE DRILLED 12/13/06� Zip Code
5. TOTAL DEPTH 605
6. CUTTING COLLECTED ❑ YES a NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 3 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE
Amount:
13. CASING:
Amount: 16.5
From
From
From
14. GROUT:
Depth
From 0 To
From To
15. SCREEN:
Depth
From _ To
From To
From To
16. SAND?GRAVEL
Depth
From To
From To
17. REMARKS:
Wall Thickness
Depth Diameter or Weight/Ft Material
0 To 100 Ft. 6-1/4" SDR.21 PVC
To Ft.
To Ft.
Material Method
20 F . >;); OTE POURED
Diameter Slot Size Material
— Ft.. in in.
Ft. in. in.
_ Ft. in. in.
PACK:
Size Material
Ft.
Ft
DEPTH
Formation Description C.rb
tiro
tin
t4
If additional is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RT. ON HWY
JACKSON GROVE RD. LEFT ON SILO RD. TURNS INTO
ON
SOUTH PHILLIPS RD. LOT 1/2 MILE ON LEFT
Dlu. ORECEIVED o All`
JAN 9 6 2U07
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER. FOR OFFICE USE ONLY —
Quad No:
Serial No.
SIGN • •F PERSO. CO T STRUCTING l WELL, Su ginal to Division of Water
Quality, Groundwater Section within 30 days
DA
GW-1 REV. 12/99

9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth): _
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Pt. Material
From 0 To 50 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. ____ in.____ in.
From To _ Ft. in.in.
From _ To Ft. ^ in._ tn._
16. SAND?GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft. _
17. REMARKS:
North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #: _
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial ❑ Agricultural U Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
8653 HWY. #108 DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER ALLEN RICKMAN
Address 8653 HWY. #108
(Street or Route No.)
MILL SPRING NS 28756
City or Town State Zip Code
4. DATE DRILLED 09/28/06
5. TOTAL DEPTH 205
6. CUTTING COLLECTED 0 YES ® NO RECEIVED
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO DIV. OF WATER QUALITY
8. STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Use"+" if Above Top of Casing) OCT 06 2006
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING. 4.2 MILES ON LEFT. 2-
STORY WHITE HOUSE WITH WHITE FENCE.
RECEIVED
OCT 17 MS
Asheville Regional Office
A infer Pr^??C'i^^
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
dif�STIGNA P N CONSTRUCTING TTIIEE WELL it original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.
e

,
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERTIFICATION # 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON County POLK
693 RAMBLING CREEK RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: TONY OWENS
Address 693 RAMBLING CREEK RD.
(Street or Route No.)
TRYON NC 28722
City or Town State Zip Code
8( 28) — 674-6779
Area Code Phone number
4. DATE DRILLED 03/21/06
5. TOTAL DEPTH: 405
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 4 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 10.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 50 FL 6-1/4" SDR21 PVC
From To Ft _
From ToFt.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
14.SCREEN: Depth Diameter Slot Size Material
From _To_Ft. _ in. _ in.
From _ To _ Ft. _ in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _To_Ft.
_
From To Ft.
16. REMARKS:
Topographic/Land setting
0 Ridge 0 Slope ❑ Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
SANDY PLAINS RD. RIGHT INTO VISTA
(RIVERBANK) ONTO BRIDGE LANE. LEFT ON
RAMBLING CREEK RD. APPROX. 1/2 MILE ON
LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR CTION STANDARDS,
AND THAT A COPY OF Tr RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

— Borth Carolina Depan: meat of Environment and Natural Resources —Division of Water Qality — Groumdwater Section
636 Mail Service Cent=— Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION # 3417
STATE WELL CONSTRUCTION PERMIT #:
327379
. WELL USE (Check Applicable Box): ® Residential 0 Mimicipal ❑ Industrial 0 Agricultural ❑ Monitoring
El Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location 'below)
dearest Town: MILL SPRING County: POLK •
tIDGEVIEW SUBDV. LOT #1 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER MARSHALL SEAY
kddress RIDGEVIEW SUBDV. LOT #1
Street or Route No.)
al I SPRING NC 28756
:ity or Town State Zip Code
L. DATE DRILLED 05/30/06
i. TOTAL DEPTH 365
i. CUTTING COLLECTED El YES El NO
'. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
i. STATIC WATER LEVEL Below Top of Casing: 160 FT.
Use "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated ator below land surface requires a variance in accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 5 METHOD OF TEST: ARD
1. WATER ZONES (depth):
.2. CHLORINATION: Type: CHLORYTE Amount: 9
L3. CASING:
From
From
From
14. GROUT:
Depth
From 0 To
From T
15. SCREEN:
Depth
To
To
To
Wall Thickness
Depth Diameter or Weight/Ft Material
0 To 85 Ft. 6-1/4" SDR.21 PVC
To Ft.
To Ft.
Material Method
20 Ft QUTKRETE POURED
o Ft.
16
From
From
From
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9N. FROM MILL SPRING. RT. ON GRASSY KNOB RD.
RT. INTO RIDGEVIEW SUBDV. lsr DRIVE ON RT. LOT #1.
1 DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
911
de
[a�kE OF PRSRSON CONSTRUCTING �1 WELL DATE
bout original to Di on of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Ik.twrhnent of Environment and Natural Resources — Division of Water
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] Quality —Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural gri ❑Monitoring
0 Recovery ❑Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
GREENRIVER FARMS -LOT #5 DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER BOB TURNER
Address GREEN RIVER FARMS -LOT #5
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
4. DATE DRILLED 11/29/06
5. TOTAL DEPTH 605
6. CUTTING COI.I.FCTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 50 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From _ To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. _ in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
33.5718
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING. LEFT ON REVEL RD.
RIGHT ON GREEN RIVER FARMS. TAKE Isl. RIGHT. 2Nn
DRIVE ON LEFT.
RECEIVED
f11/ or WATER QUALITY
DEL 1' '3 '/_QOE
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
/ r/�h. /!/Ja`/l[� %7- ,9 jam' - () 4SIGNA OF PERS CONSTRUCTING THE WE DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

n r- E'? ak r� A&F WELL DRILLING
— r, e' AND PUMP SERVICE, INC.
911 Hwy. Business 74
wens Cases • DaC.r.aar= N Se+Uararanl and Maui linau�eae • el Wary May "� swain Bostic, NC 28018
1.:1. MS sr** raw - A WIo14 M.C- 7t7N�'11r roils 828-247-1773
WELL CONSTRUCTION RECORD wEu.co tTRACTOR: fr F 'i,"V i CA /7,��
. WELIcoNTRACTon ClI TW1CATION it: --V T S;
STATE WELL CONSTRUCTION PEANUT,:
1. flu. U$E Ants* $ $ Rsd.ntla MUIIWO 0 0 wM � Monitoring CI
0 Hoot Purr. wale ki..bn 0 Darr CIII Or n , UN Uss
2. WELL LOCATION; (Show of Me Roslyn below) Snot Tom {/ ,.im i Le 5 Cara; „i0C1
"us _ C. GAT � 7
p1aMNara o.awraq. aMAL/ =� -
3. OWNER v�_eJ a / , .gyp ci Fara Ti
Addis ,9 ,� 6' `�. e/eJ 6404.-
waspwarima
•. DATE DRILLED Z5
S. TOTAL DEPTH 3 '
S. CUTTINGS cOIiEGTID VEs[� NoL.1aJ
7. DOES WELL REPLACE WOVE`WEtl1 YES_ NO
al C3
S. STATIC WATER LEVEL kb* Too Coming FT.
.. PM 4•. PS TM SI QMM
S• TOP OF CASING IS 1 to FT. Above Land Swims
Rea er gain L- anal ewer taw
was .Cdtaa
ID. YIELD (SP* .,11.— METHOD OF TEST i i r
11. WATER ZONES (depth): Y /)
•
12. CHLORIIATIOIt Typo C%L-=df.r Mond
%
13. CASINO: i ' 4q . e'C' (Ii,K elm
Warmidaws
prow
FrondoP °To. /7'Via "
Fenn... .---
Fran Te FL
14. GROUT:
Depth WSW
From iia4:1— To SLR. SurVi M If
From To FL
15. SCRUM
Wah Okrrie Slot Skip
From To _ Ft In. In.
From To FL_ In. In.
From To __ Ft _ In. In ____.-----
or", ki y 1 "
is. SAND/uRAYELPACK:
Dept Ow WSW
From To FL
From To FL
17. REMARK&
IDoHERESYCERTIFY THAT THIS WEu.WAS CONSTRUCTEDINACCOP WTHISA NCO EC. WELL
CONSTRUCTION MTANDAN:A NCTHAT ACDPYOF THIS RECORD HAS 1101 FRONDED 70114E WELL DIP.
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*AS WOW NDliredNSW Da1 sOrswd!ve_Saws A S30C t tobIsEr.+:n

RESIDENTIAL WELL CONSTRUCTION REcoRn
Noah Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138.
1. WELL CONTRACTOR:
James W. Camo_
well Cmtmaa.(IndMdual) Name
Camp's Well & P1amo CD. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City a Tam ' State Zip Code
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tor applicable) •
STATE WELL FERMIUM applicable)
DWQ or OTHER PERMIT Elf applicable)
WELL USE {Check Applicable Bcu): Residential Water Supply❑
DATE DR�C (� ILLED U" • D
TIME COMPLETED I .30 AMp PMV'
3.WELLLOCATI N:
CITY: �)1Or. COUNTY e
PA, Jvtk.
(Seep! Nama,1 mbees, Commurd Su�NaiT No., Parcel, C
TOPOGRAPHIC / LAND SETTING:
CI Slope Itatey OFlat ❑Ridge ❑Oter
(Capri[ appropdatabox)
LATITUDE J5,�1p1� .4 S3 2 p-
LONGITUDEL_VIIS 45 • LsOD
Latitude/longitude source: siGPS OTopographic map
(loca88an of wel must by shown on a USGS topo map end
attached to this form I not using GPS)
%v
4. WELL OWNER ��//��++
OWNER'S NAME .a. J)J. llh,LLYL P.iS
ADDRESS �t g n i lei 13
tit).eta iUC al77.2
May be In depea,
minutes, seroods a
m a dedmal format
City or Tam State Zip Cede
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: J n S
b. DOES WELL REPLACE EXISTING WELL? YES p N0 01,
c. WATER LEVEL BelowTop of Casing: 0 FT,
(Use If Above Top of Casing)
d. TOP OF CASINO IS • 1 FT. Above Land Surface*
'Top d aging tandnatad Elm below butyl surface may require
■ valance In accadance with 15A NCAC 2C .0118.
e. YIELD (gam): 10 METHOD OF TEST (Lk
T. DISINFECTION: Type chlorine Amount Iyg-[:a.
g, WATER ZONES (depth):
From To From To
From To From To
From To From - To
6. CASING:
l Thal
llogl esu/
DTo From 0tki G. Ft Ot SDR21 P C
L 6
From To F_
From To .Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To FL
From . To FL
8. SCREEN: Depth Diameter
From To Ft. is
From To Ft. In.
From To FL In. in.
IPS
Slot Size .Material
In.
'ACK:
Ft.
Ft
Clrr1a ( m!nRkKS 2 Ft
rv. urtIL.:.NG Ly(i
From a To.
•
11. REMARKS:
Size Material
Fomnatbn�e�J1bstuiptio i
C Qa t
N
0
I WHEREBY CERTFYTHATTWS WELL WAS WN5rRUClED NACCORDANCE VMS
IMNCAC CO WELL CONSTRUCTION STANDARDS, MID THATACOPYOF THIS • :11
RECORD HAS BEEN PRONIDEDTOTHE WELL OWNER
ci
SI RE OF CERTIFIED WE ANI)TRACTOR bias
amesames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submltthe original to the Division of Water Duality within .30. days. Attn: information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699-1517 ' Phone No. (9191733-7015 ext 568.
Form GW-la
Rev. 7/05

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Diktat-feE �EG,�
Well Contractor �dividual) Name
Ck®Y- r Oilraireve.Q ea
Well Contractor Company Name
STREET ADDRESS p?AD UTSLr(Ses eD,
Afpntithas sG ateitrdi
City or Town State Zip Code
(8iu )-.till-77t.1-
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT n (if applicable) Ld l°lS k 1 iP
DWQ or OTHER PERMIT 1/ (if applicable)
WELL USE (Circle applicable use): Monitoring
Municipal/Public Industrial/Commercial Agricukura
Recovery Injection Irrigation
Other (list use)
3. WELL LOCATION:O2
COUNTY pbL1C QUADRANGLE NAME
NEAREST TOWN: Littpeum. 4C
L(SD //urr/ rAily eJ ' ry ,t'D.
(Street/Road Name, Number, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC/LAND ETTING:
Slope Valley IOW'dge Other
(Circle appropna setting)
LATITUDE id IAgee/
LONGITUDE 2p0
Latitude/longitude source: GPS Topographic map
(Location of well must be shown on a USGS topo map and
attached to this form ifnol using GPS.)
4a. FACILITY -The name of the business where the well is located. Complete 4a and4b.
(If a residential well, skip 4a complete 4b, well owner information only.)
May be in degrees,
minutes, seconds, or in a
decimal format
FACILITY ID #(if applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State
4b. CONTACT PERSON/WELL OWNER:
Zip Code
NAME g E ?. ,p,2eysee
STREET ADDRESS 1.45e7 M4 urs-Air Coe..4ila /
7:1040e/t/ .t/G 4,7j,7
City or own State Zip Code
Area code - Phone number
Amount
5. WELL DETAILS:
e-/ �l O_i/ 11
a. Total Depth: / d R. Diameter: L9 y tiOn.
b. Water Level (Below Measuring Point): I ft.
Measuring point is % ft. above land surface.
6. CASING:
Length Diameter
� ~
a. Casing Depth (if known): 1 i ` ft. 1o1% p1q.
b. Casing Removed: ft. in.
7. DISINFECTION: e 13161CL Age
(Amount of 65%-75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement Ib.
Water gal.
Bentonite
5RtUtivt
r)N (1>TER QU,UTY
NOV 0 2 2006
Bentonite lb.
Type: Slurry_ Pellets_
Water gal.
Other
Type material aireW/41/ peackeretreta
ydd
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
oft Cake rtcicC
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials used.
11. DATE WELL ABANDONED �eVeat/di
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
.42
ATE
SIGNATURE FPRIVATE LL OWNER ABANDONING THE WELL. DATE
(The private well owner must be an individual who personally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
�4a4r Dater leedwa)
PRINTED NAME OF PERSO ABANDONING THE WELL
atCtilt'E.ri ae. 4.Z2t t.r, e)
Submit a copy to the owner and the original to the Division of Water Quality within 30 days.
Attn: Information Management, 1617 Mail Service Center— Raleigh, NC 27699-1617, Phone No. [phone] ext 5613.
Form GW-30
Rev. 5/06

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # c / 3 S
1. WELL CONTRACTOR:
.\C SAvkstvk
Well Contractor (Individual) Name
rAtA.B (3VM f Cu 1_14c
Well Contractor Company Name 1 ,
STREET ADDRESS N. t)'act V 2 "I(�
-V etV &t (kb 1`1c aso4b
City or Town State Zip Code
($b0 }Ill). S-)3L
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #pr applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Publicir
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationp Other ❑LtI (list use) f
DATE DRILLED • I�ccl . (� {ice
TIME COMPLETED 4 .,yi) O 11 AM ❑ PM ❑
3. WELL LOCATION:
CITY: SO1) OQ
Pace /1'1tt • Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
_. TOK/GRAPHIC-I t ANp SETTING_. __ --.._.._
❑ Slope ❑Valley ❑ Flat pillage ❑ Other
(check appropriate box) LATITUDE _6 (3 624 (.4
LONGITUDE .S 5 1. I.t)
COUNTY PO Y
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACIUTY- is the name of Me business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY TkOriL Of Salado.
STREET ADDRESS
0g)oX ALi
SaCkd& t/c n75773
City or Town State p c e
CONTACT PERSON To tD 0 4 u 0.
MAILING ADDRESS 9 &H't C
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 7D S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: (0 0 FT.
(Use '+'iif Above Top of Casing)
326967
3no kw
d. TOP OF CASING IS ire j FT. Above 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): ( 0 METHOD OF TEST
f. DISINFECTION: Type Z(` 144) Amount
g. WATER ZONES (depth):
From To 350 From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Dikmeter Wit Mkt
From_ To 6 Lt FL g � STpr
From To Ft.
From To Ft.
7. GROUT: Depth Material D MethodFrom(l — To 5 L4 Ft. EL--2.. �-I11 c U \_ YA
From To Ft.
From To Ft.
8. SCREEN: Depth
Diameter Slot Size Material
From To Ft. in. _ in.
From To Ft. in. _ in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
() 6Lk
n Formation Description
flat--&-wv\-y.9
ellI r b 5' (`ika. Yv t R
MC -Mr
SUN t? ci 200b
11. REMARKS:
zErri
y �}
w 1"1
T P
tv
0
I DO HEREBY CERT FY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WnH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
t) U i CeoYrt� sc i v b
SI� A Writ
or CERTIFIED WELL C NTRACTOR DATE
�1 �Lwtes Wr / awl �)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Infonnation Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/OS

