Ru 2 CY2006

rth 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 #:
WELL USE (Check Applicable Box): ® Residential 9] Municipal 0 Industrial 0 Agricultural ❑Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
merest Town: MOORESBORO County: RUTH
::CKS GROVE EXT. RD. DRILLING LOG DEPTH
pad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER JAMES BROOKS
idress HICKS GROVE EXT. RD.
treet or Route No.)
OORESBORO NC 28114
ity or Town Slate Zip Cate
DATE DRILLED 06/05/06
TOTAL DEPTH 145
CUTTING COI I .Ft:MD ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 20 FT.
rK "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surface'
'op of casing terminated actor below land surface requires a variance in actor-
nce with 15A NCAC 2C.0118
J YIELD (gpm): 75 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 3
3. CASING:
Depth
From 0 To
From To
From To
4. GROUT:
Depth
From 0 To
From To
5. SCREEN:
Depth
To Ft.
To Ft.
From To Ft
6. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft
7. REMARKS:
Wall Thickness
Diameter or Weight/Ft Material
60 Ft. 6-1/4" SDR.21 PVC
Ft.
Ft
Material Method
20 Ft.OUILKRETE POURED
Ft
From
From
Diameter Slot Size Material
M. in.
in. in.
in. in.
Material
AUG 1 n 2006
If additional space is needed use back of form
LOCATION SKETCH
($how direction and distance from at least two State
Roads, or other reference points)
HWY. #221 S, FROM RUTHERFORDTON. RT. ON HICKS
GROVE RD. LEFT ON HICKS GROVE EXT. GO TO END OF
PAVEMENT.
r_
c_
r
ry
0
0
0
DO CERTIFY THAT THIS WELL WAS CONSTRUCIkD IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
Quad F OFFICE USE ONLY �� ?ILL
I S'Oet
No: Offr -- S Z
Serial No. Submit
OF P N C STRUCTING THE WELL DATE
Submit to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

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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 #: _
. 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:
. WFMJ LOCATION: (Show sketch of the location below)
learest Town: LAKE LURE County: RUTH
WILLIAMS CIRCLE DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER CRAIG EVANS
Wdress WILLIAMS CIRCLE
Street or Route No.)
.AKE LURE NC 28146
City or Town State Zip Code
DATE DRILLED 06/26/06
TOTAL DEPTH 785
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WFJI ? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 0 FT.
Use "+" 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-
iance wild 15A NCAC 2CA118
0. YIELD (gpm): 0 METHOD OF TEST: ARD
1. WATER ZONES (depth):
l2. CHLORINATION: Type: CHLORYTE Amount 21.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 35 Ft 6-1/4" SDR21 PVC
From _ To Ft
From To Ft.
l4. 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.
.6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
7. REMARKS:
33 13O3u
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. RT. ON BILL'S
CREEK RD. LEFT ON CEDAR CRK RD. LEFT ON
RIDGECREST. LEFT ON HICKORY NUT LANE. RT Z3N
WILLIAMS CIRCLE. LOT APPROX 1/10 MILE ON Kt.
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 ONSTRUCTING THE WFI.I 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 Quality - Groundwater Section
S36 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
JELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): 0 Residential ❑ Municipal
❑ Recovery 0 Heat Pump Water Injection 0 Other
. WELL LOCATION: (Show sketch of the location below)
fewest Town: LAKE LURE County: RUTH
90 LILY MAE DR
load Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER JIM MARLETT
.ddress 290 LILY MAE DR
Street or Route No.)
,AKE LURE NC 28746
'Sty or Town State Zip Code
. DATE DRILLED 06/08/06
. TOTAL DEPTH 305
. CUTTING COLLECTED ❑ YES ® NO
. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 40 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 I5A NCAC 2C.0118
0. YIELD (gpm): 12 METHOD OF TEST: ARD
1. WAFERZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 7.5
3. 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.
.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 FL in. in.
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
❑ Industrial ❑ Agricultural ❑ Monitoring
If Other, List Use:
DRILLING LOG DEPTH
Formation Description
If additional space is needed use back of form
A -a
m
rn
TTY
0
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. RT. ON
MCENTIRE RD. LEFT ON RAINBOW RAPIDS RD. LEFT INTO
RAINBOW RIDGE ESTATES. 3/4 MILE ON RT. HST BEFORE
CUL-DE-SAC.
C
✓
r;
oN O• rr
0
- G
DO CLKTIFY 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 WFJ d OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
...a:c7079 (
T1_R�E�Tf . A' �,�. , -
SIGNA OF
CONSTRUCTING THE L DATE
Submittef mal to Division of Water Quality, Groundwater 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 RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Bo:): ® Residential 0 Municipal ❑ industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
1. WELL LOCATION: (Show sketch of the location below)
dearest Town: LAKE LURE County: RUTH
!Si LILLIAN DR DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
1. OWNER GWEN GILBERT
4ddress 281 LILLIAN DR
Street or Route No.)
„AKE LURE NC 28746
My or Town State Zip Code
t. DATE DRILLED 06/14/06
5. TOTAL DEPTH 285
i. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 20 FT.
Use "+" 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-
iance with 15A NCAC 2C.0118
10. YIELD (gpm): 4 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 6.5
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.OU1LKRETE 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
Formation Description
0-40
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. #64t74A W. FROM RUTHERFORDTON. RT. ON BILL'S
CREEK RD. LEFT ON BUFFALO CREEK RD. RT. ON HERMA11
WILSON RD. LEFT ON LILLIAN DR HOUSE AT DEAD END
ON LEFT. o
0
c'
[ DO CERTIFY THAT THIS WELL WAS CONSTRUCIE D IN ACCORDANCE WITH 15A NCAC 2C, WELL
ZONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
GN TUREdi WCXXa.. Eo -41
S GNA OF PERSON C f STRUCTING THE WE d DATE
Submit d"rrginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Iorth Carolina — A.ynA,uent of Environment and Natural Resources —Division of Water Qulity — 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 Boz): ® Residential 0 Municipal 0 Industrial ❑ Agricultural ❑ Monitoring
0 Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
4earest Town: LAKE LURE County: RUTH
SILVER TREE LANE DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
;. OWNER BRIAN POWLEY
lddress SILVER TREE LANE
Street or Route No.)
.AKE LURE 'NC 28746
:ity or Town State Zip Code
S. DATE DRILLED 06/14/06
;. TOTAL DEPTH 185
CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
S. STATIC WA lut 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-
lance with 15A NCAC 2C.0118
to. YIELD (gpm): 15 METHOD OF TEST: ARD
1. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3.5
t3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 120 Ft 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
l4. 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.
Rom To Ft. in. in.
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
7. REMARKS:
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)
HWY. #64/74A W. FROM RUTHERFORDTON. LEFT ON
JUSTICE DR RIGHT ON SILVER TREE LANE. 1sr LOT ON
RIGHT.
r—
t
0
0
DO CERTIFY THAT THIS WFJ J 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.
SIGNdTURE OF PERSCJN CONSTRUCTING THE DATE
ginal 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]
JELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): all Residential ❑ Municipal 0 Industrial 0 Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
fearest Town: SPINDALE County: RUTH
/HITESIDE RD. DRILLING LOG DEPTH
load Name and Numbers, Commmlity, or Subdivision and Lot No.) From To Formation Description
. OWNER ROGER SHEEHAN
ddress WHITESIDE RD.
Street or Route No.)
PINDALE NC 28160
:Sty or Town State Zip Code
. DATE DRILLED 06/29/06
. TOTAL DEPTH 41
CUTTING COLLECTED 0 YES ® NO
DOES WELL REPLACE EXISTING WET d ? ❑ YES ® NO
STATIC WA 1 LR LEVEL Below Top of Casing: 21 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 I5A NCAC 2C.0118
0. YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
1. WAIE'R ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount_ 9.2
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 41 Ft. 24 CEMENT
From To Ft. _
From To Ft.
:4. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
L5. 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 21 To 41 FL 78M GRAVEL
From To Ft.
.7. REMARKS:
c;
0
m
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)
SPINDALE ST. FROM SPINDALE. RT. ON WHITESIDE RD. In
DRIVE ON LEFT.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.1
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
f/c
n)9-,
SIGI4ATURE O1'-PERSO •NST tfcltlG THE WELL DATE
Submit original to Division of Water '!'sty, Groundwater Section within 30 days
GW-I REV. 12/99