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(IndMdual) Name
Camp's Well & PumD Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tom State hip Code
( 828)- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
PO In Co La PA
STATE WELL PERMIT#(aapplicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Appliicc'Iable Box): Residential Water Supply Ip
/
DATE DRILLED I 1- ^^" I• 0 I.
TIME COMPLETED d OU AM PM13--
3. WELL LOCAT ON:
CITY::( YI).`- Ce z COUNTY e11�
(Street Nary Numbers,
y ...
Narp Numbers, Community, Subdivision, Lot No., Parcel Zip Code)
TOPOGRAPHIC I LAND SETTING:
°Slope °Valley ❑Flat Widge ['Other
(check appropriate box)
LATITUDE . - ``k, t�` . r).
LONGITUDE V tv Uy 1,
Latitude/iongitude source: TeGPS °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 C. ,�ny (� -
OWNER'S NAME �-H�-rJ•�`��) T ttI11J✓`
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS
City
Spy?
c'
Area code Phone number
5. WELL DETAILS:
3 a. TOTAL DEPTH: 1 S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO t4
c. WATER LEVEL Below Top of Casing: I DO FT,
(Use if Above Top of Casing)
d. TOP OF CASING 15 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 7S METHOD OF TEST a M
335459
f. DISINFECTION: Type chlorine Amount Cu s
g. WATER ZONES (depth):
From To From To
From To From To From To From To
6. CASING:
Depth
From 0 To7 3
Diameter
Ft. 63
From To Ft.
From To Ft
Thickness/
Weight Material
SDR21 PVC
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft
From To Ft.
8. SCREEN: Depth Diameter Slot Size .Material
From To Ft. in. In.
From To Ft. In. In.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-12)
11. REMARKS:
fiFonnatIoppesctip(bn
uq �-QMAU
r
NO
tC tI
i-TIVI f7F V'YF.TEP C�11
DEC 5 2006
1 DO HEREBY CERTIFY THATTNIS 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
C/L (-30-66
SI� A URE 0 CE' IFIED ELL NTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30. days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
334257
1. WELL CONTRACTOR:
James W. Camp
Well Cantractor.(IndMdual) Name
Camp's Well & Pump Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
City orTown State
(828- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL IDr1(0 applicable) '
STATE WELL PERMIT#(Vapplicable)
Zip bode
DWG or OTHER PERMIT #Qf applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 10 I I -D L
TIME COMPLETED 31 ' 3o AM PM817
3. WELL LOCALOCATION(/� i ,
CITY: n JpV/nCOUNTY (D)k
,Se c`l'on/ C
(Street Name, Numbers. Community. SubdMNslon, LotNo., Parcel, Zip Code)
T POGRAPHIC / LAND SETTING:
Slope Malley CFlat ❑Ridge ❑Other
(check appropriate box)
•
LATITUDE 2 l i. 6 A 1I'
LONGITUDE 2° /2 .O4-5
Latitude/longitude source: kr6PS ❑Topographic map
(location of we/must be shown on a USGS topo map and
attached to this tom 1 not ushg GPS)
4. WELL OWNER'S
ER ''T' -
OWNER'S NAME (l )nYVI sy� t/ S$p G
STREET ADDRESS P P too 1,1 5
�ar7`Aptbarq 5 L. ,R93DS
orTown J State Zip Code
May be in degrees,
minutes, seconds or
in • decimal format
Area code • Phone number
5. WELL DETAILS: �L a. TOTAL DEPTH: J i.S_
b. DOES WELL REPLACE EXISTING WELL? YES p NO('
e. WATER LEVEL Below Top of Casing: FT,
(Use'{' 0 Above Top of casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Tap of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 100 METHOD OF TEST GL / r
f. DISINFECTION: Type chlorine Amount 1/a /tn /n
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Material
From 0 To .3.3 Di eter Wei ht Ft 6 r SDb1 PVC
Ran To Ft. _
From To Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft
From To Ft
8. SCREEN: Depth Diameter Slot Size .Material
From To 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.
0. 33
11. REMARKS:
Fortpation Description
SAn c.1 ay
Cof5olidicted rock
g .Gcrn Q) WTZV
2'Y�h
rSLI� - 1.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND DATA COPY OF THIS
REC9RD HAS BEEN PROVIDED TO THE WELL OWNER
4/wti,a—
SIGNATURE OF CERTIFIED WELL
ro-30-6C
RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Divtslon 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 Deparonent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIPICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Cann
Well Contractor (Individual) Name
Camp's Well & Pump Co. Inc'.
Well Contractor Company Name
STREET ADDRESS P 0 BoX 429
Ellenboro NC 28040
City orTewn State Zip Code
(828- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #of applicable) '
STATE WELL PERMITSOlVIAND%)
DWI) or OTHER PERMIT #(8 applicable)
WELL USE (Check ApijJc&lO BOX): Residential Water Supply in
DATE DRILLED RiT ((`�
I U /
TIME COMPLETED , 30 AM CI PM IV
3.WELL L�O�C�IQ)N:
CITY: 1 v1,i LX Y�!,""'a. COUNTY 1 (lam
cet Rif\
(Street Name, Numbers, Community, SubdiNtlon, La No., Parc alir Cab)
TOPOGRAPHIC 1 LAND SETTING:
let* DVaSey anal ORIdge ❑Other
(check approp iatabwQ
LATITUDE J'1_ �1 to 71n l
LONGITUDE$rA_.
Latitude/longitude source: OGPS DTopographic map
(forager of we/ must be shown on a USGS topo map and
attached to thb form ►not ushg GPS)
IMayMIn degrees,
minutes, seconds or
in a decimal format
4.WELL OWNER r pl
OWNER'SNAME GLI' as&c�I/��L��ul'itttSTREET ADDRESS IF IT'•d 19 N
f l,71 Sf jr ti NC- ,22 9s`6
City or Town 1 State Zip Code
Area code Phone number
5. WELL DETAILS: C
a. TOTAL DEPTH: 8J ..
b. DOES WELL REPLACE EXISTING WELL? YES O NOW
e, WATER LEVEL Beim Top of Casing:
(Use 'r'.8 Above Top of Casing)
d. TOP OF CASING IS 1 • FT. Above Lena Surface*
'Top el cuing terminated actor beim land surface may require
a valance In accordance With 15A NCAC 2C .0118.
,
e. YIELD (gem): `Tb METHOD OF TEST QtiA
oh 4a6
t. DISINFECTION; Type Ch10r lne Amount 4.1.4.(5
g. WATER ZONES (depth):
From To From To
From To Fran To
From To Rom - To
6. CASING: ]�nohr
From 0 DToh'Tg Ft D6#
From To Ft
From To Ft.
7. GROUT: Depth Material Method
FranL___ To 20 FL Sackrete Hand
Fran To Ft
Fran To Ft.
8. SCREEN: Depth Diameter . Slot Sire .Materiel
Fran To Ft._In. in.
Fran To Ft. in. In.
Fran To Ft. In in.
9. SAND/GRAVEL PACK: maws
Size Ma
Fraq^T_Ter— Ft
From_To___ Ft.
Fran To Ft
Thickness/
Weight Material
SDR21 'PVC
10. DRILLING LOG
From
• `lC t Fomratipo Desa p n
lJl-U,t� J.(l
11. REMARKS:
of uf-\\ \ \FASC'
P,r ...it
N0N 2
I Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE YAM
1MSac
20,BEEN.CONsTRUC ION THE WELL OW
NER.
WTACOPY OF nilS •
RECORD HAS
M1D W C„l1 /0- 36-06
SIG l E OF CERTIFIED WELL 'CONTRACTOR I ATE
mes W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1Submit the original to
17 Mall Service Center — Raleigh, NC 276994617 Division of Water QualityPhone No. 9 9) 733 9 6 ext 568.uon Mgt.,
Form GW-1a
Rev. 7/05

RESIDENTIAL WELLCONSTRvcnONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Cam°
Well Contrado.(IndWiduaq Name
Camp 's Well & Pt1mo Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Torn State Zip bode
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Of applicable)
STATE WELL PERMIT#Of appeuble)
DWQ or OTHER PERMIT 0(11 applicable) • /
7
WELL USE (Check Applicable Borg: Residential Water Supply U
DATE DRILLED �l �/II — 0 6 '-/'
TIME COMPLETED AM ❑ PM Si
3. WELL LOCATION:p
CITY: (r1.11:14,rt s COUNTY P
(Street Name. Numbers, Community. SubdMslon, Lot No.. Parcel.2lp Code)
TOPOGRAPHIC / LAND S NG:
DSbpe OVatey °Flat dge ❑Other
(aherk appropdattbo0
LATITUDE _C° /� • 3°t9
LONGITUDE 9 .�. , 3. 49 q
Latitude/longitude source: 'hrOPS oTopographic map
�echedM well
shown )GStopomapand
May be in degrees„
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME Jo e lseta-c 1'ti
5 K �7 d I
STR ADDRESS J le) D
n tn (ltt -
10i 6; 3 s c zv20 Li
City or Tavm State Zip Cede
Areas code Phone number
5. WELL DETAILS: fr
a. TOTAL DEPTH: 10 1 S ..
b. DOES WELL REPLACE EXISTING WELL? YES ° NO TX
C. WATER LEVEL Below Top of Casing: a 0 0 FT,
(Use '+'.if Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top of casing terminated at/or below )end surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):, METHOD OF TEST Q.. A
t DISINFECTION: Type chlorine Amount 3- I-uf 5
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thiclmess/
Depthrl 1 Diameter Weight Material
From 0 To „t0 Ft 6a SDR21 PVC
From To Ft.
From To .Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Slze .Material
From To Ft. In. In.
From To Ft. In. In.
Rom To Ft. in. In.
9. SANDIGRAVEL PACK:
Depth Slze Material
From To Ft
Rom To Ft.
Fron______To Ft.
10. DRILLING LOG
From To.
0•
Sava
Form© eci. ssiptbn
;l(f (p 0 S eL1 (x.4,rn.t1
11. REMARKS:
C7
W
DO HEREBY CERTIFY
ACCORDANCE
NE. WELLCOOTRUCTION STANDARDS. AND VAT OF THIS
RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER
alArs0 1/0 RE OF CERTIFIED WE CONT CTOR DATE
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit 1617 Mall Service Centerinal to - Raleigh, NC 27 99 1 1e Division of Water 7 antPhone No. (9 9) 733 7015 ext 68.tton Mgt.,
Form GW-la
Rev. 7105

• RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138.
1. WELL CONTRACTOR:
James W. Camp_
Well Contractor.(IndMdual) Name
Camp's Well & PumD CO Tnc.
Well Contractor company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City or Town . State ZIP Cotle
(828). 453-7322
Area code- Pharr number
2. WELL INFORMATION:
SITE WELL ID #Orspoileable) .
STATE WELL PERMRS(gapplable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply (�
DATE DRILLED 4 • OA• O t0
TIME COMPLETED a: CO AMID PM cV
3. BUELL LOCA'T�IppN: 11 py,,
CTTY: M/JU SS?kk U, COUNTY \ cJ(/1�
1 LS Adek &relcne IZd
(Street Name, Number, Community, Subdivision, Lot No.. ParaI; Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope Malley taw ORldge OOther
(ehaek apprepdaebn*)
LATITUDE ss?1 Mc(
LONGITUDE12. t1) o't2-
May Ili In dogma,
minute; seconds or
in a decimal brat
Latitude/longitude source: MOPS OTopograpbic map
(baton of wet must be shown on a USGS topo map and
attached to thb him Plot usip GPS)
4. WELL OWNER ^�
OWNER'S NAME
STREET `IESS
1
City or Town
( 1•
Je Y1 G/een.e Rd
C 2$'156
Area code- Phone number
5. WELL DETAILS: n ryry
a. TOTAL DEPTH: V `LU
Zip Cede
b. DOES WELL REPLACE EXISTING WELL? YES p N01�
c, WATER LEVEL Below Top dCasing: (s() FT,
(Use'+' 8 Above Top of Casing)
d. TOP OF CASINO IS 1 . FT. Above Land Surface*
'Top d casing terminated atlor below land surface miry require
a variance In accordance with 16A NCAC 2C .0118.
e, YIELD (gpm): C METHOD. OF TEST (tit A
1. DISINFECTION: Type Chlorine Amount 14 C„p(
g. WATER ZONES (depth): I
Fran To • From To
Fran—.--__ To
Fran To
Fran To From To
e. CASING: DiameterMamma/
Weight
en
'From 0 Depth
Ft b# SDR21 .
Fran To Ft -
Fran To .Ft�
7. GROUT: Depth Material Method
Fran 0 To 20 Ft Sackrete Hand
Front_ To Ft
Fran To Ft
8. SCREEN: Depth Diameter . Slut Slze .Material
From To Ft•__in. hi.
Fran To _ Ft. In. In.
From To Ft In. in.
9. SAND/GRAVEL PACK:
Depth Slze Material
From . To_ Ft
From To Ft.
From To Ft
10. DRILLING LOG ..,
From .S 3 rrrlatbp.91. n f a
11. REMARKS:
JM4
I DO FEREBY CERTIFY MATINS WELL WAS CONSTRUCTED N ACCORDANCE Walt
16A NCAC2C, WELL CONSTRUCTION STANDARDS, AND 'Mincer( rats •
RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER.
T i C
SIGNA. OF DWE CONT CTOR bATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within.30.days. Attn: Information Mgt,
1617 Mall Servlee Center— Raleigh, NC 276994617 ' Phone No. [phone] ext 568. .
Form GW1a
Rev. 7/05

CltycrTam State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID SW applicable) '
RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATIONS 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractot(Indlvdual) Name
Camp's We11 & _P11mD Co. 7ne-
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
Zip bode
STATE WELL PERMIT#(appfoahk)
DWQ or OTHER PERMIT #(e applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED i ._ / 4 — 06
TIME COMPLETED T:3O
AMC PMd
3. WELL LOCAL O' N:
CITY: A" COUNTY (.313-
_I-cke Adger De t
(Street Nams, Numbers. community. SubdiNeiondlol No Parce&21p Code)
TOPOGRAPHIC 1 Vat
SETTING:
[Slope [Valley pttat [Ridge [Other
(check appropdateM+x)
LATITUDE J._ ) I. 45- 4 N
LONGITUDEI 1° i i' h'za w
Latitude/longitude source: 1 %PS [Topographic map
(Waltnd to ti►n of wd mushn ushg on a U
GS topo map and 7
att
4. WELL OWNER
OWNER'S NAME o�`..P'1J,6•.V.,�••'.� (j,,F ( k.5L
STREET ADDRESS'r�.O Ayin �
ey "`�p
Iam ' Dr'
itor Town State ZipCode
May be in degrees,
minutes, seconds et
in ■ decimal format
( )- ggq'D/14
Area code- Phone number
6. WELL DETAILS: t
a. TOTAL DEPTH: `D bS
b. DOES WELL REPLACE EXISTING WELL? YES Q NO 9k
e. WATER LEVEL B&&WW Top of Casing: D FT,
(use'r'.if Above Top of Casing)
d. TOP OF CASING IS 1 Ff. Above Lend Surface'
'Top at casing tennineted atfor below lend surface melt require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST U CA,
i
f. DISINFECTION: Type chlorine Amount c."es
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth•O (ji) Ft 6apeter Weight
PVC
erial
Fran 0 To
From To Ft
From To .Ft
I
7. GROUT: Depth
From 0 To 20
From To
From_ To
S. SCREEN: Depth
From To
From To
From To__
Material Method
Ft Sackrete Hand
Ft.
FL
Diameter Slot Size Material
FL In N.
Ft. In. __ In.
Ft. In In.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
Frorn To Ft.
Size Material
From T2 Ft.
10. DRILLING LOG
From To
0• (ph
AVP
formatiop Oeseripticy(
ion 5 • b Li &Ain
11. REMARKS:
t
r
p'
I00 HERESY CER1#Y1HATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm1
15A NCA 2C, EENP OVTH
E EWELLRDS,AND MAT ACOPY OF. THIS•
RECORD
l.0 (14. q-�S-o6
,Tt7REOFCERTIFIED WELL CONTRACTOR DATE
dames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within;30. days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. (919%.733-7015 ext 568.
Form GWta
Rev. 7/05

From: Scott Gantt 7044347212 To: Stephenie Wilson
Date'. 2/8/2007 Time: 11:10:35 PM Page 2 of 4
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Well Contractor Certiftcation # 2584
1. WELL CONTRACTOR:
ALAN SCOTT GANTT
Well Contractor (Individual) Name
CAROL,INA WELL DRILLERS, INC.
Well Contractor Company Name
STREET ADDRESS: 522 GANTT S GROVE CHURCH RD
MOORESBORO, NC 28114
[phone]
Area code — Phone number
2. WELL INFORMATION
SITE WELL ID #(ww APPLIACBLE)
STATE WELL PERMIT # (w APPLICABLE)
DWQ or OTHER PERMIT # (IF APPLICALBE)
WELL USE (check Applicable Box): Residential Water Supply ❑
DATE DRILLED 12/9/06
TIME COMPLETED 3 AM 0 PM ❑
3. WELL LOCATION:
CITY: COLUMBUS COUNTY: POLK
SHUFORD DR.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope 0 Valley © Flat ❑ Ridge ❑ Other
Latitude/Longitude Source: ❑ GPS 0 Topographic map
LATITUDE 35.14.088
LONGITUDE 82.13.114
(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 HORTON HOME OF RUTHERFORDTON
STREET ADDRESS 342 HWY 74 BYPASS
RUTHERFORDTON NC 28139
City or Town State Zip Code
828-287-3366
Area code - Phone number
5. WELL DETAILS:
A. TOTAL DEPTH: 300
B. DOES WELL REPLACE EXISTION WELL? YES ❑ NO
C. WATER LEVEL Below Top of Casing: 55 FT
D. TOP OF CASING IS 2 FT Above Land Surface*
"Top of casing terminated at'or below land surface may require
a variance in accordance with I5NCAC 2C .0118.
E. YIELD (gpm): 8 METHOD OF TEST ARDM
EDISIN FECTION:TypeHYPOCHLORI TEAmt:120Z
g. WATER ZONES ( depth)
From 285 To 285 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From + 2 To 74 Ft. 6 1/8 SDR21 PVC
From
To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 2 Ft. GRAVEL MIX GRAVITY
From 2 To 20 Ft EASY SEAL GRAVITY
From To
8. SCREEN: Depth
Ft
Diameter
From To Ft.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth Size Material' _ ,
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To Formation
0 65 CLAY
65 300 CONSOLIDATED ROCK
Slot Size Material
in in
in in
in in
11. REMARKS_
RECElvtu
O!V OF WATER OlUAUITY
FEB 0 9 2007
I DO HEREBY CERTIFY THAT T'HLS WELL WAS CONSTRUCTED UP ACCORDANCE WITH 15
HOAR 2c WELL CONSTROCTIN STAITEARDS, AND THAT A COPY OF TIES RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE 1/1/07
ALAN S. GANTT
PRINTED NAME OF PERSON CONSTURCTING 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
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contracta. (IndMdual) Name
Camp'S Well & PumD CO. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Torn State •Zip bale
( 828). 453-7322
Area cods Phone number
2. WELL INFORMATION:
SITE WELL ID S(N spoilable)
STATE WELL PERMIT#(If apPBuble)
DWQ a OTHER PERMIT 0(if applicable)
WELL USE (Check Applicable Bee): Residential Water Supply W
DATE DRILLED 6 - -66
TIME COMPLETED J : 4 c- AM O PM IV'
3. WEGITLL LOIAON15Y�/Tree) K I COUNTY 0 1<
der Flakla/1ds
(Street Name, Numbers, CammuNty,dMsIon, Lot No, Parcer.21a Cade)
7T°GRAPHIC/ LAND SETTING:
lope °Valley OFIat ❑Ridge °Other
(ahedr Rpmpdatal t
LATITUDE $ El I7• S Z tI
LONGITUDE goo 62. •338 y�1
Latitude/longitude source: ttr6PS °Topographic map
(bcatbn ewe; must be shown on a USGS topo map and
attached to fhb firm /not using GPS)
4. WELL OWNER .1 `'
Gl T J OWNER'S NAME C ) i? nn e-) C. y
STREEET ADDRESS i iifOs H- t) y / 4I R t45 •
RDSlre _NC- 2TOlB
MAY beIndegrees.
minutest seoaods a
in a decimaifomm
City oTown State Zip Cede
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 6or7
b. DOES WELL REPLACE EXISTING WELL? YES D NO p
c. WATER LEVEL. BebeTop of Casing: SO rr,,
(Use •+•.If Above Top dCasing)
d. TOP OF CASING IS • 1 . FT. Above Land Surface*
'Top d casing tinted et/or balm land surface may mquire
a variance In axadance with 15A NCAC 2C .0118.
e. TIED (ppm): J� METHOD OF TEST a 1 r
• 1
f. DISINFECTION: Typo Chlorine Amount Q Lk s
g. WATER ZONES (depth):
From To From To
Fran To
From To
From To From To
6. CASING: ThIclahe�ss/
Material
Fran 0 T Ft Dlai- Diameter SDR21 PVC
From To Ft 6�
From To Ft
7. GROUT: Depth Mates Method
From 0 To 20 Ft Sackrete Hand
From To Ft
From . To Ft
a. SCREEN: Depth Diameter . Slot Size .Mates
From To Ft. In. In.
From To Ft In. In.
From To Ft In. In.
9. SAND/GRAVEL PACK:
Depth Slze Material
From ' To FL
From To Ft
From To Ft
10. DRILLING LOG
From �Y .o
Cif 171
11. REMARKS:
Formation Description
sated clay
/nnsol;datrd rear
L
r-
r�
N
100 NERDY CERIFYDATUM WELL WAS CONSTRUCTED N ACCORDANCE WITH
1M NCAC 2C. WELL CONSTRUCTION STANDARDS, AND 1HAT A COPY 9F TM
RECORD HAS BEEN PRCMm1170THE WELL OWNER.
SIRE bF ERTIFIED'WELL'CONThACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Dfvfsion of Water Quality within la days. Attn: Information Mgt., .
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. (9191733-71315 eat 568. .
Form GW-la
Rev. 7/05

RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Nature) Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Caneacta.(Indlvidual) Name
Camp's Well & _Pump Co. Tnr-.
Well Contractor Company Nerve
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(lt applla ble) '
Zip e
STATE WELL PERMIT#(lappaeable)
D W Q a OTHER PERMIT #(I applicable)
WELL USE (Check Applicable Box): Rasklenaal Water Supply°
DATE DRILLED / — / 3-0 6
TIME COMPLETED + : 00
3. WELL LOCATION:(
CITY: M I L T E I y1 cowire f/ 1
(Street Name, Numbers. ConununItyIon, Lot No.. Para477p Code)
TOPOGRAPHIC RAND SETTING:
OSlope I(ida3ey DFlat ORldge OOther
(
•
LATITUDE,. �° ego, (9'7
LONGITUDE Sia° /2.•31I-I
Amp PM ($"
minute; Nardi or
in a decimal iamat
Latitude/longitude source: t S °Topographic map
*Mtn of we: must be sham on a USGS topo map and
attached to this tom} Snot using GPS)
4.WELLOWNER �. /A
OWNER'S NAME \ I $YW (J� (lV (55oC.
STREET ADDRESS 7 0 8 c 7 4 l 2.5
Spivhutbuy4 S L 2g5o5
a Tam State Zip Cede
A[ea code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTIt
b. DOES WELL REPLACE EXISTING WELL? YES ID NOp
a WATER LEVEI. Belau Top d Casing: an Fr,
(Use '+'.IfAbove Top d casing)
d. TOP OF CASING 1S 1 FT. Above Land Surface'
. 'Tap d easing tan*iatad agor Wow laid surface mgy rib
it vailra 1h accardatcew8h 15A NCAC 2C .0118.
e. YIELD Wpm): C - METHOD OFTEST ltI
t• DISINFECTION:Typa chlorine Amount
g, WATER ZONES (depth):
From To From To
Fran To From To
From To From To
S. CASING:
Fran 0 To 40_Ft Tire*
From To Ft
From To .Ft.
Cc,05
7. GROUT: Depth
From 0 To 20
From To
From . To
.Thlelmesat
Weight
DR21
Material
Ft Sackrete
Ft.
Ft
Method
Hand
B. SCREEN; Depth Diameter . Slot Size .Material
From To FT.�in. h.
Fran To Ft In. In.
From To _ Ft in. In.
B. SANDIGRAVEL PACK:
Depth Size Material
FL
From
Fran To Ft.
Front_To_____ o Ft.
10. DRILLING LOG
From To . FormDosed bon
. 0 • ..To
C Qation A \ %pm-.
11. REMARKS:
r
n)
m
Cl
1 DO HEREBY CERTFYTHATTNIB WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15l IY.AC 2C, WELL CONSTRUCTION STANDARDS, AND THATACOPY QFTHIS •
• RECORD HAS BEEN PROVIDER TO THE WELL OWNER.
I REob
l e l) r'1�i ?•
bA E
SI T. RE OF CERTIFlED•W�-"CONT CTOR BATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submf the original to the Division of Water Quality within.30 days. Attn: information Mgt,, .
1617 Mail SONIC, Center —Raleigh, NC 27699-1617 ' PhoneNo. (9191733-7016 ext 568.
Form GW-la
Rev. 7/05

Ind
(Street Name, Numbers, unity. SubeilValontLot No.. PareN;Zlp Code)
TOPOGRAPHIC! LAND SETTING:
❑Slope fif0alley DFlal ORidge °Other
toned spprepdW boo
LATITUDE 3S Qo
LONGITUDE �b
Latitude/longitude source: V}PS °Topographic map
(bcatbn otwel maths shown on e USGS topo map end
attached to this form /not ushg GPS)
4. WELL WSNER y S I l l
OWNER'SNAME .Jl_ WI 55pL.
eaffarLbur9 a
byaTown State
Area cede • Phone number •
5. WELL DETAILS:
a. TOTAL DEPTH:
4 , .
REESIDENTLI L WELL 1, CONflUflIort RECORD
North Carolina Deportment of Environment and Natural Resources- Division of Water Quality
WFd.i, CONTRACTOR CERTIFICATION a 213 8 '
1. WELL CONTRACTOR:
James W. Camn
Well Contractor (Individual) Name
Camp's Well & pugs Co. Tnr_
Well Contractor Company Name
STREET ADDRESS to 0 Box 429
Ellenboro NC 28040
City or State Zip Code
(828. 453-7322
Area rode- Phase number
2. WELL INFORMATION:
SITE WELL ID es '
STATE WELL PERMITf(aappbahb)
DWQ or OTHER PERMIT e(If applicable)
W EI L USE (Check Applicable 1Bo:): Residential Water Supply 0
DATE DRILLED d ,,��jj— i of -D G /
TIME COMPLETED ; <F'S AM O PM itt
3, WELLLOCATICITY: IY ) $pY I Vlq couNTY PO I K
Maybur9depea,
minutes, seconds or
bra dermal karat
ADDRESS ° box 4I2S
7 o5
Zip Cate
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX
c. WATER LEVEL SOON Top of Casing: y 0 FT,
(Use W if Above Top o( Casing)
d. TOP OF CASING IS 1 PT. Above Land Surface*
Tap d tashg tenninated at/ar below lend surface may tegare
■ wince h axardancewith 15A NCAC 2C .0118.
a YIELD (gpm): 3 0 METHOD OF TEST a I Y
f. DISINFECTION: Type chlorine Amountyr>cp5
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:D..@g 44
• From 0 Tom90 er Ft_ SDtth21
From To Ft
From To .Ft
7. GROUT: Depth Material
From 0 To 20 Ft Sackrete
From To Ft
Fran To Ft
From To
From To
From To
.ThkWatssl
Materialp
Method
Hand
a. SCREEN: Depth Diameter . Slot Sate Material
From To Ft. in, In.
From Tr‘_ Ft. In. b.
From To Ft In, yr,
9. SAND/GRAVEL PACK:
Depth Sae Material
From ' Tq Ft
From To Ft
Fraq,T_To Ft
10. DRILLING LOG
Ftom ou
.o'
5to sacs •
11. REMARKS:
0
rr i1I
I DO HEREBY CERTIFY M ATTla6 WELL WAS CONSTRUCTED IN ACCORDANCE WIN
119.NCAC2C. WELL CONSTRUCTION STANDARDS, AND THATACOPY gFneS
RECORD HAS SEEN PRCJDEOTOTHE WELL OWNER
SIGPiskiP
) 1 OF CERTIFIED 'W �CTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitthe original to the Division of Water Quality within 30. days. Attn: information Mgt, .
1617 Mall Service Center -Raleigh, NC 27699-1617 ' Phone No. (9191733-7015 ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nattaal Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138 '
1. WELL CONTRACTOR:
James W. Camp
Weer Cantraatoc(IndMduaf Name
Camp's Well & Pump Cb. Tnr
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tam . State - Zip bode
(828} 453-7322
Area coda- Pha+e numbs 2. WELL INFORMATION:
SITE WELL ID 9preppnaWs) •
STATE WELL PERMIT#prappaeable)
DWO or OTHER PERMIT Cr applicable)
WELL USE (Check Applicable Bak): Residential Wafer Supply 0
DATE DRILLED '7- // - 0 6
TIME COMPLETED 3 : 14 0
3. WELL LOCATION:
CITY: l)lpp° O
COUNTY c)O
l ei
(Street Name. Numbers. Cahmwty, SebdMsio, Lot No., Pareef;7lp Code)
TOPOGRAPHIC / LAND SETTING:
0Slope Watley DFIat ORidpe ❑Other
(clam
LATITUDE _ ) g n
LONGITUDE pSCd J a 3,a2y
Latitude/longitude source: GPS iTopogmphic map
(beaten ofwet must be shown on a USGS topo map and
attached to this lam inof ushg GPS)
4, WELLOWNER
OWNER'S NAME
MlYminutes, seconds
minutes, or
in a decimal format
Jim onitiht 1T55ot
I
STREET ADDRESS G Or X g J 2 S
Sip Kb 'Ark, r
rk,sc. 2133o
C orTamZip Cede
Area code • Phone number .
5. WELL DETAILS: T�
a. TOTAL DEPTIh
b. DOES WELL REPLACE EXISTING WELL? YES l i N0 ({
C. WATER LEVEL Be1avTap d Casing: .IA u FT,
(Use '+'.IfAbove Tap d Casing)
d TOP OF CASING IS 1 . FT. Above Land Surface*
Too d—te mhiated Misr WNv hind suffice moy mike
■ valance al accordance se 15A NCAC 2C .0118.
a. YIELD (gpm): S p METHOD OF TEST all,
t. DISINFECTION: Typachl or ine Amount .2 ca qs
p. WATER ZONES (depth): /
From To • From To
From To From
From To F
6. CASING:
• D
From 0 To c8 Ft r
t
From To F
Fran To .Ft_
From
To
To
ThrrSiess/
All 1 Iate
C.
7. GROUT: Depth Material Method
From 0 To 20 Ft, Sackrete Hand
From To Ft,
From . To Ft
8. SCREEN: Depth Diameter . Slot Sign .Materiel
From To Pt In. In
Fran To Ft. In. In.
From To Ft In. in.
9. SAND/GRAVELPACK:
Depth Sim Material
Frrini Ter FL
From To Ft.
From To FL
10. DRILLING LQG
From .To. ormatbn
. 0 ' 3� ( tC \ f�}a �n
11. REMARKS:
ro
On
ry f%
c;
I DO MEW CERTIFY THATm S WELL WAS OONsmUCIED NACCORdpcE MTH
15A NCAC2C, WELL CONSTRUCIDN STANDARD.., AHD 'DATA COPYQE1HI$ .
RECORD HAS BEEN PROVIDE? THE WELL OWNER.
"'/)
SI ,'URE OF C FIED WELLl
ONTRACTOR GATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•1
Submit the original to the Division of Water Quality within 3adays. Ate: lntotmatlon Mgt, .
1617 Mall Service Center— Raleigh, NC 27699-1417 ' Phone No. (9191733-7015 ext 568.
Form GW-la
Rev. 7/D5