orth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
)36 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
YELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ 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: ELLENBORO County: RUTH
IGHT PRONG RD. DRILLING LOG DEPTH
load Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER KENNY TERRY
Actress RIGHT PRONG RD.
Street or Route No.)
I.LENBORO NC 28040
Zip Code
'Sty or Town State
. DATE DRILLED 06/08/06
. TOTAL DEPTH 68
CUTTING COLLELTED ❑ YES ® NO
. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WA t'hR LEVEL Below Top of Casing: 48 FT.
Jse "+" 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.01IS
0. YIELD (gpm): 20 METHOD OF TEST: STEEL TAPE
1. WAILR ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 9.2
3. CASING:
Depth Diameter
From 0 To 68 Ft. 24
From _ To Ft.
From To Ft
4. GROUT:
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 48 To 68 Ft 78M GRAVEL
Wall Thickness
or Weight/FL Material
CEMENT
From To Ft.
7. REMARKS:
Formation Descries ..
is
0
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)
HOLLIS RD. FROM ELLENBORO. RT. ON HOPEWELL RD.
LEFT ON MT. OLIVET CHURCH RD. RT. ON RIGHT PRONG
RD. 1/2 MILE ON LEFT.
r
c
c
DO CERTIFY THAT THIS WELL WAS CONSTRUC 1'hD 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.
SIG ATURE
Submit original to Division o
STR TANG THE DATE
Water. ty, Groundwater Section within 30 days
GW-1 REV. 12/99