• .RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natud Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8 '
1. WELL CONTRACTOR:
James W. Camp
Wee Cmtraetar.(IndMdual) Name
Camp's Well & _PpmD Co Tnc
Well C ntractar Company Name
STREET ADDRESS P 0 Box 429
Ellenboro NC 2 040de
Zip
City aTom • State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mir applicable)
STATE WELL PERMIT#(sappliable)
DWQ a OTHER PERMIT #(tapptcable)
WELL USE (Check Applicable Boa): Residential Water Supply p
DATE DRILLED 1 Q1n
TIME COMPLETED C: /7/AMID PM$
3. WELL ,v,LOCATION: py'�
CITY: X ScAkm.% COUNTY e (Y�.V�
(Street Name ,Ncmbers . Subdivision. Lot No. Para421p Code)
(
TOPOGRAPHIC/ LAND SETTING: •
❑Slope Vaeey °Flat ❑Ridge ❑Other
(oherA hhpEa° rtD
LATITUDE
LONGrIUDEJ'�L° n Il. b�ql
May be io deyee.
mimes, seconds or
in a dadmat format
Latitude/longitude source: DIGPS °Topographic map
(baGMr ofwe?mart 6e shown on a USGS tops map and
attached to this Tam ?not using GPS)
4.WELLOWNER 1�_ y'��, yj•
4
jj'i
OWNER'S NAME V)tYk S+.l�lr\ y TI ss Dc,
STREET ADDRESS f D B o X has
xbtiY S c a93 c�
City
Ton Zip Cede
A[aa code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: v D
b. DOES WELL?WELL REPLACE EXISTING jg YES NO
a WATER LEVEL Belay Teo d Casing \p o) FT,
Wen' Above Top d Casing)
d. TOP OF CASING IS 9 , FT. Above land Surlaai•
'Tap dcashg Laminated odor belay lend surface may require
a wanes In a�cco.lrdance with 15A NCAC 2C .0118.
all
e. YIELD(gpm): METHOD OF TEST QAu4
1. DISINFECTION: Type Chlorine Amount ckps
g. WATER ZONES (depth): /
From To . From To
From To From To
From To From To
6. CASINO: Th s/
Depth DI Weigh Material
From 0 To D FL 6vr SDR21 .
Fran To Ft
Frain To Ft
7. GROUT: Depth
Fran 0 To 20
Fran To
From - To
Material Method
Ft, Sackrete Hand
Ft
Ft
S. SCREEN: Depth Diameter . Slat Size .Material
From ToFt--.In• ___ h.
From To FL In. in.
From To FL In. In.
9. SAND/GRAVEL PACK:
Depth
Fran Tq Ft
Fran To Ft.
From. Tq Ft,
10. DRILLING LQG
From .To
.0 Can
tau ko0ts
11. REMARKS:
Size Material
ormationscriptIoY
r
ry
c
I DO IER®YCERTFYTNATMIA WELL WAS OONSiaUC1ED NACCOP0N CE WIIH
1MN000E% WELLCONS1RUGNDN STANDARDS. AND 1HATACOPY PFTRAS •
RECORD HAS SEEN PRONmEEDTOTHE WELL OWNER
INRE • GF CERRL1L"CO ED RACTOR DATE 6
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: information Mgt.,
1617 Malt Service Center— Raleigh, NC 27699-1817 ' Phone No. (9191733-T015 ext 568. .
Form GWla
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
Noah Carolina Department of Environment and Natural Resources- Div)sion of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
1. WELL CONTRACTOR:
James W. Camn
Well Cmtracla.(IndMdual) Name
Camp's Well & PumO CO. Tar
Well Contractor Qanpany Name
STREET ADDRESS P 0 BOX 429
Elienboro NC 28040
City oTo/m ' State Zip GoSe
(828} 453-7322
Area code. Phone number
2. WELL INFORMATION:
SRE WELL ID SOtapplicable) '
STATE WELL PERMIT#OtappOuble)
DWQ a OTHER PERMIT WUapplicable)
WELL USE (Check Applicable Box): Residential Water Supply ID
DATE DRILLED 7 — b C.
TIME COMPLETED g: 30 AM ❑ PMMI
3. WELLLOCATIO�VY:,,
CM: it-TheY ydbi&ourity /Z)k
Ore en Rule Y JIi k laflds-Let/46
(Stresf Name, Numbers, Caanunily. SnbNr n, La No., Pareal;.Zlp Code)
TOPOGRAPHIC / LAND SETTING:
❑slope [Pinky DPiet DRidge ❑Other
(ahem apwapdah beer)
LATITUDE 3S 1 5Q �(
LONGITUDE, a. fog
minutes, moods or
Ina decline' Meet
Latitude/longitude source: DOPS OTopographic map
(Staten ofwel must be shown on a USGS topo map and
attached bath lam Snot using GPS)
4. WELL OWNER
OWNERS NAME
De )GYPnS±.
STREET ADDRESS P D 8 o X a 3
Bps ,80 l S
Cltyy orTavn State Zip Cede
Area code- Pirate number
5. WELL DETAILS:
a. TOTAL DEPTH: a D S '
b. DOES WELL REPLACE EXISTING WELLYES
? p N0
ilk
a WATER LEVEL BelowTop dS
Casing: bd Ft
(Use wlAtxwe Top of Casing)
d. TOP OF CASING I$ .1 . FT Above Land Sulfa*
. 'Top d wing tendtmtad slot below lend surface may regibe
a=knee In accordance with 15A NCAC 20.0/1�16.
1
e. YIELD (gpm):411_ i _ M$T lkETNOD OF TE)JA
t DISINFECTION: Typo chlorine Amount / 2 PN/0
g. WATER ZONES (depth):
From To From To
Fran To Fran To
From To From To
6. CASINO:
Fran 0
From
Fran
Dep6) Thicknesa/
WeigTo 4. Ft__Dr Cr SDRh21 VMateC.
To Ft
To .FL.
7. GROUT: Depth
From 0 To 20
From To
Front To
Maoris
Ft Sackrete
Ft
Ft
Method
Hand
S. SCREEN: Depth Diameter . Slot Size .Material
From To Ft. In. In.
From To Ft. In. In.
Front To Ft In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Frank' To Ft
From To Ft.
Front To__ Ft
•
10. DRILLING LOG
From TR ormafbnppstxipio
. 0 • 9l Q ate Jikinj
�s fir;IA) (ittfAlah
11. REMARKS:
0
r
rV
100 MEW WWI MATINS WELL WAS DONSIRUCIED NACCORDANcEWITH
15A NCAC2C, WELL CONSTRUC1IDN STANDARDS, ANDTHATACOPY QFTNIS •
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
RE OF CERTIFIED 'CONTRACTOR GATE
James W. Camp •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within S0.days. Attn: information Mgt,
1617 Man Service Center— Raleigh, NC 27699.1¢17 ' Phone No. (9191733-7015 ext 568. .
Form GW1a
Rev. 7A5

RESIDENTIAL WELL CONSTEULT OLtrIECORD
North Carokut Deparbnent of Environment and Natural Resources- Melaka of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8 •
1. WELL CONTRACTOR:
James W. Cam
W ea Cantraeta.(1ndMdual) Name
Camp's Well & Pump Cb. Tnr_
Well Contractor Qompan9 Norma
STREET ADDRESS P 0 BOX 429
Ellenboro NC
City or Tom State
( 828). 453-7322
Area code. Phone number
2. WELL INFORMATION:
SITE WELL m #(Dappneabte) •
STATE WELL PERMIT#(aapplkable)
28040
Zip Code
DWQ er OTHER PERMIT R Happliable)
WELL USE{Cheek Applicable Boa): Res' 'donee: Water Supplyp
DATE DRILLED 7 "" 2,0 O C
TIME COMPLETED oC: 30 AMP PMMi
3. WELL LOCATI i 1J/1 (�
CITY: IC er-J yei4bounin ! b!k
re eve e)- M k (ar4s -Lel 46
(Street Name, Numbers.. Sub dMESu, Lot No., Paraf,.Zb Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope Maley PFht DRidge DOther
Deere roptepdatatwi
LATITUDE 3.5 11 gq 3
LONGITUDE . 0 a_ (Cq 1
Laftuddlongiade source: LGPS OTopographio map
(badwt dad snot be shown on a USGS topo map and
alfachmd iota yam not ushg GPS)
4. WELL OWNER CONER'S NAME Ike ) GY�try l _)251-•
STREET
TTJADDRESS P D 1' 0 X 2 3
a—j c s 7L c Ric •itJ
City orTom, Shts Zip Code
•
weeds or
Ina daelmal fame
Area code- Phone number
5. WELL DETAILS: / DS a. TOTAL DENTED L.f
b. DOES WELL REPLACE EXISTING WELL? YES p NDD
c. WATER LEVEL BebwTcp el Casing: ' IS led FT,
(Uw'+WIabove Top el Casing) •
d. TOP OF CASING I3 _ • 1 FT. Above Lame Surface*
, 'Top d cube terminated at/cr beim land surface may squire
a veinal) matinee vAth 15A NCAC 2C .01116.
e, WELD(gpmr i
`ilv \ METHODOFTEsT'kA
t DISINFECTION: Type ch1 Ora. Ile Amount /7 relit
u. WATER ZONES (depth): /
From To From To
Fran To From To
From To From . To
6. CASINO: .ThsIcl�Wha(aal
DRSZ1 _MPVVC.
From 0 ll L, -L Ft D
From To Ft
From To .Ft
7. GROUT: Depth
Fran 0 To 20
From To
Fmm_,_ To
Material Method
Ft, Sackrete Hand
Ft,
Ft
S. SCREEN: Depth Diameter . SlotSiae .Watatai
From To Ft____In* h
From To Ft`_In, h
From To Ft In. In.
9. SANDIGRAVEL PACK:
Depth Slur Material
Fran To Ft.__
Fmrn___To Ft
Fran. To Ft
1D. DRILLING LOG
From n formation paseriptIoR
0
11. REMARKS:
IDOIEREBYCERtf TUTTae WELL WAS OaA9RUCIED NACWRDNYE WITH
GA NYAC 2e, WELL CotaTRUCTON STANDARDS, nor) 7HATA Miler= •
RECORD HAS BEEN PROJIDEDTOIHE WEILOWNER
URE OF CERTIFIED O RACTOR TE •
James W. Camp
)+RINTED NAME OF PERSON CONSTRUCTING THE WELL
Subina the original to the Division of Water Quality within 31/days. Attn: infotmatlon Mgl,
1617 Mall Service Center— Raleigh, NC 276994617 • Phone No. (9191733-7015 ext 566: .
Form GW-la
Rev. 7I05

•RESIDENTIAL WELL CONSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. CaHID
Wel Coetraetar.(IndMdual) Name
Camp's Well & PunD Co. Tnr.
W ea Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tam ' State Zip code
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID MU applicable)
STATE WELL PERMIT#(BaPPli able)
DWQ or OTHER PERMIT #(a applicable)
WELL USE (Check Applicable Box): Residential Water Supply❑
DATE DRILLED g -6
4
TIME COMPLETED : 3n
3. WELL LOCATION: j� I/
CITY: M;�I Set IYtQ couhiTY T'r)k
M 1 N PiA" �J'P'�ham' ]IE
(Street Noma. Numbers. Gommutury, SubdlNsion,.LotNo.. ParoalaZip Code)
IITOPOGRAPHIC I LAND SETTING:
Iope OVarey OFIld ORidge ❑Other
(dasdrkappopia4691Q
LATITUDE _ S° AO. 4 l2
LONGITUDEI 11 • L!F•g 14)
Latitude/longitude source: OPS OTopographic map
(loeatbn ewer must be shown on a USGS topo map and
girdled to thb lam /not ushg GPS)
AM El PMLV/
May be In degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
•
OWNERS NAME I i r
STREET ADDRESS
s aTt&tbU>''
City orTom
Syvufit t /-t550G.
State Zip Code
Aceaa code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 5 / O ''//
b. DOES WEU. REPLACE EXISTING WEU.? YES a NO)p.
c. WATER LEVEL awItA Top ofCasD FT.
ing).
d. TOP OF CASING 18 1 . FT. Above Lend d Surface*
.Top d casing wed aUa below land surface mty require
a variance b1 accordance with 15A NCAC 2C .Otte.
YIEID wpm): i' METHOD OF TEST A.I i
t. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
Frain To • From To
From To From To
Rom To From - To
6. CASING:
From 0 DTepolh 7g
Fran To
From To Ft.
Thlepbss/
Dla�eter Wei M Matedd
jrt 6:r SDR21 PVC
Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
From To Ft
8. SCREEN: Depth
From__To
From To
From To
Diameter Slot Size .Material
Ft. In In.
Ft In. in.
FL In. h.
B. SAND/GRAVEL PACK:
Iepth_Size Material
From '' To Ft
From To Ft.
From To_ Ft
10. DRILLING LOG
From Ts . Formation Description
.0 7 ��tv
79ronso; acted Ynt
11. REMARKS:
r.
W
IDO HEREBY RAOCOMIQICEVIMI
15A NGC2C, WELL CONSTRUCTION STANDARDS. AND A COPT WPM
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
NNW' W /Y�� �O 073 0,
STy.. RE OF CERTIFIEDC�LL"COM'RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit
ery cehe (nal to Center- Division of Water Raleigh, NC 27699- 6`17 Phone No. (9 91733 9Attn: ext 568.«on Mgt.,
Form GW1a
Rev.7105

inn ui'. amvrma — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567 336545
STATE WELL CONSTRUCTION PERMIT #:
1 WELL USE (Check Applicable Box): 0 Residential Q municipal
0 Recovery ❑ Heat PumpWater Injection If Ither, a ❑ Agricultural
RIG TIO ❑Monitoring
J ®Outer If Other, List Use: IRRIGATION
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
COLLINSVILLE RD
(Road Name and Numbers, CommuniDRILLING LOG DEPTH
3. OWNER ANN ALLEN ty, or Subdivision and Lot No.) From To Formation Description
Address COLLINSVILLE RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code 141-. ?$` 1Z` 5, u2.° IJ ,
4. DATE DRILLED 12/15/06 lo"5 $Z° -] : 3., -0° LJ
5. TOTAL DEPTH 27 ry
6. CUTTING COLLFCTED
® YES ®NO
7. DOES WELL REPLACE EXISTING WELL? Q YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 7 METHOD OF TEST: STEEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount:
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 27 Ft. 24 CEMENT
From To Ft. _
From To Ft. 14. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in, in.
ToFt.
From in.
16. SAND?GRAVEL PACK Depth Size Material
From 20 To 27 Ft 78M GRAVEL
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING, RT. ON COLLINSVILLE RD.
GO PAST PHILLIPS & SOUTH PHILLIPS . WILKERSON
HOLLOW RDS. SMALL DIRT ROAD ON LEFT JUST BEFORE
HUGHES CREEK BRIDGE WELL SITE CLOSE TO BACK OF
FENCE.
OlV. OF WATER QD ALITY
JAN f) 5 2007
I DO CERTIFY THAT THIS WELL WAS CONSTRUt.1 ED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG AT4fit.4 »-/�-/C66
-
[1RE PE ' v rr NSTRUCTTNG THE WELL
Submit original to Division of Wa �� : 'ty, Groundwater. Section within 30 days DATE
GW-1 REV. 12/99

forth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center — Raleigh, N.C. 27699-1636 —Phone [phone] YELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS 327 6 99
WEI i CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
learest Town: COLUMBUS County: POLK
OHN WEAVER RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description_._ ..
. OWNER CHARLOTTE M. COSTA
(tddress JOHN WEAVER RD.
Street or Route No.)
'OLUMBUS NC 28722 k �„ t� 'ity or Town State Zip Cc
ode 1 3 S 13 2.6.3
DATE DRILLED 05/04/06 bA) 52° eV V t o, 3 -1 " 4
. TOTAL DEPTH 425
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WEI S ? ❑ YES ® NO
. STATIC WAFER LEVEL Below Top of Casing: 60 FT.
Ise "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in acoor-
mce with 15A NCAC 2C.0118
0. YIELD (gpm): 60 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION:
3. CASING:
Depth
From 0 To 135
From To
From To
4. GROUT:
Depth
From 0 To 20
From To
5. SCREEN:
Depth
From To
From To
From To Ft.
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
7. REMARKS:
Type: CHLORYTE Amount: 12
Wall Thickness
Diameter or Weight/Ft Material
Ft.6-1/4" SDR21 PVC
Ft.
Ft.
Material Method
Ft. QUILKRETE POURED
Ft.
Diameter Slot Size Material
Ft. in. in
Ft. in. in.
in.
If additional scare is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RIGHT ON JOHN WEAVER
RD. NEW DRIVE 6/10 MILE ON RIGHT.
c
c
N
N
O
DO CERTIFY THAT THIS WELL WAS CONSTRUC 1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
INSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
IGNATL OF PERSON C STR CTAG THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

JorthCarolina-DepartmentofEnvironmentandNanaalResources—DivisionofWaterQuality—Groundwater Section
636 Mail Service Center— Raleigh, N.C. 27699-1636 —Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
327692
WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
'. WELL LOCATION: (Show sketch of the location below)
dearest Town: COLUMBUS County: POLK
3LACK WOOD RD. DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation DescripttOtt- "'
.OWNER JOHNEDNEY
kddress BLACK WOOD RD.
Street or Route No.)
:OLUMBUS NC 28722 Zak- SS° I3! c+ 51 " tS
:ity or Town State Zip Code to ,5 $ 2 + D 55. lS
-. DATE DRILLED 05/23/06
TOTAL DEPTH 605
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 40 FT.
:se "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
rop of casing terminated atlor below land surface requires a variance in accor-
nice with I5A NCAC 2C.0118
0. YIELD (gpm): 1 METHOD OF TEST: ARD
1. WAIERZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 16.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 90 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
4. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From To Ft.
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
6.SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
DEPTH
If additional spare is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
FROM MILL SPRING. HWY. #9 S. LEFT ON OLD CHESNEE
RD. LEFT ON BLACKWOOD RD. GO 6/10 MILE . DRre ON
RIGHT.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
2
SIGN TORE OF PERS I t CONSTRUCTING THE L DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
1

\forth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
'.636 Mail Service Center— Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential U Municipal ❑ Industrial ❑ Agricultural U Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
BY THE WAY SIDE DRILLING LOG DEPTH
;Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER MIKE KAUT
Address BY THE WAY SIDE
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Cndr
4. DATE DRILLED 07/13/06
5. TOTAL DEPTH 205
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
'Top of casing terminated ator below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 55 Ft 6-U4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft (W]KRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
ki 36" tlo' l.catn" rs
leA) "2-" cs 21.2S w
If additional space is needed use back of faun
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
FROM COLUMBUS. GO OUT HOUSTON RD. LEFT INTO
WHITE OAK MTN. LEFT ON HEMLOCK TRAIL. LEFT ON BY
THE WAY SIDE. HOUSE AT DEAD END.
I DO CERTIFY THAT THIS WFJ J WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRU
Submit original to Division of Water Quality, Ground
47'O 7-/3- cG
DATE
on within 3U days
GW-1 REV. 12/99
AUG <)200J

forth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
7VELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ❑ Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
!. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
WOODLAND DR DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3.OWNER JOE WEISS
Address WOODLAND DR
;Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 07/ 10/06
5. TOTAL DEPTH 205
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WF!.i ? 0 YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use `+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with l5A NCAC 203118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 60 Ft. 6-1/4" SDR21 PVC
From To Ft_
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 FL OUILKRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To FL _ in._ in.
From To Ft. in. in.
From To Ft in. in.
16. SANDTGRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
�24 36° IS' `► �2`:
I0,) O L °
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM COLUMBUS. RIGHT ON FOX MTN. LEFT
ON WOODLAND DR 2l° HOUSE ON LEFT.
c
C7
v
0'
I DO CERTIFY THAT THIS WELL WAS CONSTRUC FED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
toz,le nv, 7/G
IGNAT'JRE OP PERSON C S CTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

From 0 To 74 Ft. 24
From To Ft
From To Ft
t4. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. _ in. in.
From To Ft in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Sine Material
From 59 To 74 Ft 78M GRAVEL
orth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
336 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
tearest Town: COLUMBUS County: POLK
QKORY GROVE CHURCH RD. DRILLING LOG
load Name and Numbers, Community, or Subdivision and Lot No.) From
. OWNER ANDREW MCSWAIN
Lddress HICKORY GROVE CHURCH RD.
Street or Route No.)
:OLUMBUS NC 28722
:ity or Town State Zip Civle
DATE DRILLED 07/27/06
.TOTAL DEPTH 74
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WA t E:lt LEVEL Below Top of Casing: 59 FT.
Use "+" if Above Top of Casing)
I. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
aace with 15A NCAC 2C.0118
0. YIELD (gpm): 15 METHOD OF TEST: S 'EEL TAPE
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount 6.9
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
CEMENT
From To Ft
17. REMARKS:
DEPTH
To Formation Description
IAA 35' 12' SY, 35" tJ
ton) '62° 4' 21. um“
If additional space is needed use back of form
c-
a
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RT. ON HWY. #14. LEFT ON
HICKORY GROVE CHURCH RD. 1/4 MILE ON LEFT. 1ST
DRIVE ON RT. SINGLE WIDE AT DEAD END ON LEFT.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WFTI OWNER
O.
r—
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNAT 0
Submit original to Division of Water
UCTIRG THE WELL
undwater Section within 30 days
GW-1 REV. 12/99

forth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
[636 Mail Service Center- Raleigh, N.C. 27699-1636 - Phone [phone] (�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON �1
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County. POLK
GREENWAY RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER PAUL KEITH
Address GREENWAY RD.
(Street or Rothe No.)
COLUMBUS NC 28122
City or Town State Zip Code
4. DATE DRILLED 07/18/06
5. TOTAL DEPTH 225
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WFJ1 ? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing laminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.011S
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WA fhR ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 70 Ft 6-1/4" SDR.2I PVC
From To Ft.
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
From To Ft in. in.
16.SAND?GRAVEL PACK
Depth Size Material
From To FL
From To Ft
17. REMARKS:
PO 351' HI 32.(A' tJ
to.t) g • 4' 9.10" vLi
If additional space is needed use back o1 ThFii
3 3 k5
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON HORNE RD. LEFT
ON GREENWAY RD. APPROX 1/2 MILE ON RT.
I DO MITIFY THAT THIS WELL WAS CONSTRUCPED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
S7-/a-d6
0-NATURE OfYPER.SON CONSTR G WELL DATE
ubmit original to Division Water Quidity, Groundwater Section within 30 days
GW-1 REV. 12/99

4octh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Giamdweter Section
1636 Mail Service Center- Mash, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIIRCATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
R a
a
I. WELL USE (Cheek Applicable Bo4 tgl Residential ❑ Municipal 0 Industrial 0 Agriadhxal ❑ Monitoring
D Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: TRYON County POLK
PINEFIELD DR DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER JAN LEE WHTIEHURST
Address PINEFIELD DR.
(Street or Route No.)
TRYON NC 28752
City or Town State Zip Code
4. DATE DRILLED 07/26/06
5. TOTAL DEPTH 245
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WFJJ REPLACE EXISTING WELL? 0 YES ►�1 NO
8- STATIC WATER LEVEL Below Top of Caging 20 FT.
(the "s^ if Above Top ofCaeog)
9. TOP OF CASING IS 1-112 FT. Above Land Surface*
rrvv of casing Iamionied atior below land awfaoe requires a viamcmacoor-
dance with I5ANCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To 100
From To
From To
14. GROUT:
Depth
From 0 To 20
From To
15. SCREEN:
Depth
From To
From To
From To
Type: CHLORYTE Amount: 6
Wall Thickness
Diameter or Weight/Ft Material
Ft. 6-1/4a SDR21 PVC
Ft.
Ft.
Material Method
FL QUIKREIE POURED
a
Diameter Slot Size Material
FL in. in.
FL in. in.
Ft. in_ in_
16. SAND?GRAVEL. PACK
Depth Size Material
From To FL
From To FL
17. REMARKS:
j# 35" 4' 416,5`I" t4
low) (62' 2` 3q.o'. " N'
If additional we is needed use back of from
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON CONE RD. RT. ON
PINEFIELD DR 1st DRIVE ON LEFT
0
0
rr.
I DO CERTIFY THAT TI11S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
a' • ya`a CONSTRUCTING WELL DATE
original to Division of Water Quality, Groundwater Sertim within 30 days
GW-1 REV. 12/99

forth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
L. WELL USE (Check Applicable Bo:): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
Tearest Town: COLUMBUS County: POLK
,AKE ADGER PARKWAY DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
r. OWNER FRANK STRAIT
lddress LAKE ADGER PARKWAY
Street or Route No.)
:OLUMBUS NC 28722
;ity or Town State Zip Code
1. DATE DRILLED 06/01/06
i. TOTAL DEPTH 245
i. CUTTING COLLECTED 0 YES ® NO
t. DOES WFJ J REPLACE EXISTING WELL? 0 YES ® NO
1 STATIC WATER LEVEL Below Top of Caging: 100 FT.
Use "+" if Above Top of Casing)
). TOP OF CASING IS 1-1t2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
Iance with 15A NCAC 2C.0118
10. YIELD (gpm): 12 METHOD OF TEST: ARD
l 1. WA fhit ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 6
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 105 Ft. 6-1/4" SDR21 PVC
From To Ft
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth
From To
From To
From To
16. SAND?GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
Diameter Slot Size Material
Ft. in. in.
Ft in._ in.
FL in. in.
\ 41)r 3s.e i 41.*4-'
long ZZ„ rt-' '1c 32 w
If additional space is needed use back of form
LOCATION SKETCH
tShow direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING LEFT ON GARRETT RD.
RIGHT ON GREEN HILLS RD. LEFT ON LAKE ADGER
PARKWAY. STAY LEFT ON LAKE ADGER PARKWAY.
HOUSE 1.3 MILES ON RIGHT.
RECEIVED
._.0 .. 3
DO CERTIFY THAT THIS WELL WAS CONSTRUCT ED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.1
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
r^
c�
-71
FOR OFFICE USE ONLY
Quad No:
Serial No.
z hi _-274 e/Xsu A —/ —6 C
GNATURE 0 • tl• ON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
AUG , _ 201.16

uth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
36 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
TELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
.. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use: _
WELL LOCATION: (Show sketch of the location below)
earest Town: COLUMBUS County: POLK
DORS FORD RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER TIMOTHY GOSNELL
kddress POORS FORD RD.
Street or Route No.)
;OLUMBUS NC 28722
;ity or Town State Zip Code
. DATE DRILLED 06/15/06
. TOTAL DEPTH 44
CUTTING COLLECTED 0 YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
i. STATIC WA IEIt LEVEL Below Top of Casing: 24 FT.
Use "+" if Above Top of Casing)
1. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated Odor below land surface requires a variance in senor -
lance with 15ANCAC 2C.0118
0. YIELD (gpm): 20 METHOD OF TEST: S 1'EhL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
From
From
From
14. GROUT:
Depth
From 0 To 20
From To
15. SCREEN:
Depth
From To
From To
From To K 16. SAND?GRAVEL PAC
Depth Size Material
From 24 To 44 Ft 78M GRAVEL
From To Ft.
17. REMARKS:
Wall Thickness
Depth Diameter or Weight/Ft Material
0 To 44 Ft 24 CEMENT
To_ Ft
To Ft
Material Method
Ft. CEMENT POURED
Ft.
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft is in.
4t- 55° Iz Si, $t'„
lo, cc-C 0' o.zl" 1
If additional space is needed use back of form
)
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON OLD CHESNEE
HWY. LEFT ON POORS FORD RD. NEW DRIVE ON RIGHT.
BEFORE 2 STORY LOG HOME.
RECEIVED
c
c
r
0
0
V
0
r
J
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATORR OF
Submit original to Division of
n--r7,n,6-/5 -6e
CONSTRUCTING THE WELL DATE
Quality, Groundwater Section within 30 days
GW-I REV. 12/99
AUG () 2006

2. WELL I.OQATKMt skskh of the baton below) /
Napo Tint cam, /..O, /�« - / r - c Ceen r d` 7-e
, ____ rlr .-aa-1/,' r// ,r �,rad7
/perISe W tapra*4.Rs,ar+rwrtm WI DRIwP4Gl00
3- OWNER J*c % /1 / cec. ' 127=
o /4 lciiQ/ia) 0 47 o/ An-
a.L�.%:. /44 , n tt
aar. nFtab
4. DATE DRUM
5. TOTAL DEPTH .O 5/
6. CUTTINGS COLLECTED YES
T. DOES WELL RWLACE E1( W SLLT YES Q NO
6. STATIC WATER LEVEL Eslaw Tap al Calm yO FT.
r& n law'•' INMI lip e CaMM
6. TOP OF CASING IS / FT. Above land WNW
'fee N are h.eth.Cua-Var balsa Sa«IKar ±- • airbus In Car
aanaae IIAfat MA
%O. YIELD(Wm): MEMO OFTESTf9-;
11. WATER 2ONES NspOS: 4,2 5-
Address
ago
tZ. CH N *ATIOFt Typo r/hK--o1'e
%a. CABINS: p
F'ts la
Arnauspsi
Noah Craft t M a A � ~ ant ICIIM My q 7b Walt OuN�r. Giw�Wwwr Simian
WELL CONSTRUCTION RECORD WELL CONTPACTOR : 4- •t/ rt.,) 67, /ice •'CZ wy
WELL CONTRACTOR CEPTWICATION t: a /a
STATE WELL CONSTRUCTION MERMITI: Q 2 g #1 / c2i-c
10 331169
1. WELL NISI- Moots sot Rsaldrh6Y[nMunkipal InohnNd I1prb 1111rs1 Mahlbrbq
RaatvvMootsHos Pomp Water kiselan p Otter p it oils. Ur Use:
A&F WELL. DRILLING
AND PUMP SERVICE, INC.
911 Hwy. Business 74
Bostic, NC 28018
-828-247-1773
Fawaloh D--wrrlbst
1r Wooed moot V sew we bead tra
N/YhWnM
Depthelr: DbassNt «WelOWL ISsa.W
Ien1-4142—To .F� FL '" _ /)/7 L
Franca To R.
Frrs To a
14. GROUT:
Depth MOSS Mahtd
helm 2,24 To 2 1 FL-.1,.A/.47'\' PC&IC Fc/
Hem _ _ To R
15. SCREEN
Depth
Fran __Ts
Fta6 TO
From _ __ To
It SANOIGRAVEL PACK
Dope%
From To
From _ To
17. IIEMAIS
DI«ntter eel Sae Iklalal
Ft _ In. In.
R_ In. In
R_ In. h.
Stte Mali
FL
(Show Oradse and data cobsss M ban in f1a1a
Rosh. sew NeSuns RA
0
lid- r35a It I S1"gfL1
'c^^) 81' S1 '4' 47&F WE DRILLtiet
E,INC
.18
AND911 PUMPHwy. SER Busi.:I
Bostic, NC ,y
828-247-
SF3
I DONEREEY CERTIFYTWIT MU REEL WAS COIISTRUCTEO PI *ODDIMANCE MRTN ISA MAC It V/9L
CONSTlm1CRCNSTANDNM)S.ANDTWITACOPYOF1MISRECORD Ina BEEN FRDYE]EDTONE Vial credit
PPOR OFFICE WIII ONLY C�r/�� /
3raa 110 MIENARSEOr PMR ION OMINIRUGIM6 WIwill.wop IL
Il bdwy*a011SWMtOWELOawembtawsari17PI lls
N
am PIEY. uR
-24-20'3 10N 11:31AM ID:

North Carolina — DeParhuent of Environment And NaturalONSTRUCTION RECORD 1 2 l �a
WELL CONTRACTOR (INDIVIDUAL) NAME (print)ODNEY BOBBINS of Water Section
WELL CONTRACTOR COMPANY N Quality —Groundwater
STATE WELL CONSTRUCTION PERbG# PITTMAN WELL CERTIFICATION # 2785
RING LLC PHONE # [phone]
(if applicable) ASSOCIATED WQ applicable)
# L —
(if applicable)
1. WELL USE (Check Applicable Box
MOLL USE 0 Rkc) Residential ® Municipal/P°blic 0 Industrial 0 Agricultural ❑
2. WELL LOCATION: rY ❑ Heat Pump Water Injection
❑ Other 0 If Other, List Use
Nearest Town: MILL SPRING
SYLV—LANE County POLL{ --
Topographic/Land Name, Numbers,o tYSubdivis on Lot No., Zip Code) ❑ Ridge ❑ope ❑ Valley ❑ Flat
3. OWNER:RY
ER
Address SYLVAN (check appropriate box)
(Street or Route No.) Latitude/longitude of well location
MILL SPRING NC
City or Town State 28756 (degrees/minutes/seconds
828)or Town 06 Zip Code Latitude/longitude source: 0 GPS 0 To Area Code Phone number (check box) Topographic map
4. DATE DRILLED 01/04/06 DEPTH
5. TOTAL DEPTH; 24 5 From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below To of DRII LING LOG
P Casing: q_FT. Fro
8. TOP OF CASING IS 1-1/2To
(Use "+" if Above Top of Casing) *Top CAS terminatedS at/2rT. Above Land Surface}
ofe m casing
with or below land Csurface.0118. reqUires a LOCATION SKETCH
9. YIELD (gpm): METHOD OF TEST ARD Show direction and d��
10. WATER ZONES (depth): Two State Roads ors miles from at least
number and common nam County Roads.dude the road
11. DISINFECTION: Type CHLORYTE HWY. #9 N. FROM MILL SPRING. LEFT ON
12. DISINFECTION:
CASING: Amount 6 SILVER CREEK RD, RIGHT
Depth Diameter Wall Thickness DRIVE ON ON SYLVAN LAB lsr
From 0 To 140 Ft 6- or Weight/Ft Material
FromToFty4 SDR21 PVC ( 35° Ib I 4 .02" h/
From To Ft
13. GROUT: Depth to„5 $�'' ill SS.&I " v✓
From Material Method
To 10 t.FPOURED
From
14.SCREEN: Ft.
From Depth Diameter Slot Size Material
From ;n.RECEIVED
in.
15. SAND/GRAVEL PACK:F
in.
From Depth Size Material MAR 0 8 2005
To
From Ft a
To Ft _ Asheville Regional Office
A.uiter Protection
0
a,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STANDARDS AND THAT A COPY OF t
2 , RECORD WITH ISA NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONS ' UCTINn ESL % -
Submittheori 'e Cr `t WELL DATE ��
S2ubmit
Phone l to the ) Division
32of within Quality, Groundwater
hin 30 days.
Secfion,1636 Mail Service Center— Raleigh,
GW-1 REV. 07/2001NC
16. REMARKS:

Mesh Cesar . Ohrwwu e16w- I «4 NM.r Ramat - CPAS" M WS
u]eMee Straw - KC. 1n urea 7rrpremms
WELL CONSTRUCTION RECORD 'vcj Bi14J
1,3
nth commenset non
STATE was. OONOTRUCNON Fi111Rrr: •� 1 -
AAF WELL DRIWNG
. _____eer tram AND PUMP SERVICE, INC.
911 Hwy. Business 74
1.
Z
3. OWNER
Address _a:._ +top -s 61.4 •
tor) Ate ‘t c_ c
« as
DATE GRILLED - 'a E
4.
O. 'TOTAL WPM
S.
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WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERTIFICATION # 2785
WELL CONTRACTOR COMPANY NAME PITMAN WELL BORING. LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON
ASTER LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: CLAY JORDAN
Address ASTER LANE
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
(828) — 863-1374
Area Code Phone number
4. DATE DRILLED 03 02/06
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 60 METHOD OF TEST ARD
10. WATER ZONES (depth):
County POLK
11. DISINFECTION: Type CHLORYTE Amount 13.5
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 90 Ft. 6-1/4" SDR21 PVC
From
From _
13. GROUT:
From 0
From
14.SCREEN:
From _
From
To Ft_
To _
Depth Material
To 20 Ft. QUIKRETE
To
Depth Diameter
To Ft.
To Ft.
Method
POURED
Slot Size Material
in. _ in.
in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To FL_
To FL
From
From
16. REMARKS:
Topographic./Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at (east
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
GREEN CREEK DR. LEFT ON CORE RD. RIGHT
ON MCENTIRE RD. LEFT ON ASTER LANE WHEN
DRIVE SPLITS STAY STRAIGHT THROUGH RD
GATE. HOMESITE AT END OF DRIVE.
;44 55° ILI' 32.2-5" e J
to '15 52° Z.' 3J.53" t^!
TJ
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON UCfl9N STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
o es r s��, ov .-) 6 ri
SIGNATURE OF PE ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ROBIN MCNEELY CERTIFICATION # 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ® MlmicipaVPublic ❑ Industrial ❑ Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON
TRICYCLE HILL LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: HUBERT METCALF
Address TRICYCLE HLL LANE
(Street or Route No.)
TRYON NC 28722
City or Town State Zip Code
8828) — 899-4905
Area Code Phone number
4. DATE DRILLED 03/16/06
5. TOTAL DEPTH: 51
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 36 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 15 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County POLK
11. DISINFECTION: Type CHLORYTE Amount 6.9
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 51 Ft. 24" CEMENT
From To FL
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To FL
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 36 To 51 Ft. 78M GRAVEL
From To FL
16. REMARKS:
Topographic/Land setting
0 Ridge 0 Slope 0 Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
TURNER RD. RIGHT ON TRICYCLE HILL LANE.
APPROX. 1/2 MILE ON LEFT.
jai 35°15' 3'3.5'-1° N
Go, 6Z° 5'IZ,a1' LA)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUE 1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS CTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ n
SIGNATURE OF
a/1 >4fir Q 3-is •ol
0 ONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