Environment Carolina — A.padu,ent of Envirotent 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: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
WELL USE (Check Applicable Box): ® Residential 0 Municipal El Industrial 0 Agricultural ElMonitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
crest Town: FT .T ENBORO County: RUTH
=D BARN RD DRILLING LOG
:oad Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER JOE TONEY
ddress RED BARN RD.
.treet or Route No.)
LLENBORO NC 28040
ity or Town State Zip rode
DATE DRILLED 06/09/06
TOTAL DEPTH 58
CUTTING COLLECTED ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? El YES ® NO
STATIC WATER LEVEL Below Top of racing: 40 FT.
Ise "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Cop of casing terminated at/or below land surface requires a variance in accor-
mce with 15A NCAC 2C.0118
0. YIELD (gpm): 18 METHOD OF TEST: S MEL TAPE
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 8.28
3. CASING:
Depth
From 0 To
From To
From To
4. GROUT:
Depth
From 0 To
From To
5. SCREEN:
Diameter
58 Ft 24
Ft.
Ft.
Wall Thickness
or Weight/Ft Material
CEMENT
Material Method
20 Ft CEMENT POURED
Ft
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 40 To 58 Ft 78M GRAVEL
From To Ft
7. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
u
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HOLLIS RD. FROM ELLENBORO. RT. ON RED BARN RD. GO
4/10 MILE & RT. ON ASPHALT DR. GO 100 YDS. & RT. ON
GRAVEL DR HOUSE AT DEADEND ON LEFT.
L
c
r-
1
O
DO CERTIFY THAT THIS WELL WAS CONSTRUCiE1i 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.
IS GNI4TURF OF TING THE WELL
Submit original to Division of Water Iyty, 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]
WELL 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
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
dearest Town: ET .I .FNBORO County: RUTH
i69 SUTTLES RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
t. OWNER GALL HAGER
address 669 SUITLES RD.
Street or Route No.)
ELLENBORO NC 28040
:try or Town State Zip Code
t. DATE DRILLED 06/14/06
i. TOTAL DEPTH 30
5. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 20 FT.
Ilse "+" 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 acoor-
Janee with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: S I IthL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.6
13. CASING:
Depth Diameter
From 0 To 30 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 Material
From 20 To 30 Ft. 78M GRAVEL
Wall Thickness
or Weight/Et Material
CEMENT
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
'(Show direction and distanre from at least two State
Roads, or other reference points)
HOLLIS RD. FROM ELLENBORO. LEFT ON DUNCAN CREEK
RD, RIGHT ON APPLE ORCHARD RD. RIGHT ONSUTTLES
RD. I MILE ON LEFT.
r—
cr
N 1'7:1
can
•
�v
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.
A.A.3efiFiksie 6�
SIG2�ATUR �F P�C6NS1'1FUCTING THE WELL DATE
Submit original to Division of W ty, Groundwater Section within 30 days
GW-1 REV. 12/99

arth Carolina —Department of Environment and Natural Resources —Division of Water Quality — Groundwater Section
136 Mail Service Center— Raleigh, N.C. 27699-1636 — Phone [phone]
JELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
327707
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)
earest Town: RUTHERFORDTON County: RUTH
:CENTIRE RD. DRILLING LOG
toad Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER NANCY LEDFORD
ddress MCENTIRE RD.
street or Route No.)
UTHERFORDTON NC 28139
ity or Town State Zip Code
DATE DRILLED 05/01/06
TOTAL DEPTH 71
CUTTING COLLECItI) 0 YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 51 FT.
se "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 FT. Above Land Surfaces
'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: S 1F±.L TAPE
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 9.2
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 71 Ft. 24 CEMENT
From To Ft.
From To Ft.
4. GROUT:
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 51 To 71 Ft. 78M GRAVEL
From To Ft.
7. REMARKS:
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)
HWY. #64/74A W. FROM RUTHERFORDTON. RIGHT ON
MCENTIRE RD. GO ACROSS BIRDGE. LEFT (STILL ON
MCENTIRE RD.) 3/10 MILE ON LEFT.GO BEHIND BRICK
HOUSE ABOVE GARDEN TO DAUGHTER'S HOUSE
0
Dn
r11—
o
0
m
r—
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJJ
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG A
SIG T[IRE ERSO 1PERS
I
Submit original to Division of Water
i
ef STRUCTING THE L DATE
QI a1ity, 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]
JELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
327682
WELL USE (Check Applicable Boz): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
earest Town: LAKE LURE County: RUTH
'6 ELKWOOD DR - DRILLING LOG
toad Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER TOM COX
ddress 176 ELKWOOD DR
;tree or Route No.)
AKE LURE NC 28746
ity or Town State Zip Code
DATE DRILLED 05/22/06
TOTAL DEPTH 145
CUTTING COLLECIED ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 20 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 I5A NCAC 2CA1I8
). YIELD (gpm): 40 METHOD OF TEST: ARD
1. WATER ZONES (depth):
I. CHLORINATION: Type: CHLORYTE Amount: 3
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 45 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.
S. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in.
From To Ft. in. in.
5. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
rn
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. RIGHT ON
BUFFALO SHOALES RD. CROSS DAM. APPROX 1 MILE TO
ELKWOOD DR ON LEFT. WELL SIGHT AT DEAD END ON
LEFT.
0
N On
>
r
DO CERTIFY THAT THIS WELL WAS CONSTRUC tED IN ACCORDANCE WTTH I5A 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.
CONSTRUCTIN(1THE WEI.L DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