326118
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ROBIN MCNEELY CERTIFICATION # 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIAIEL WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON
HENRY THOMPSON RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: TRAVIS THOMPSON
Address HENRY THOMPSON RD.
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
(828) — 863-0413
Area Code Phone number
4. DATE DRILLED 04/11/06
5. TOTAL DEPTH: 60
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County POLK
11. DISINFECTION: Type CHLORYTE Amount 9.2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
CEMENT
From 0 To 60
From _ To _
From _ To _
13. GROUT: Depth
From 0 To 20
From To
14.SCREEN: Depth
From To
From To
Ft 24"
Ft _
Ft.
Material Method
Ft. CEMENT POURED
Ft
Diameter Slot Size Material
_ Ft _ in. _ in.
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From 40 To 60 Ft 78M
From To FL
16. REMARKS:
Material
GRAVEL
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
SANDY PLAINS RD. LEFT ON HENRY THOMPSON
RD. LEFT AT FORKS. GRAY SINGLEWIDE AT TOP
OF HILL ON LEFT.
Ink.n.� 3S$2 5
° fs' 2t.'4' /
� u
1' !U n
,‘J. It' tu.J
Z 2 . �(�I " td.J
0
—y-;t
>0
co rn.
N QITI
n�
r—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS T TION STANDARDS, AND THAT A COPY OF TFJS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE'OF P
NSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

Iorth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
WELL USE (Check Applicable Box): ® Residential U Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
4earest Town: MILL SPRING County: POLK
AKE ADGER PARKWAY
DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
i. OWNER CARROLL DANIELS
address LAKE ADGER PARKWAY
Street or Route No.)
vIILL SPRING NC 28756
'City or Town State Zip ode
1. DATE DRILLED 06/29/06
5. TOTAL DEPTH 545
i. CUTTING COLLEC1LD 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO
1. STATIC WATER LEVEL Below Top of Casing: 60 FT.
Use "+" if Above Top of C"sing)
). TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
lance with 15A NCAC 2C.0118
10. YIELD (gpm): 50 METHOD OF TEST: ARD
11. WAILRZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 15
13. CASING:
Depth
From 0 To
From _ To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
Wall Thickness
Diameter or Weight/Ft Material
100 Ft 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
From To FL
16. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
is in.
in. in.
in. in.
Material
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
IShow direction and di tanre from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. LEFT ON SILVER CREEK
RD. GO PAST CHURCH & RT. ON LAKE ADGER PARKWAY.
2N. DRIVE ON RT.
C
lea. 35° ('1' 56.2-4" (N o
(one $Zv I3° 3-7.011" IN
T —,
( DO CERTIFY THAT THIS WELL WAS CONSTRUCT hill IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
ATURE OF PERS N C-bNSTRUCTING THE TiEEiLIL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
n
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
335 WHITETAIL LANE DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER GENE WILSON
Address 335 WHITETAIL LANE
(Street or Route No.)
MILL SPRING 28756
City or Town State Zip Code
4. DATE DRILLED 08/14/06
5. TOTAL DEPTH 42 t-0."k 3S° IS s5 41 7J
6. CUTTING COI.T:FCTED ❑ YES ® NO Loki. '62) 'II K.4' tJ
7. DOES WELL REPLACE EXISTING WFJI ? ® YES 0 NO
8. STATIC WA rat LEVEL Below Top of Casing: 32 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: S IhEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amolmt 4.6
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 42 Ft. 24 CEMENT
From _ To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft CEMENT POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 32 To 42 Ft 78M GRAVEL
From To Ft.
17. REMARKS:
If additional space is needed use back of form
) 3
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING, APPROX. 3 MILES.
RIGHT ON WHITETAIL LANE. GO TO VERY END OF ROAD.
rn
b
I DO CERTIFY THAT THIS WFT T WAS CONSTRUL A W IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
L—t �e
SI NA OF PtSON C
Submit original to Division of Water Quali
G THE WELL DATE
Groundwater Section within 30 days
GW-1 REV. 12/99

326135
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JEFF MELTON CERTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential / t MunicipaUPublic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: COLUMBUS County POLK
119 HORN RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: EDNA FLORIG
Address 119 HORN RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
(828) —817-1278
Area Code Phone number
4. DATE DRILLED 04/12/06
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER. LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 2 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 13.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 35 Ft. 6-1/4" SDR.21 PVC
From _To FL _ _
From _ To �_
13. GROUT: Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From _To_Ft _
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in _ in. _
From _ To _ Ft. _ in. _ in. _
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To _ Ft
From _ To _ Ft
Topographic/Land setting
0 Ridge 0 Slope 0 Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH DRILLING LOG
From To From To
i t ,s° 11-1' S 34" N
�8^5 `62" 4' 21.5S` N/
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
FROM MILL SPRING. HWY. #9 S. LEFT ON
HORN RD. 167 DRIVE ON LEFT. NEW HOUSE AT
DEADEND ON RIGHT.
0
JUN
-c
CO
N
n
CT+
o+
an
mil
7i<
0 Ell
cr. 0
r-
r
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCI hD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TTHAT}A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ft%
‘11
✓iLo `�-/ � -L9 6
SIGNA OF PERSON CONSTRUCTING THE�WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

❑ Recovery ❑ Heat Pump Water Injection ❑ Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
2222 PALMER RD.
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER BIRGHT'S CREEK GOLF CLUB
Address 2222 PALMER RD.
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
4. DATE DRILLED 04/05/06
5. TOTAL DEPTH 345
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
9, TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 8.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 40 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft.
From To Ft.
From To Ft.
16. SAND7GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in. IR
_ in. in.
1/1 in.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
326120,
1. WELL USE (Check Applicable Box): ❑ Residential ❑ Municipal ❑ Industrial / 1 Agricultural ❑ Monitoring
If Other, List Use:
DRILLING LOG DEPTH
Formation Description
LM 35° Ill 37iq" ^/
Lon `62' IS' 41.38" W
If additional space is needed use back of form
LOCATION SKETCIj
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. LEFT ON SILVER CREEK
RD. LEFT ON PALMER RD. APPROX. 2 MILES ON LEFT.
CO
0
0
0
0
-tom
fen
IDP1
cD
;>
r-
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PER N CONSTRUCTING THE WELL DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
JUN 06 2005

North Carolina —Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-I636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
326121
1. WELL USE (Check Applicable Box): 0 Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
2222 PALMER RD. DRILLING LOG DEPTH
(Road Name and Numbers, Commimity, or Subdivision and Lot No.) From To Formation Description
3. OWNER BIRGHT'S CREEK GOLF CLUB _
Address 2222 PALMER RD.
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code (av} 35 (q' 35 tC N/
4. DATE DRILLED 04/05/06 LQ S22" iS' sD Tr " fry5. TOTAL DEPTH 345 �1
6. CUTTING COLLECIED ❑ YES NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 30 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 50 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 60 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space is needed use back of font
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. LEFT ON SILVER CREEK
RD. LEFT ON PALMER RD. APPROX. 2-1/2 MILES ON RT.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
�J�zs , T � v�i 4 Y 5 — 0
SIGNATURE OF P N CONSTRUC G DATE
Submi 'giant to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

326122
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERTIFICATION # 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. L USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WEI T LOCATION:
Nearest Ton COLUMBUS County POLK
FOXWOOD HILLS -LOT #34
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: KRIS STINES
Address FOXWOOD HILLS
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
8(28) - 243-4027
Area Code Phone number
4. DATE DRILLED 04/11/06
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WAIbR LEVEL Below Top of Casing: 50 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 4 METHOD OF TEST AHD
10. WATER ZONES (depth):
11. DISINFECTION: Type CBLORYTE Amount 13.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 120 Ft. 6-1/4" SD1L21 PVC
From _To_Ft_ _
From To Ft
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To _ Ft
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in.
From _ To _ Ft _ in. ___ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _To_Ft_
From To Ft
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley [plat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
FROM COLUMBUS GO UP PENIEL RD. LEFT
ON HUGH CHAMPION RD. LEFT INTO FOXWOOD
HILLS. 2/10 MILE. NEW DRIVE ON LEFT. <
O
s'S' ISM 5Z.o2" NJ
41 52 7' 31.444 kJ
JUN 0 6 2
CO
_N
rn
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJS
CONSTRUCTIQN STANDARDS AND THAT A COPY OF 'HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JEFF MELTON CERTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: COLUMBUS
1705 OLD CHESNEE RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: IAN TRACE
Address 1705 OLD CHESNEE RD.
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
(828) — 698-2993
Area Code Phone number
4. DATE DRILLED 03/31/06
5. TOTAL DEPTH: 605
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 0 METHOD OF TEST ARD
10. WATER ZONES (depth):
County POLK
11. DISINFECTION: Type CHLORYTE Amount 16.5
Wall Thickness
Diameter or Weight/Ft Material
Ft 61/4" SDR21 PVC
Ft. _
Ft
12. CASING:
Depth
From 0 To 45
From To
From To
13. GROUT: Depth Material
From 0 To 20 Ft QUIKRETE
From To Ft. _
14.SCREEN: Depth Diameter
From _To_Ft._
From To Ft.
15. SAND/GRAVEL PACK:
Depth Size
From To _ Ft. _
From To Ft
Method
POURED
Slot Size Material
is _ in.
in. in.
Material
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH DRILLING LOG
From To From To
Lev{ 35" 12' 314t"N
(z.') tat- I' 2.e.i," W
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
OLD CHESNEE RD. GO APPROX. 2 MILES.
DRIVE ON LEFT.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A QOjY OF THIS RECOHAS BEEN PROVIDED TO THE WELL OWNER
6
IGNATURE OF ERSON CONSTRU G THE WEL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center — Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ROBIN MCNEELY CERTIFICATION # 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING. LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® 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: MILL SPRING
340 BURT BLACKWELL RD.
(Street Name, Numbers, Community, Subdivision, Lot No
3. OWNER: RICK BOLT
Address 340 BURT BLACKWELL RD.
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
(864) - 237-5691
Area Code Phone number
4. DATE DRILLED 03/09/06
5. TOTAL DEPTH: 80
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County POLK
Zip Code)
11. DISINFECTION: Type CHLORYTE Amount 9.2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 80 Ft. 24" CEMENT
From To FL_
From To Ft. _
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To FL
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 60 To 80 Ft. 78M GRAVEL
From To Ft.
16. REMARKS:
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
FROM MILL SPRING HWY. #9 N. RIGHT ON
BURT BLACKWELL RD. APPROX.1/4 MILE ON
RIGHT. GRAVEL DRIVE A BOX #340.
LM 35' i9.' 233z" N
:.� ice to, 3t.&V1w
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONStBUCTION STANDARDS, ANDTHAT A COPY OF TH),41 ECORD HA BEEN PROVIDED TO THE WELL OWNER
SIGNAF PERSPCONSTRU ING THE WELL
/1 c 3-- 76c
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERTIFICATION # 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: MILL SPRING
BISHOP LANE -LOT #20
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: RICKY ROBINSON
Address BISHOP LANE -LOT #20
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
(8� — 670-6289
Area Code Phone number
4. DATE DRILLED 03/22/06
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 30 METHOD OF TEST ARD
10. WATER ZONES (depth):
County POLK
11. DISINFECTION: Type CHLORYTE Amount 7.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 20 Ft. 6-1/4" SDR.21 PVC
From ____To ____ Ft ____
From _To_Ft.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From _____To ____ Ft.
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft.
From _ To _ Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To _ Ft. _
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 N. FROM MILL SPRING. LEFT ON
SILVER CREEK RD, RIGHT ON BISHOP LANE. 1
2/10 MILE ON LEFT.
Uak 35° f°I' 11.13"
l r) 152' 13'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONS CTION STANDARDS, AND THAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
.47 oar �
GNATUItE OF PERSON CQf.ISTR 1 C ING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

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--CC/r���
WELL CONTRACTOR CERTIFICATION #: iI S ��
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential u1 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: %�yd,/ Ale County /4-2.c*Li'
etb-?2//tea//7G
(Road Name and Numbed, Community, or Subdivision and Lot No.)
3. OWNER 54/,APd*''Y/1 I -e!'4 , qc
Address /'d� ,f/Er % 4 5t'—sr
`Street or outs o. '�'1
T. V,24i ,rzG alof'k?aoa
City or Town State Zip Code
4. DATE DRILLED, r�/G-D�o
5. TOTAL DEPTH 5eiO'
6. CUTTINGS COLLECTED YES IThrNO❑
7. DOES WELL REPLACE EXISTING WELL? YES NOF7
8. STATIC WATER LEVEL Below Top of Casing: it FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS / FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0 18
10. YIELD (gpm)- METHOD OF TEST ///t*'
11. WATER ZONES (depth): a f.4:2011 6 /7e "
12. CHLORINATION: Type rdelater.da-Amount,3'�l
13. CASING:
Depth FromTo -�Z.? Ft
From To Ft.
From To Ft.
14. GROUT:
From
From
15. SCREEN:
Depth Diameter
From To Ft in
From To Ft. in
From To Ft In
16. SAND/GRAVEL PACK:
From
From
17. REMARKS:
Depth Size
To Ft
To Ft
Wall Thickness
Diameter or Weight/Ft. M ledal
/NOD "Pal/
DRILLING LOG
From To
p /01
43'
sao
DEPTH
Formation Description
erebe.04/ tor
a,n -race
REc
VED
ev;ire f Hice
If additional space is needed use back of form
/ Depth , Material Method
To age Ft S%Gfl.✓6er Titsfst?s. 0
To Ft
Slot Size Material
in
in
in
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
e5° it' O.c-1,` Ni
cie i-S 27 kir.
444,04011
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN PR VIDEO TO THE WELL OWNER.
� ,G-e. -3-02126
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.

Cs 17 n
a:-' 0..
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ROBIN MCNEELY CERTIFICATION # 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON County POLK
N. MCDADE RD. BREEZY HILL SUBDV.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: HUBERT METCALF
Address N. MCDADE RD.
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
(828) — 899-4905
Area Code Phone number
4. DATE DRILLED 02/24/06
5. TOTAL DEPTH: 66
6. DOES WELL REPLACE EXISTING WELL? YES NO 0
7. STATIC WATER LEVEL Below Top of Casing: 47 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 19 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 874
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
Ft. 24" CEMENT
Ft _
Ft
From 0 To 66
From To
From To
13. GROUT: Depth
From 0 To 20
From _ To
14.SCREEN: Depth
From To
From To
Material Method
Ft. CEMENT POURED
Ft
Diameter Slot Size Material
Ft. _ in. _ in.
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From 47 To 66 Ft 78M
From To Ft
16. REMARKS:
Material
GRAVEL
Topophic/Land setting
❑ Ridge D Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 S. FROM MILL SPRING. LEFT ON
SANDY PLAINS RD. R. ON FLOYD BLACKWELL
RD. LEFT ON N. MCDADE RD. 1sT DRIVE ON RT.
LOT #6.
RECEIVED
MAR 27 2006
Asheville Regional Office
Aquifer Protection
3
(.3
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC IIsD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTION STANDARDS, AND THAT A COPY OF THIS RE HAS BEEN PROVIDED TO THE WELL OWNER
a aV6
TURE OUC T G THE WELL ` DATE
Submit the original to the Division of Water Quality, Groundwater Secdon, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

fl
Jn
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JEFF MELTON CERTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: TRYON County POLK
128 FERN GLEN DR.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: THERESA ALLEN
Address 128 FERN GLEN DR.
(Street or Route No.)
TRYON NC 28782
City or Town State Zip Code
(828) — 279-1166
Area Code Phone number
4. DATE DRILLED 02/06/06
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 80 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CIILORYTE Amount 7.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 80 Ft 6-1/4" SDR.21 PVC
From _ To _ Ft
From _ To _ Ft
13. GROUT: Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From _To_Ft.
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in. _
From _To_Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _To_Ft_ _
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check app.op late box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
(check box)
DEPTH DRILLING LOG
From To From To
(MI- 3S /3'17.5' °N
(o..) iiz 13 IS,S3" ki
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
FROM COLUMBUS. GO DOWN HWY. #108 W.
LEFT AT LYNN ON CAPPS RD. RIGHT ON
GUNNING RD. LEFT INTO SCRIVEN'S HILLS
SUBDV. RIGHT ON FERN GLEN DR. DRIVE ON
RIGHT AT CUL-DE-SAC.
RECEIVED
MAR 2 7 2006
Asheville Regional Office
A•uifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IGNATURE OF ONSTRUCTING TH6 WE DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JEFF MELTON CERTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING. LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ® If Other, List Use IRRIGATION
2. WELL LOCATION:
Nearest Town: MILL SPRING County POLK
SILVER RIDGE RD.-LOT #22
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MIKE MESCH
Address SILVER RIDGE RD.-LOT #22
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
88228) — 894-6136
Area Code Phone number
4. DATE DRILLED 02/03/06
5. TOTAL DEPTH: 425
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 9.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 120 Ft. 6-1/4" SDR.21 PVC
From _To_Ft_
From To Ft. _
13. GROUT: Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From _____To ____ Ft ____ _
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in. _
From _ To _ Ft. _ in. _ in
15. SAND/GRAVEL PACK:
Depth Size Material
From _____To ____ Ft ____
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH DRILLING LOG
From To From To
Lwt i I2, "N
L-0-) cf2.' 14. it "Ron
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #9 N. FROM MILL SPRING. LEFT ON
SILVER CREEK RD. CROSS GREEN RIVER &
RT. ON LAKE ADGER RD. GO APPROX. 1/4
MILE & LEFT ON NORTH HIGHLANDS RD. RT.
ON SILVER RIDGE RD. 4/10 MILE ON LEFT.
LOT #22.
RECEIVED
MAR 2 7 2006
Asheville Regional Office
A.uifer Protection
0
CFI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Q THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PE ON CONSTRUCTING THE WELL
/YY1\
D TE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