rth Carolina — DepaRment of Environment and Natural Resources — Division of Water Quality — Grramdwater Section
36 Mail Service Center— Raleigh, N.C. 27699-1636 —Phone [phone]
'ELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WFd.I. CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
327883
WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural ❑ Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
merest Town: FOREST CITY County: RUTH
T. VISTA DR -LOT #67 DRILLING LOG DEPTH
oad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER KELLY LATHAM
idress MT. VISTA DR -LOT #67
beet or Route No.)
)REST CITY NC 28143
ty or Town State Zip Code
DATE DRILLED 05/18/06
TOTAL DEPTH 305
CUTTING COLLEC1hD ❑ YES ® NO
DOES WFJ 1 REPLACE EXISTING WELL? 0 YES ® NO
STATIC WA TER LEVEL Below Top of Casing: 60 FT.
3e "+" 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-
rce with 15ANCAC 2C.o1I8
YIELD (gpm): 20 METHOD OF TEST: ARD
. WATER ZONES (depth):
If additional space is needed use back of form
:. CHLORINATION: Type: CHLORYTE Amount: 7.5
CASING: LOCATION SKETCH
Wall Thickness (Show dira,lion and distance from at least two State
Depth Diameter or Weight/Ft Material Roads, or other reference points)
From 0 To 80 Ft. 6-1/4" SDR21 PVC FROM SHILOH GO DOWN CLEGHORM MILL. RD. LEFT ON
From To Ft. COX RD. LEFT INTO RIVER RIDGE SUBDV. LEFT ON
From To FL MOUNTAIN VISTA DR 1/10 MILE. NEW DRIVE ON LEFT.
1. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
i. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
i. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
7. REMARKS:
0
C 0
z Drn
r=
DO CERTIFY THAT THIS WELL WAS CONSTRU(.1'hD IN ACCORDANCE WITH 15A NCAC 2C, WELL —I
ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNEl
FOR OFFICE USE ONLY
Quad No:
Serial No.
o flt-r1
0 O
A OF , RS i CONSTRUCTING THE DATE
original to Division of ater Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Yorth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Ceuta- Raleigh, N.C. 27699-1636 -Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
327684/
1. WELL USE (Check Applicable Boa ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
1earest Town: UNION MILLS County: RUTH
LOCUST RIDGE -LOT #18 DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER ROBERT BLACK
Address LOCUST RIDGE -LOT #18
;Street or Route No.)
UNION MILLS NC 28167
City or Town State Zip Code
4. DATE DRILLED 05/15/06
5. TOTAL DEPTH 605
6. CUTTING COLLECT!•.1) ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ 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-
iance with I5A NCAC 2C.0118
10. YIELD (gpm): 1 METHOD OF TEST: ARD
11. WA TER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 65 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. in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Road., or other reference points)
HWY. #64 E. FROM RUTH. RT. ON CANE CREEK MTN. RD.
RT. ON MTN. FOREST RD. RT. ON LOCUST RIDGE. APPROX.
1 MILE ON LEFT.
I DO CERTIFY THAT THIS WELL 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.
S GNAA OF P)?I2S0 ONSTRUCT TI? R71 ' DATE
tS C
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

forth Carolina —Department of Environment and Natural Resources — Division of Water Gr Quality — rnmdwater Section
636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WTI CONTRACTOR CERTIFICATION it: 3417
STATE WELL CONSTRUCTION PERMIT if:
. WELL USE (Check Applicable Box): ® Residential El municipal
❑ Recovery 0 Heat Pump Water Injection 0 Other
WELL LOCATION: (Show sketch of the location below)
tearest Town: BOSTIC County: RUTH
'HERRY RIDGE -LOT #24
load Name and Numbers, Community, or Subdivision and Lot No.) From To
.OWNER KENKASTLER
.ddress CHERRY RIDGE -LOT #24
Street or Route No.)
IOSTIC NC 28018
:ity or Town State Zip Code
. DATE DRILLED 05/15/06
. TOTAL DEPTH 185
CUTTING COLLECTED 0 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*
rop of casing terminated at/or below land surface requires a variance inaccor-
mce with I5A NCAC 2C.0118
0. YIELD (gpm): 40 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION:
3. CASING:
Depth
From 0 To 60
From To_
From To
4. GROUT:
Depth
From 0 To
From To
5. SCREEN:
Depth
To
From To
From To
Type: CHLORYTE Amount: 3.5
Wall Thickness
Diameter or Weight/Ft Material
Ft 6-1/4" SDR21 PVC
Ft.
Ft.
Material Method
20 Ft. QUIKRETE POURED
Ft.
Diameter Slot Size
Ft. in. in.
Ft. in. in.
Ft in. in.
6.SAND7GRAVEL.PACK:
Depth Size
From To Ft.
From To Ft
7. REMARKS:
Material
Material
327385
❑ 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)
FROM BOSTIC GO OUT BOSTIC/SUNSHINE HWY. RIGHT ON
SALEM CHURCH RD. LEFT INTO CHERRY RIDGE. FJGHT
ACROSS DAM. LOT #24 ON LEFT
DO CERTIFY THAT THIS WELL WAS CONSTRUC 1'EO 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.
�f
SIGNATURE O PERSON CONSTRUCTING THE WFL.i
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 40 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft
t. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
i. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in. in.
From To Ft. in. in.
From To Ft. in. in.
SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
rV
mh 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: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
317686
WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List use:
WELL LOCATION: (Show sketch of the location below)
earest Town: LAKE LURE County: RUTH
VEST BRIAR FARMS NORTH -LOT #60 DRILLING LOG DEPTH
.oad Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER JESSE HUTCHINSON
'dress SWEERT BRIAR FARMS NORTH
treet or Route No.)
AKE LURE NC 28746
.ty or Town State Zip Code
DATE DRILLED 05/11/06
TOTAL DEPTH 585
CUTTING COLLECTED ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER LEVEL Below Top of Casing: 160 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-
ice with I5A NCAC 2C.0118
1. YIELD (gpm): 100 METHOD OF TEST: ARD
. WATER ZONES (depth):
Formation Description
If additional space is needed use back of form
:. CHLORINATION: Type: CHLORYTE Amount: 15.5
CASING: LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74 E. FROM LAKE LURE. LEFT ON BILL'SSREEK
RD. LEFT INTO SWEETBRIAR FARMS N. LOT #60 <
c ��
>0
N rr$O
<
C—,
r
4
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.
citegt:CC / /dna, J //-? 6
SIGNATURE •F ' a' •N CONSTRUCTING THE WELL DATE
ubnlit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

orth Carolina - DO:miment of Environment and Natural Resources - Division of WaTer Quality - Groundwater Section
536 Mail Service Center - Raleigh, RC. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
327887
WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pomp Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
earest Town: RUTHERFORDTON County: RUTH
REEMANTOWN RD. DRILLING LOG
load Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER NORRIS HILL
.ddress FREEMANTOWN RD.
Street or Route No.)
UTHERFORDTON NC 28139
ity or Town State Zip Code
DATE DRILLED 05/04/06
. TOTAL DEPTH 105
.CUTTING COLLECTED ❑ YES NO
. DOES WETREPLACE EXISTING WFJ.1 ? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 10 FT.
'se "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Cop of casing terminated at/or below land surface requires a variance in actor -
trice with 15A NCAC 2C.0I18
J. YIELD (gpm): 75+ METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION:
3. CASING:
Depth
From 0 To
From To
From To
4. GROUT:
Depth
From 0 To 20
Type: CHLORYTE Amount: 2
Wall Thickness
Diameter or Weight/Ft Material
30 Ft. 6-1/4" SDR21 PVC
From To
Ft,
Ft
Material Method
Ft. QUIKRETE POURED
Ft.
5. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. itt
6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
7. REMARKS:
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)
HWY. #64/74A W. FROM RUTHERFORDTON. RIGHT ON
COVE RD. LEFT ON FREEMANTOWN RD. 1/2 MIEL ON
RIGHT. (404 ON MAILBOX) o
0
c - �r
z nr
N flm
�<
N 0r;
>'''
r
DO CERTIFY THAT THIS WELL WAS CONSTRUC 1t:t) 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.
y
1n /., c J—V QK
SIGN A 0 PERSON CONSTR THE WFJ 1 DATE
ubmit original to Division of Water Quality, Groundwater 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 Carter —Raleigh, N.C. 27699-1636 —Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
327390
. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
iearest Town: LAKE LURE County: RUTH
IUFFALO CREEK RD. DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER MELANIE WRIGHT
address BUFFALO CREEK RD.
Street or Route No.)
,AKE LURE NC 28746
7ity or Town State Zip ('Me
DATE DRILLED 05/26/06
TOTAL DEPTH 305
CUTTING COLLECTED ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 40 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 I5A NCAC 2C.0118
0. YIELD (gpm): 20 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 180 Ft.6-1/4" SDR21 PVC
From To Ft.
From To Ft.
L4. 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
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. 64/74A W. FROM RUTHERFORDTON. RIGHT ON
BILL'S CREEK RD. LEFT ON BUFFALO CREEK RD. 3 MILES
PAST ENTRANCE TO FAIRFIELD MTN. ON RIGHT?
c_
0
m
DO CbRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WF1.I
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
^�✓�J11✓r 4.
Submit on
GNATI7IFE dF IIERSON CONSTRUCTING THE WELL
to Division of Water Quality, Groundwater Section within 30 days
Ac cc,-2t
DATE
GW-1 REV. 12/99

torth Carolina —Department of Environment and Natural Resources — Division of Wat& 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 #:
327889
. WELL USE (Check Applicable Boz): ® Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
rearest Town: RUTHERFORDTON County: RUTH
:NGINEER RD. DRILLING LOG
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER PERRY WELLMON
lddress ENGINEER RD.
Street or Route No.)
:UTHERFORDTON NC 28139
:ity or Town State Zip Code
. DATE DRILLED 05/01/06
TOTAL DEPTH 405
CUTTING COLLECIED 0 YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
STATIC WATER 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 accor-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 20 METHOD OF TEST: ARD
1. WATER ZONES (depth):
DEPTH
Formation Description
If additional space is needed use back of form
2. CHLORINATION: Type: CHLORYTE Amount: 10.5
3. CASING: LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
BUS. 74 E. FROM FOREST C1TY. LEFT ON BOSTIC/SUNSHINE
HWY. LEFT ON ANDREWS MILL RD. RT. ON ENGINEER RD.
SINGLE WIDE SITS BACK OFF RD.
>0
N rnfrl
<
N O(`-:
o w
m r-
r—
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 75 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.
From To Ft. in. in.
[6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
i7. REMARKS:
DO CERTIFY THAT THIS WELL WAS CONSTRUUIED 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.
�� , / ✓
-G
-SIGNATURE OF P to ON ONSTRUCTING IE WELL DATE
ubmit original to Division of Water Quality, Groundwater 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]
NELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT if:
327688
WELL USE (Check Applicable Bor): CO Residential 0 Municipal 0 Industrial ❑ 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: RUTHERFORDTON County: RUTH
TOPE DR. PLEASANTVIEW SUBDV. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER BETTYTRUITT
kddress HOPE DR
Street or Route No.)
tUTHERFORDTON NC 28139
'ity or Town State Zip Code
DATE DRILLED 05/04/06
i. TOTAL DEPTH 605
CUTTING COLLEClbD ❑ YES ®NO
'. DOES WFT.T REPLACE EXISTING WELL? ❑ YES ® NO
;. STATIC WATER LEVEL Below Top of Casing: 60 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-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 1 METHOD OF TEST: ARD
I. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 16.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 170 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.
5. 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. #64/74A W. FROM RUTHERFORDTON. LEFT ON
MAPLE CREEK RD. RT. ON HOPE DR. INTO PLEASANTVIEW
SUBDV. 4/10 MILE ON LEFT. (LOT #16)
c
C
N
a
[ DO CERTIFY THAT THIS WELL WAS CONSTRUC fhll 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 P ON CONSTRb'CT1N LL DATE
ubmit original to Division of Water Quality, Groundwater 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]
VELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
3(
v'
.. WELL USE (Check Applicable Boz): ® Residential 0 Mmucipal U Industrial ❑ Agricultural ❑ Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
'. WELL LOCATION: (Show sketch of the location below)
learest Town: BOSTIC County: RUTH
96 MTN. LOOKOUT DR DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To FormatiouDa tfr "idn '---
,
1. OWNER BILL SMITH
kddress 296 MTN. LOOKOUT DR
Street or Route No.)
3OSTIC NC 28018 IL.
-
ity or Town State Zip f itdr u .,
t. DATE DRILLED 07/20/06 N,
:21
r
r::
t,l
5. TOTAL DEPTH 605
5. CUTTING COLLECIED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 600 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-
lance with 15A NCAC 2C.011g
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 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 Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To FL in. in
16. SAND?GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
If additional space is needed use back of form
1 `,
LOCATION SKETCH
'(Show direction and distance from at least two State
Roads, or other reference points)
BUS. 74 E. FROM FOREST C1TY. LEFT ON BOSTIC/SUNSHINE
RD. LEFT ON LUCKADOO MTN. RD. LEFT ON FIRE TOWER
RD. RT. ON AMELIA LANE INTO GOLDEN VALLEY
ESTATES. RT. ON MTN. LOOKOUT DR APPROX 1 MILE ON
RT.
0
I DO CERTIFY THAT THIS WELL WAS CONSTRUL LED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.t
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
�SIGNA OF PERSON CON TRUCTING THE WFJ i DATE
Submit ojjgfnal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