`, 6: n n 9 i!
North Carolina — D WELL CONS v v `` " ``
WELL CONTRACTOR� °1e1u of Environment L Natural CONSTRUCTION RECORD
(INDIVIDUAL,) NAME sources — Division of Water WELL CONTRACTOR COMPANY N_ (print) N WELL RO LNG Quality Groundwater Section
STATE WELL CONSTRUCTION PERMIT #PLANT I BORING RDV LG LC CERTIFICATION # 2785
(if applicable) ASSOCIATED WQ PERMIT # PHONE # [phone]
1 WELL USE (if applicable)
(Check Applicable Box): Residential
Monitoring 0 Recovery 0 Heat Pumpnj Mn Other 0 Other,
2. WELL LOCATION: Water Injection 0 Other 0 Agricultural 0
Nearest T ❑ U Other, List Use
Town: COLUMBUS
486 BILL wn COLSRD County POLK
(S
3. OWing
NER: Name,: CALVIN GDoBS unity, Subdivision, Lot No., Zip Code) g ❑ l0 Topographic/Land )
_ ❑Ride Valley ❑Flat
Address 486 BILLLLOCINS RD/ (check appropriate box)
(Street or Route No.) Latitude/longitude of well location
City o.COLrrT4oBwnS State NC 28722 (d stets/minutes/seconds)
MO — 894-8315 Zip Code Latitude/longitude source: 0 GPS ❑ Topographic map
Area Code Phone number (check box)
4. DATE DRILLED 01/25/06 DEPTH
5. TOTAL DEPTH: 245 From To
6. DOES WELL REPLACE EXISTING WELL? YES gam,
7. STATIC WATER LEVEL Below TopDRILLING LOG
of Casing: 20 FT. From To
8. TOP OF CASING IS 1-1/2 (Use + if Above Top of Casing)
`Top of casing CASING
IS terminated /2r FT. Above Land Surface*
variance in a below land surface requires a LOCATION SKETCH
9 YIELD accordance with 15A NCAC 2C .0118. Show di (gtm): 100+ METHOD OF TEST ARD motion and distance in miles from east
10. WATER ZONES (depth); Two State Roads or County
number and common nameRoads. Include the road
12. 11.
DASIINIVFG CTION: Type C—TE Amount 6 FOX M N#108 W, FROM MILL SPRING. LEFT ON
RD LEFT ON BILL COLLINS RD.
Depth Wall Thickness RIGHT ON DRIVE AT BOX #486.
From 0 To 30 Diameter or Weight/Ft Material
FromPt 6-114 SDR21 PVC 3S° fb 3'7.u3"iv
From To Ft
To Ft (a �Z 91 �alq
Z' �)
13. GROUT: Depth Material —
From 0 To 20 Ft. Method
From To Ft TE D
14.SCREEN: Depth Diameterot Size Material From To Ft.
From in. in.
15. SANDG To Ft.
RAVEL PACK: in.
in.
From DTToo FL Size Material
From To Ft
16. REMARKS.
RECEIVED
MAR 08 2005
Asheville Regional Office
A • uifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED WITH
I DOS CT STANDARDS CTED IN ACCORDANCE
AND THAT A C P OF THIS RECO HAS BEEN PROVIDED I5AO THE
2C, WELL
O
THE WELL OWNER
SIGNA OF PERS ONSTRUCTING
Submit the one THE
FELL DATE
27699-1636 Phone No. (919)r733-32211, withinvision of Water Qu days. Groundwater Section, Mail Service Center Raleigh,NC
GW-1 REV. 07/200
0
Jl

North Carolina - D WELL CONSTRUCTION RECORD
WELL aepartment of Environment And Natural Resources - Division of Water Quality - Groundwater Section
NTRACTOR (INDIVIDUAL) NAME (print) JEFF MELTON
WELL CONTRACTOR COMPANY NAME PITTMAN WELLBORING LLC CERTIFICATION # 3417
STATE WELL CONSTRUCTION PERMIT #
ASSOCIATED WQ PERMIT # PHONE # [phone]
(if applicable) --
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public Monitoring 0 Recovery 0 Heat Pump Water Injection Other Industrial ❑ Agricultural
2. WELL LOCATION:
If Other, List Use
Nearest Town: COLUMBUS
53 HEMLOCK CO County POLK
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) Topographic/Land setting
3. OWNER: PAUL TAYLOR 0 Ridge ❑Slope 0 Valley ❑Fla[
Address 53 HE (check appropriate well
box)
HEMLOCK COURT Latitude/longitude of well location
(Street or Route No.)
COLUMBUS NC 28722 (degrees/minutes/seconds)
City or Town State Latitude/longitude source: ❑ GPS 0 To
28 - 696-5421 Zip CodeTopographic map
Area Code Phone number DEPTH (check box)
4. DATE DRILLED 01/19/06 FromDRILLING LOG
5. TOTAL DEPTH: 145 To From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
EA
7. STATIC WATER LEVEL Below Top of Casing: 40 FT LAt 32
Ito road N
8. TOP OF CASING IS 1- (Use+ if Above Top of Casing) �'� ti2' .3' zv. zt ` vJ
1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 30 METHOD OF TEST `RD LOCATION SKETCH
10. WATER ZONES (depth): Show direction and
distance in miles from at least
Two State Roads or County, Roads. Include the road
number and common names
16. REMARKS:
11. DISINFECTION: Type BYTE, Amotmt 3
12. CASING: Wall Thickness FROM couuWRITE OAK
GO OUT HOUSTON RD.
Depth Diameter or Wei t/Ft LEFT ON WHITE OAK MTN. TRAIL, LEFT ON
From 0 To 80 Ft 6-1/4" 21 Material HEMLOCK TRAIL. GO TO TOP OF HH.L. LEFT
SDR21
From To Ft PVC ON HEMLOCK COURT. U10 MILE ON LEFT.
From To Ft —
13. GROUT: Depth Material
From 0 To 20 Ft UIKRETE Method
From To Ft --- POURED
14.SCREEN: Depth Diameter Slot Size
rti
From To Ft. in Material -Fr-0
From To Ft.in. — RECEIVED _
15. SAND/GRAVEL PACK:in--
From DTo� Ft Size Material MAR 0 8 cuuu 0
From To Ft
; Asheville Regional Office
Aouifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON TRUCTION STANDARDS AND THAT A C• 'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE • PERSON CONSTRUCT t G THE r
DATE
27699-1636 Phone No. [phone], within 30 days.
Submit the original to the Division of Water Groundwater Section,1636 Mali Service Center -Raleigh, NC
GW-1 REV. 07/2001

North Carolina — D WELL CONSTRUCTION RECORD
WELL CONTRACTOR Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section
(INDIVIDUAL) NAME (print) JEFF MELTON CERTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING LLC
STATE WELL CONSTRUCTION PERMIT # PHONE # [phone]
(if applicable) ASSOCIATED WQ PERMIT #
(if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other, Li 0 Agricultural ❑
2. WELL LOCATION: 0 If Other, List Use _
Nearest Town: MILL SPRNG County POLK
ORCHARD VIEW ESTATES -LOT #9 Topographic/Land setting
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) 0 Ridge 0 Slope 0 Valley 0 Flat
MIKE 3. OWNER: E TONEY (check appropriate box)
Address ORCHARD VIEW ESTATES Latitude/longitude of well location
(Street or Route No.)
MILL SPRING NC 28756 (degrees/minutes/seconds)
City or Town State Zip Code Latitude/longitude source: 0 GPS 0 Topographic map
828 - 625*1786 (check box)
Area Code Phone number DEPTH DRILLING LOG
4. DATE DRILLED 01/16/06 From To From To
5. TOTAL DEPTH: 585
6.
ES VVELL REPLACE
7. DTOATI WATER LEVEL Below
Top of Casing 140 FT.
LL? YES ❑ NO El ,1„,„ 35a 23' 5. 525'N
(Use "+" if Above Top of Casing) c"."> y2.4 (l SS i¢ j" VJ
8. TOP OF CASING IS 1-11/1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface
requires a
variance in accordance with 15A NCAC 2C .ol 18.
9. YIELD (gpm): 3 METHOD OF TEST ARD miles
LOCATION SKETCH
10. WATER ZONES (depth): Show direction and distance in mfrom at least
Two State Roads or County Roads. Include the road
11. DISINFECTION: Type CHLORYTE Amount 15.5 number and common names
12. CASING: HWY. #9 N. GO PAST SUNNYVIEW GEN.
Wall Thickness Depth STORE 1 MILE TO LAUGHTER RD. ON LEFT.
Diameter or Weight/Ft. Material From 0 To 65 Ft 6-1/4" SDR21 1/2 MILE TO LOT ON LEFT. 1 LOT ON LEFT
From _ To _ Ft C SIDE OF RD. LOT #9.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft UI'KRETE POURED
Front _ To Ft rn
h ni
14.SCREEN: Depth Diameter Slot Size Material co
From To Ft. in
From To Ft in.
15. SAND/GRAVEL PACK: 'n — RECEIVED o
From Depth Size Material
—ToFt.
—
From To F MAR 08 2006
— t —
16. REMARKS:— Asheville Regional Office
fer
CONSI DO HEREBY CERTIFY THAT THUS WELL WAS CONSTRUCTED IN ACCORDAANCErWITH lo5A NCAC 2C, WELL
UCTION STANDARDS, AND THAT A COOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ I S NA v eta P . • CONSTRUCT
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

4iorth Carolina— Department of Fnvirmmat and Natural Resources — Division of Water Quality — Grounds ata Section
1636 Mail Service Ceuta — Raleigh, N.C. 27699-1636 — Prone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION Y: 2567
STATE WELL CONSTRUCTION PERMIT it:
I_ WELL USE (Check Applicable Boxx) ® Residential U Municipal U Industrial U Agricultural U Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Odn If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING Cranny: POLK
1022 LAKE ADGER RD. DRILLING TOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER JODY BLANTON
Address 1022 LAKE ADGER RD.
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip Code
4. DATE DRILLED 07/27/06
5. TOTAL DEPTH 41
6. CUTTING COLLECTED 0 YES IN NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing 21 FT.
(Use `+^ if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surfaces
Top of easing terminated sitar below Ind surface spices a variance in aaur-
dancewith 15A NCAC 2C.01IS
10. YIELD (gpm): 20 METHOD OF TEST: S !EEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 9.2
13. CASING:
From To
14. GROUT:
Wall 'Thickness
Depth Diameter or Weight/Ft Material
From 0 To 41 Ft 24 CEMENT
From To Ft
Ft
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. is is
From To Ft in. in.
From To Ft in. in
16. SAND?GRAVEL PACK:
Depth Size Material
From 21 To 41 Ft 78M GRAVEL
From To Ft
17. REMARKS:
DEPTH
Formation Description
r__
CC+
If additional Tart is needed use It of form
n n '
u J
LOCATION SKETCH
' (Show direction and distance from at least two State
Roads, or other rem points)
HWY. P9 N. FROM MILL SPRING. LEFT ON COOPER GAP RD.
LEFT ON LAKE ADGER RD. LOT ON RIGHT.
(.C.k 35-0 Et' 52.n" IJ
$z' 13' Z1.(° t-)
0
c�
t
J
0
0
0-
,
I DO CERTIFY THAT THIS WELL WAS CONFIRM 1ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WFTJ OWN▪ E- R.
FOR OFFICE USE ONLY
Quad No:
Serial No.
0
0
Cr.
o. 7
SIGNATURE OF ' a' a 1Tr UCTING THE WELL - DATE
Submit original to Division of Water • , Grotmdwata Section within 30 days
GW-1 REV. 12/99

Forth Carolina - Department of Environment and Natural Resources —Division of Water Quality — Groimdwater Section
636 Mail Service Center —Raleigh, N.C. 27699-1636 —Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural ❑ Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
learest Town: COLUMBUS County: POLK
140 HONEY HILL LANE DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER JAMES SAYER
kddress 1140 HONEY HILL LANE
Street or Route No.)
:OLUMBUS NC 28722
:ity or Town State Zip Code
DATE DRILLED 05/19/06
TOTAL DEPTH 225
CUTTING COLLEC 1 hD ❑ YES ®NO
'. DOES WELL REPLACE EXISTING WFJ J ? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 60 FT.
:se "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance in accor-
ance with I5A NCAC 2C.0118
0. YIELD (gpm): 30 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 Ft.6-U4" SDR.21 PVC
From To Ft.
From To Ft.
:4. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From To Ft.
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
If additional space is needed use back of form
2'7 93
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. RIGHT ON PENIAL RD.
RIGHT ON BILL HOLBERT RD. GO THORUGH ENTRANCE
TO HONEY HILL COVE. ROAD CHANGES TO HONEY HILL
LANE. LAST DRIVE ON RIGHT AT END OF PAVEMEgf.
--# 35' ICI 3 it,
cp
C 1T
rri
<
N c r1
0 oL7
m
r
DO CERTIFY THAT THIS WFJJ WAS CONSTRUCIEU IN ACCORDANCE WITH 15A NCAC 2C, WELL
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
Q\ ,E 6
SIGNATURE OF PE N CONSTR WELL DATE
Soriginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina :Department of Environment and Natural Resources —Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
327880
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural ❑ Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
RIDGEVIEW-LOT 6 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER ERNEST FLANDERS
Address RIDGEVIEW-LOT #6
(Street or Route No.)
MILL SPRING NC 28756
City or Town State Zip OAP
4. DATE DRILLED 05/24/06
5. TOTAL DEPTH 405
6. CUTTING COLLEC1hD 0 YES ® NO
7. DOES WFJ 1 REPLACE EXISTING WELL? 0 YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 140 FT.
;Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
•Top of casing terminated at/or below land surface requires a variance in accor-
:iance with I5A NCAC 2C.0118
10. YIELD (gpm): 4 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 10.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 155 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
If additional spare is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N. FROM MILL SPRING. RT. ON GRASSY KNOB RD.
RT. INTO RIDGEVIEW. LAST LOT ON LEFT. (LOT #6)
Ht SS- Is' 5L.2• Li
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFT•1
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
Gam.. s aV-
lc
J SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ubmit original to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

❑ Recovery ❑ Heat Pump Water Injection D Other
. WELL LOCATION: (Show sketch of the location below)
learest Town: TRYON County: POLK
2 MORNING RIDGE DR
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER RODERICK BUSBY
iddress 12 MORNING RIDGE DR
Street or Route No.)
RYON NC 28782
:ity or Town State Zip Cade
DATE DRILLED 06/22/06
TOTAL DEPTH 805
CUTTING COLLECIED 0 YES ® NO
'. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 0 FT.
Jae "+" if Above Top of Casing)
1. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 0 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 22.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 40 Ft 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
4. GROUT:
Depth Material Method
From 0 To 20 Ft. OUILKRETE POURED
From To Ft.
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft in in.
From To Ft in. in.
From To Ft. in. in.
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
( crt SS'' I & Sta.14 fJ
"or h Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
536 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
Willi- CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): 0 Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring
If Other, List Use:
DRILLING LOG DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HOUSTON RD. FROM COLUMBUS. LEFT ON WHITE OAK
MTN. RD. RT. ON MORNIGN RIDGE DR DEAD END ON RT.
DO CERTIFY THAT THIS WFJ d WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
.. oano .2 -, .2 y
SIGNATURE OF PERSON CONSTRUCTIN THE V DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

orth Carolina - Department of Environment and Natural Resources - Division of Water Quplity - Groundwater Section
536 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
e
et,LCt1
.. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
leanest Town: MILL SPRING County: POLK
70 CROSS RIDGE DR GREENRIVER HIGHLANDS DRILLING LOG DEPTH
Road Name and Numbers, Comnumity, or Subdivision and Lot No.) From To Formation Description
. OWNER STEVE SEPER
tddress 270 CROSS RIDGE DR
Street or Route No.)
MILL SPRING NC 28756
:ity or Town State Zip CMr
DATE DRILLED 06/07/06
t. TOTAL DEPTH 305
J. CUTTING COLLECTED 0 YES ® NO
'. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of' Casing: 60 FT.
Use "+" if Above Top of Casing)
). TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
iance with 15A NCAC 2C.0118
.0. YIELD (gpm): 5 METHOD OF TEST: ARD
.1. WATER ZONES (depth):
,2. CHLORINATION: Type: CHLORYTE Amount: 7.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 100 Ft.6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1t4 35°i7'36.11"N
(cnn `62:2 Z-V38-'lfJ
If additional space is needed use back of form
LOCATION SKETCH
tShow direction and distance from at least two State
Roads, or other reference points)
HWY. #221 S. FROM RFTD. RIGHT ON COXE RD. INTO POLK
CO. RT. INTO GREENRIVER HIGHLANDS. STAY LEFT ON
RIVER CREST PARKWAY. RIGHT ON CROSS RIDGE DR
APPROX. 1/4 MILE ON RIGHT. TOP OF HILL. LOT #82.
)
DO WtTIFY THAT THIS WF7.1 WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
X)NSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
— —a 6
SIGNA1TJI3E OF PEKSON CONSTRUCTING THE WELL DATE
.bmit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

orth Carolina -Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
i36 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
• WELL CONTRACTOR CERTIFICATION #: 3417
_ STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
tearest Town: TRYON County. POLK
835 MOORE RD, DRILLING LOG
load Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER WAYNE COLLINS
Actress 1835 MOORE RD,
Street or Route No.)
RYON NC 28782
'ity or Town State Zip Code
DATE DRILLED 06/02/06
TOTAL DEPTH 205
p. CUTTING COLLECu D ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 80 FT.
Use "+" if Above Top of Casing)
P. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 10 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 4.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 55 Ft 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
i4. GROUT:
Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From To Ft.
i5. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
From To Ft in. in_
'.6. SAND?GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft.
.7. REMARKS:
Lnf "3S ° i t.,' 5i.41 " N
Lcn� t2.' u' 45,5/ a W
DEPTH
b j
itL.em
5
f
0
ti
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON SANDY PLAINS
RD. LEFT ON MOORE RD. 2-1/2 MILES ON LEFT. (1835 ON
MAILBOX)
c
c
r—
1
c
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.I
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
NATURES /lJFll�Fu�Vfrli °. !n - .-2 - V e<
GNATURE OF j�� O STRu TING' " WFJ.i DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