loath 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 E: 2785
STATE WELL CONSTRUCTION PERMIT 0: __
'6 4 0 4
I. WEILUSE (Check Applicable k ® Residential ❑ Municipal 0 Industrial ❑ Agi num! ❑ Monitoring
0 Recovery 0 &at Pump Water Injection 0 Other If Other, List Use:
I. WELL LOCATION: (Show sketch of the location below)
4earest Town: BOSTIC Civility: RUTH
3WY. 5226 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation —"-"-`"°` 1
3. OWNER BRUCE BAYNARD
Address HWY. 3226
'Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code a
1. DATE DRILLED 07/25/06 1�,,
J. TOTAL DEPTH 405 - c''
6. CUTTING COLLECTED ❑YES ®NO c^'+
7. DOES WELL REPLACE EXISTING WELL? El YES 0 NO cc 3
w
8. STATIC WATER LEVEL Below Top of Caving 60 FT.
(Usc ^+^ if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing tammated at/or below land surface requires a variance in actor- i
dance with 15ANCAC 2C.01I8
10. YIELD (8pm): 2 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 70 Ft.6-U4' SDR.21 PVC
From To FL
From To FL
14. GROUT:
Depth Material Method
From 0 To 20 Ft, OUILKRETE POURED
From To 11.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To F4. in. in.
From To Ft. in- in.
16. SAND?GRAVEL PACK
Depth Size Material
From To FL
From To FL
17. REMARKS:
If additional spice is nccded use bock of form
LOCATION SKETCH
'(Show direction and distance from at least two State
Roads, or other reference points)
BUS. 74 E. FROM FOREST CITY. LEFT ON BOSTIC/SUNSHINE
RD. LEFT ON HWY. #226. GRAVEL DRIVE 3/4 MILE ON RT.
-1
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WF1-1
CONSTRUCTION STANDARDS, AND THAT A COPY OF TWSRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
if N0_,'7-o2 ftC
OF PFRSOfi C(9FlSTRUCIING THE DATE
to Division of Water Quality, Gm®dwata Section within 30 days
GW-1 REV. 12/99

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]
NELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industnal 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
>. WFJ 1 LOCATION: (Show sketch of the location below)
Dearest Town: RUTHERFORDTON County: RUTH
CLEAR WATER CREEK -LOT #259 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation esairrtion --
3. OWNER ROGER BREWER
Address CLEAR WATER CREEK -LOT #259
'Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
4. DATE DRILLED 07/27/06
5. TOTAL DEPTH 205
6. CUTTING COLLECIbD 0 YES ®NO
7. DOES WELL REPLACE EXISTING WELT 7 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING I5 1-1/2 FT. Above Land Surfaces
'Top of casing terminated aVor below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WAfER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 120 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. #221 N. FROM RUTHERFORDTON. LEFT ON MTN.
CREEK RD. LEFT INTO CLEAR WATER CREEK ON
CLEARWA 1'h1t PKWY. RT. ON CHIMNEY CREEK LANE. RT.
ON CROSS CREEK LANE. LOT ON LEFT ACROSS FROM
WOODSTOCK LANE.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCI'hD IN ACCORDANCE WITH 15A NCAC 2C, WELL
t
ri it;
t
CONSTRUCTION STANDARDS, AND THAT A COPY OF TIIISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNA ' OF PERSON •NS CTING THE WELL DATE
ginal to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Iorth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Center — Rakigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
= STATE WELL CONSTRUCTION PERMIT #:
s ci 4 0 r
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal
❑ Recovery ❑ Heat Pump Water Injection ❑ Other
:. WELL LOCATION: (Show sketch of the location below)
dearest Town: LAKE LURE County: RUTH
3UFFALO SHOALS RD.
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
;. OWNER JOHN MCDANIEL
%ddress BUFFALO SHOALS RD.
Street or Route No.)
.AKE LURE
ity or Town State
1. DATE DRILLED 07/12/06
5. TOTAL DEPTH 385
5. CUTTING COLLECTED ❑ YES ® NO
7. DOES WF.I.T REPLACE EXISTING WELL? ❑ YES ® NO
3. STATIC WA int LEVEL Below Top of Casing: 200 FT.
Use "+" if Above Top of Casing)
). TOP OF CASING IS 1-12 FT. Above Land Surface*
'Top of rasing terminated at/or below land surface requires a variance in accor-
iance with 15A NCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth):
NC 28746
Zip lode
12. CHLORINATION: Type: CHLORYTE Amount 9.5
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 To Ft in.
From To Ft in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
in.
in.
❑ Industrial ❑ Agricultural ❑ Monitoring
If Other, List Use:
DRILLING LOG
DEPTH
Formation'Description—t
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY, #64/74A W. FROM RUTHERFORDTON. RT. ON
BUFFALO SHOALS. RD. CROSS DAM 1.7 MILES ON LEFT.
LOT #9, PIER POINT
c
t
J
0
C1
I DO CERTIFY THAT THIS WELL WAS CONSTRUC.1 El) IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WFT.1 OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
I��
SIGNATURE OF PERStSN CbNSTRUCTING
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Youth 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 #:
c, t
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: RUTHERFORDTON County: RUTH
HWY. #64 DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER DAVID LESLEY
Address HWY. #64
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
4. DATE DRILLED 07/12/06
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 Caging: 40 FT.
(Use "+" if Above Top of owing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface`
'Top of casing terminated allor below land surface requires a variance in accor-
dance with I5A NCAC 2C.0118
10. YIELD (gpm): 100 METHOD OF TEST: ARD
11. WATER ZONES (depth):
If additional space is needed use back of form
12. CHLORINATION: Type: CHLORYTE Amount: 13.5
13. CASING: LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 90 Ft 6-1/4" SDR21 PVC
From To Ft
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft OUILKRETE 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 Ft
17. REMARKS:
' (Show direction and dictanm from at least two State
Roads, or other reference points)
HWY. #64 E. FROM RUTHERFORDTON. 1 MILE PAST
PARTON LUMBER CO. NEW DRIVE ON LEI. 1.
0
0
-
o;
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.
mot / e7 T i2,i1r .7-42
S NA OF PERSON C CT1NG THE WELD DATE
Submit or4gfnal to Division of Water Quality, Groundwater 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]
YELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): 0 Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
. WELL LOCATION: (Show sketch of the location below)
learest Town: RUTHERFRORDTON County: RUTH
;OVE RD. DRILLING LOG DEPTH
Road Name and Numbers, Commnmity, or Subdivision and Lot No.) From To Formation Description
OWNER JIMMY DANIELS
%Actress COVE RD.
Street or Route No.)
tUTHERFORDTON NC 28139
.7ity or Town State Zip Code
I. DATE DRILLED 07/06/06
;. TOTAL DEPTH 205
i. CUTTING COLLECTED 0 YES ® NO
1. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
1. STATIC WATER LEVEL Below Top of Casing: 10 FT.
Use "+" if Above Top of Casing)
). TOP OF CASING IS 1-1/2 F. Above Land Surface*
Top of casing terminated aUor below land surface requires a variance in actor -
lance with 15A NCAC 2C9118
10 YIELD (gpm): 60 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 100 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. SAND7GRAVEL PACK:
Depth Size Material
From To Ft.
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.1164/74 FROM RUTHERFORDTON. RIGHT ON COVE
RD. NEW DRIVE ON LEFT 2/10 MILE PAST PLEASANT
GROVE BAPTIST CHURCH.
C
c->
N
0
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 CONSTRUCTING THE DATE
original to Division of Water Quality, Groimdwater 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 0 Monitoring
0 Recovery 0 Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: RUTHERFORDTON County: RUTH
466 MEADOWBROOK RD. DRILLING LOG
(Road Name and Numbers, Comtmmity, or Subdivision and Lot No.) From To
3. OWNER MICK DOYLE
Address 466 MEADOWBROOK RD.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
4. DATE DRILLED 07/05/06
5. TOTAL DEPTH 305
6. CUTTING COLLEC1hD ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WA TER 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): 20 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 60 Ft 6-U4" SDR2I PVC
From To Ft
From To Ft
14. GROUT:
Material Method
From 0 Depth
pTo 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:
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)
HWY. #9 S. FROM MILL SPRING. LEFT ON OLD CHESNEE
RD. LEt 1 ON POORS FORD RD. RT. ON MEADOWBROOK
RD. 1/2 MILE ON RT. (466 ON POST)
J
0
0
rr;Li
I DO CERTIFY THAT THIS WELL WAS CONSTRUL1 hD 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.
,�c/�,� �� �iel:Q 7' c1 L
IGNA OF CO TRUCTiNG THE WELL DATE
ginal 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 — Plmne [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION it: 2567
STATE WELL CONSTRUCTION PERMIT#:
4,-. r
Pi
1_ WELL USE (Check Applicable Box): ® Residential ❑ Municipal
❑ Industrial 0 Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FOREST CITY Canty: RUTH
CHATHAM RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER JERRY WALLS
Address CHATHAM RD.
(Street or Route No.)
FOREST CITY NC 28043
City or Town State Zip Code
4. DATE DRILLED 07/26/06
5. TOTAL DEPTH 54
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES NO
8. STATIC WATER. LEVEL Below Top of Caging: 39 FT.
(use `+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surfacer
*Top of casing terminated aUor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: STh L 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 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. is
From To Ft. in. in.
From To FL in_ in.
16. SAND?GRAVEL PACK
Depth Size Material
From 39 To 54 Ft 78M GRAVEL
From To Ft
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distant from at least two State
Roads, or other reference points)
HWY. #221 A FROM FOREST CITY. RT. ON CHASE HIGH RD.
INTO SANDY MUSH. LEFT ON CHATHAM. 121. DIRT DRIVE
TO LEFT a DEAD END. NEW DOUBLE WIDE.
a
0
0
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.
NS UCTNG THE WELL DATE
Groundwater Section within 30 days
GW-1 REV. 12i99