33 435
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andtNatural Resources - Division of WaterQuality- Groundwater Section p G�
WELL CONTRACTOR (INDIVIDUAL) NA3l41at) f//Iy�/1 In fhQ dies V LQ CnnIfCATTONC Z7O
WELL CONTRACTOR COMPANY N /w ee t w abr. 1de// e �,�IAA Atio
PHONE R t m �o Y%OfO
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMED/
(ifapplicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential f3"Municipal/Public ❑ Industrial ❑ Agricaltmal O
Monitoring ❑ Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town- Pr..drlsor. flit County Polk
I?57 SQ,er. (nue iUd rile?a
(Saee[Name,NCommunity. Subdivision, na. No., rip Code)
3. OWNER: J. M MwJ\'1
Address (3S1 5pfcrr NUJ.
REA
(Sasd«Route No.)
Hens, resen .
thy or Town Stine
%llz
Zip Code
Ara code- Phone camber
4. DATE DRILLED 1VA 0 -Q G
5. TOTAL DEPTH: 3qS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO a
7. STATIC WATER LEVEL Below Top of Casing: a2- FT.
,r (Use *1-1). if Above Top of Casing)
8. TOP OF CASING IS I ZZ FT. Above Land Surface*
"Top of casing terevLated ayor below land sedan requires a
variance le accordance with ISA NCAC 2C MIL
9. YIELD (gpm): / () METHOD OF TEST TI , r d
10. WATER. ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Topographic/Land setting
❑Ridge OSlope OValley IBilat
(dock appropriate box)
Latitude/longitude of well location
(de ImbnYealsaand>
Latitude/longitude sou rce:OGPSOTopographic map
(duck box)
DEPTH PRILLING LOG
From To Formation Description
IR
11. DISINFECTION: Type C(N Amount /602
12. CASING:
Depth
D�er�
FroTo fFt 6%y
Fromm_ To Ft
From,__ To Ft.
I3. GROUT:p� Depth
From Y To '1 D Ft
From To Ft.
14. SCRE Depth
From ') To
From To
15. SAND/GRAVELPACK:
A
o From W To
From To
Wall Thickness
or WeigbttFt Material
SQR-21 puc
Y44 3s°7.2.1
3Z.37"&)
fl.° R• tat
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRULttD IN ACCORDANCE WT11115A NCAC 2C, WELL
CO ON STANDARDS THAT COPY O THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER TI
SIGNATURE OF P RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-322I, within 30 days. GW-1 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 L CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Boa): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
RIVER PARK LOT 38
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER JAY DAVIES
Address RIVER PARK -LOT #8
(Street or Route No.) NC 28756
MILL SPRING
City or Town State Zip Code
4. DATE DRILLED 10/03/06
5. TOTAL DEPTH 585
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 100 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 25 METHOD OF TEST: ARD
11. WATER ZONES (depth):
If additional space is needed use back of form
12. CHLORINATION: Type: CHLORYTE Amount: 15.5 LOCATION SKETCH
13. CASING:
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON SILVER CREEK
LEFT ON GREEN RIVER COVE. RIGHT ON RIVER PARK
LANE. BEAR LEFT @ Y FOREST BILL. DR GRAVEL DRIVE
334424
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 150 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To__._. Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUTKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From ___ To Ft. ____ in._ in.
From To Ft. in. in._
From To Ft. ___ in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
ON LEFT.
icy4. 35' I' Ib.S-tt F�
101 $j` i't /5 00 " v\I
DEPTH
RECEIVED
DIV. OF WATER QUALITY
NOV 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: 1�� /,/,_L: , - _ , �� 4V2- M.2 . () 6
Serial No. NATURE OF " SON ONSTRUCT11dG WEL DATE
mit original to Division of ' ater Qulity, Groundwater Section within 30 days GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #: __
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal
0 Recovery 0 Heat Pump Water Injection 0 Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MILL SPRING County: POLK
FOREST HILLS DR -LOT #9 DRILLING LOG DEPTH
(Road Name and Numbers, Conununity, or Subdivision and Lot No.) From To
3. OWNER DOUGLAS MACALLISTER
Address FOREST HILLS DR -LOT #9
(Street or Route No.)
MILL SPRING N� 28756
City or Town State Zip Code
4. DATE DRILLED 10/10/06
5. TOTAL DEPTH 505
6. CUTTING COLLECTED ❑ YES ®NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 140 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated al/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 100+ METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To 80
From _ To
From To
14. GROUT:
Depth
From 0 To
From To
15. SCREEN:
Type: CHLORYTE Amount: 13.5
Wall Thickness
Diameter or Weight/Ft. Material
Ft. 6-1/4" SDR.21 PVC
Ft. ___
Pt.
Material Method
20 Ft. QUIKRETE POURED
Ft.
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From _ To Ft. _
17. REMARKS:
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
❑ Industrial 0 Agricultural 0 Monitoring
If Other, List Use: _
Formation Description
Ft. 35" 19' t`/-31a"t`i
ion $Z 144ISS1S
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 N.FROM MILL SPRING. LEFT ON SILVER CREEK
LEFT ON GREEN RIVER COVE. RT. INTO RIVER PARK
SUBDV. BEAR LEFT AT Y ONTO FOREST HILLS DR LOT 39
ON LEF 1.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE
,ubmit original to Divisi
RECEIVED
DIV. OF WATER Ot iALITY
NOV 0 6 2006
SON CONSTRUC'1 AIG1TUE WELL DATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK
19 TIMOTHY LANE DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER BARBARA BRUCE
Address 119 TOMOTHY LANE
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 10/26/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 165
13. CASING:
From
From
From
14. GROUT:
Wall Thickness
Depth Diameter or Weight/Ft. Material
0 To 50 Ft. 6-1/4" SDR.21 PVC
To Ft.
To Ft.
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft.
From To Ft.
From To Ft.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
in. ln.
in. in.
in. in.
33441
jal 3St 15' tto-u.5"tv
u: ) $Z ° loI 4 5 L `.)
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM MILL SPRING. LEFT ON FOX MTN. RD.
LEFT ON WALKER RD. LEFT ON TIMOTHY LANE. LAST
HOUSE ON LEFT.
UN. OF
cb0"Ji 2006
R epEFREp PL1TY
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNA OF PERSON CONSTRUCTING WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box):
®Residential ❑ Municipal
per
2. WELL LOCATION: (Show❑sketch of ep `location below) ater Injection 0 Other
Nearest Town: RUTHERFORDTON County: POLK
1188 AIRPORT RD.
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER DANIEL TYNER
Address 1188 AIRPORT RD.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
4. DATE DRILLED 11/06/06
5. TOTAL DEPTH 505
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 100 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1 1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with I5A NCAC 2C.0118
10. YIELD (gpm): 3 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount:
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 110 Ft 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
From 0 DepthTo 20 Ft. terial QLij CRE' Method
— POURED
From To Ft.
15. SCREEN:
Depth
From To
From To Ft.
From To Ft
16. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Diameter Slot Size Material
Ft. in. in.
in. in.
in. in.
Material
13.5
0 Industrial Li Agricultural 0 Monitoring
If Other, List Use:
DRILLING LOG DEPTH
From To Formation Description
��.�. 35° tl Sq. zl" <J
(&A) co` ` Si' 33.11S" v4
If additional space is needed use back of form
0
lD
0
0
V
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING, LEFT ON OLD CHESNEE
RD. RIGHT ON AIRPORT RD. 1/2 MILE ON RIGHT. (1188 ON
POSTI
RECEIVED
r'IV OF WATER QUALITY
9EL '?, 't 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNA [UR y.OF PERSON CONSTRUCTING
Submit original to Division of Water Quality, Groundwater. Section withinn 30 days
DATE
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources —Division of Water
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] Quality — Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
I. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Recovery 0 Heat Pump Water Injection ❑Monitoring
❑�
2. WELL LOCATION: (Show sketch of the location below) OOter, List Use:
Nearest Town: COLUMBUS County: POLK
GREEN RIVER HIGHLANDS -LOT #133 DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To DEPTH
3. OWNER JOHN & CLAUDIA GEPHART Formation Description
Address GREEN RIVER HIGHLANDS -LOT #133
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 11/29/06
5. TOTAL DEPTH 305
6. CUTTING COJd.FCTED 0 YES ®NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO 1%.D
8. STATIC WATER LEVEL Below Top of Casing: 60 FT. ^�
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.o118
10. YIELD (gpm): 50 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 7.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 140 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To _ FL _
17. REMARKS:
If additional space is needed use back of form
3357J9
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #221 S. FROM RFTD. RT. ON CORE RD. CROSS INTO
POLK CO. RT. INTO GREEN RIVER HIGHLANDS. STAY LEFT
ON GREEN RIVER PKWY. RT. ON CROSS RIDGE DR GO TO
DEAD END. LOT 4133 ON SIGN.
(t k SS° t $' 4.'+5" tJ
lorvj �,2' 21 4VAI " Vd
RECEIVED
)1U.l nF NATER QUALITY
DEC 1? 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING
Subn4it�riginal to Division of Water Quality, Groundwater Sec
WE/ZZ 2 // �ATE L
LL
on within 30 days
GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial
❑ Recovery El Heat Pump❑Other R Other, Water InjectionAgricultural Monitoring
2. WELL LOCATION: (Show sketch of the location below) List Use:
Nearest Town: COLUMBUS County: POLK
923 GREEN CREEK DR
(Road Name and Numbers, Community, or Subdivision and Lot No.) From RILLING To LOG
3. OWNER ROGER HELLMUTH
Address 923 GREEN CREEK DR
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 11/27/06
5. TOTAL DEPTH 365
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 4 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9
13. CASING:
Walt Thickness
Depth Diameter or Weight/Ft Material
From 0 To 60 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.�
From To Ft. _ in, is
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. _
17. REMARKS:
DEPTH
Formation Description
0
c
If additional space is needed use back of form
335720
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #9 S. FROM MILL SPRING. LEFT ON GREEN CRK. DR
CROSS COX RD. 1/2 MILE ON LEFT. (923 ON BOX)
tit .E 55° (3' 55" rJ
1,0,1 62: Sz42-'
RECEIVED
)F WATER QI IAUT'
DEC 1 N, 2906
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
na
IGN IlaE O�TRIJ PING THE L ATE
Submiinal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina —Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
ELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal
❑ Recovery 0 Heat Pump Water Injection 0 Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: POLK DRILLING LOG DEPTH
HORSE PATH LANE -LOT #1
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER PEDRO PEREZ
Address HORSE PATH LANE -LOT #1
(Street or Route No.) NC
COLUMBUS 28756
City or Town State Zip Code
4. DATE DRILLED 09/27/06
5. TOTAL DEPTH 785
6. CUTTING COLLEUIED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a variance in accor.
dance with ISANCAC 2C.0118
10. YIELD (gpm): 1/2 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 21.5
13. CASING:
Industrial ❑ Agricultural ❑ Monitoring
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 70 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft. _
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
in. in._
in. in
in. in.�
Material
From _ To Ft.
From __ To_ Ft. _
From To Ft.
16. SAND?GRAVEL PACK:
Depth Size
From ToFt.
From To Ft.
17. REMARKS:
If Other, List Use:
Formation Description
(ivl- 35° I1' 2o•tot " tJ
� ev) Ct-° lei +O r W
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 E. FROM MILL SPRING. RT. ON PEA RIDGE. LEFT
ON HORSE PATH LANE. LAST LOT AT END. LOT #1.
RECEIVED
DMV. OF WATER nUALITY
Nov 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
NATURE PECO ) UCC G LL DATE
bmit original to Division o Water Quality, Groundwater Section within 30 days GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone] — Division of Water Quality —Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #: _
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal
0 Recovery 0 Heat Pump 0 Other Water Injection0 Industrial 0 Agricultural 0 Monitoring
2. WELL LOCATION: (Show sketch of the location below) If Other, List Use:
Nearest Town: COLUMBUS County: POLK
1050 HEMLOCK TRAIL.
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER ELLIS M. FINCHER
Address 1050 HEMLOCK TRAIL
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 09/05/06
5. TOTAL DEPTH 705
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES Q NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 19.5
13. CASING:
Wall Thickness
Depth Diameter or WeighUFt Material
From 0 To 50 Ft.6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUILKRETE POURED
From To Ft.
15. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in 16. SAND?GRAVEL PACK: Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Formation Description
2.cl
RECEIVED
OCT 1
Asheville Regional Office
A• uifer Protection
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #108 W. FROM MILL SPRING. RT. ON HOUSTON RD.
RT. INTO WHITE OAK MTN. LEFT ON HEMLOCK TRAIL.
APPROX. 1 MILE ON RT.
k4 35c 15' 53. -I t�
Q rn $2" (3' I. Icl " it)
RECEIVED
DIV. OF WATER QUALITY
OCT 08 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
UNA • OF PERSON C o STRUCTING THE WELL Submit o = • to Division of Water Quality, Groundwater Section within 30 days DATE
GW-1 REV. 12/99
-5-a4,

North Carolina - Department of Environment and Natural Resources - Division of Water 1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] Quality Groundwater Section l-S ;
WELL CONSTRUCTION RECORD a e:
WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): 1' Residential 0 M
0Heat Pump Water Injection 0 Oth gn rural U Monimring
0 Recoverymunicipal Industrial
❑ A io
2. WELL LOCATION: (Show sketch of the location below) er If Other, List Use: —
Nearest Town: TRYON County: POLL{
670 GOLDEN RD.
DRII'L I IG LOG DEPTH
(Road Name and Numbers, Co
3. OWNER DIANNE JOYCEtnmllnrty, or Subdivision and Lot No.) From To Formation Description
Address 670 GOLDEN RD.
(Street or Route No.)
TRYON NC 28722
City or Town State Zip Code
4. DATE DRILLED 09/06/06
5. TOTAL DEPTH 405
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor•
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 5 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 12.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 50 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
15. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From ToFt. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK.
Depth Size Material
From To Ft.
_
From To Ft.
17. REMARKS:
RECEIVED
DIV. OF WATER QUALITY
OCT 06 2006
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
FROM COLUMBUS TAKE PENIEL RD. RT. ON GOLDEN RD.
ABOUT 1/2 MILE ON RIGHT. GATE (a, DRIVE.
Lhf 95. 13' :01"1J
Um) $2" to' Lie. 05 " Le-)
RECEIVED
OCT 17 2U13
Asheville Regional Office
Aquifer Protection
I DO CERTIFY THAT TIES WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE �r P ONCONSTRUCTING WED
bmit original to Division of Water Quality, Groundwater Section within 30 days DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: COLUMBUS County: FOLIC
WHITE OAK MTN.-LOT #77A DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER JOSE QUINONES
Address WHITE OAK MTN. LOT #77A
(Street or Route No.)
COLUMBUS NC 28722
City or Town State Zip Code
4. DATE DRILLED 08/01/06
5. TOTAL DEPTH 185
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WETREPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated a✓or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3.5
13. CASING:
Well Thickness
Depth Diameter or Weight/Ft Material
From 0 To 75 Ft. 6-1/4" SDR.21 PVC
From To Ft _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIIG2ETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. _ in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
' (Show direction and distance from at least two State
Roark or other reference points)
HOUSTON RD. FROM COLUMBUS. LEFT ON SKYUKA RD.
RIGHT ON SKYUKA MTN. DR GO TO TOP OF MTN. LEFT C
MORNING DR LEFT ON SURPENTINE ABOUT 1/2 MILE ON
LEFT.
I DO CERTIFY THAT THIS WELL WAS CONSTRUC 1'tD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
l`tc T<� —c)
SIGNA
OF PERSON CONSTRUCTIN THE WFT.T DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/9
CLI 2'/ cu[UO