Vorth 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 #:
d 3 •'it# )
• 1. WELL USE (Check Applicable Box): IS Residential ❑ Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FOREST CITY County: RUTH
840 SHILOH RD. DRILLING LOG
(Road Name and Numbers, Conunimity, or Subdivision and Lot No.) From To
3. OWNER FRED HAWLEY
Address 840 SHILOH RD.
(Street or Route No.)
FOREST CITY NC 28043
Zip Code
City or Town State
4. DATE DRILLED 07/17/06
5. TOTAL DEPTH 305
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO
8. STATIC WA1hE. LEVEL Below Top of Casing: 60 FT.
(Use"+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surfaces
'Top of casing terminated odor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 8 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 7.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 FL 6-1/4" SDR21 PVC
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To FL in. in.
From To FL in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
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)
HWY.. #221 S. FROM RUTHERFORDTON. RT. ON SHILOH RD
1 MILE ON RT..
I DO CERTIFY THAT THIS WELL WAS CONSTRUCT ti) IN ACCORDANCE WITH 15A NCAC 2C, Wit
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS
�BEEN
jPROVIDED TO THE WELL OWNER
—et
o .(dixo 7-/7- 6C
11 SIGN�A OF PESSON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.

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 ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): El Residential 0 Municipal 0 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)
4earest Town: BOSTIC County: RUTH
)EPREST RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
S.OWNER MARK HOLLIIELD
kddress DEPREST RD.
Street or Route No.)
3OSTIC NC 28018
:ity or Town State Zip Code
1. DATE DRILLED 07/10/06
S. TOTAL DEPTH 37
i. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 22 FT.
Use "+" if Above Top of Casing)
4. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Top of casing terminated at/or below laud surface requires a variance in accor-
lance with I5A NCAC 2C.0118
1.0. YIELD (gpm): 15 METHOD OF TEST: $1 ELL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 6.9
13. CASING:
Depth Diameter
From 0 To 37 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 PACIC
Depth Size Material
From 22 To 37 Ft 78M GRAVEL
From To Ft
17. REMARKS:
Wall Thickness
or Weight/Ft Material
CEMENT
If additional space is needed use back of fonm
L.)
LOCATION SKETCH
.(Show direction and distance from at least two State
Roads, or other reference points)
BOSTIC/SUNSHINE RD. FROM BOSTIC. LEFT ON DEPREST
RD. 1 MILE ON RIGHT.
a
c->
1
v
0
0
G
0
�7-
m LJ•
[ 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 PERSON CO "i'RU G THE WELL DATE
Submit original to Division of Water Qral Groundwater Section within 30 days
GW-1 REV. 12/99
lr7'1a 7- /1

4orth 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 #: _
3 rj
1. WELL USE (Check Applicable Boar 0 Residential 0 Municipal 0 industrial 0 Agricultural ❑ Monitoring
0 Recovery ❑ Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
Z. WELL LOCATION: (Show sketch of the location below)
Nearest Town: BOSTIC County: RUTH
5318 WHITESIDE RD. DRH,LING LOG DEPTH
;Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER HELEN POWERS
Address 5318 WHITESIDE RD.
(Stipet or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
4. DATE DRILLED 07/11/06
5. TOTAL DEPTH 39
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 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 easing terminated attor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 18 METHOD OF TEST: STEEL 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 39 Ft 24 CEMENT
From To Ft
From To FL
14. GROUT:
Depth Material Method
From 0 To 20 Ft CEMENT POURED
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 WASHBURNS TAK BOSTIC/SUNSHINE RD. LEFT ON
WHITESIDE RD.
From _ To Ft c
15. SCREEN: :--
Depth Diameter Slot Sipe Material -
From To Ft _ in._ in._ c
From To Ft in. in.
From To Ft in. in. i
-..t ri'-i
16. SAND/GRAVEL PACK:
Depth Size Material rcr.-.' — —
From 21 To 39 Ft 78M GRAVEL
From To Ft
17. REMARKS:
l 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.
i
a
SIOXATURE
Submit original to Division of W
era 7-/i
CTING THE WELL DATE
ty, Groundwater Section within 30 days
GW-1 REV. 12/99

Morth 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 #:
', 3
1. WELL USE (Check Applicable Box): 13 Residential 0 Municipal 0 Industrial ❑ Agricultural ❑ 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: BOSTIC County: RUTH
CUDDLES LANE DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER CHRIS HODGE
Address CUDDLES LANE
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip ('nde
4. DATE DRILLED 07/17/06
5. TOTAL DEPTH 56
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 36 FT.
(Use "-I-- 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. WA 1 ER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 56 Ft 24 CEMENT
From _ To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft CEMENT POURED
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From To FL _ in._ in._
From To FL in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK
Depth Size Material
From 36 To 56 Ft 78M GRAVEL
From To FL
17. REMARKS:
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)
BUS. 74 E. FROM FOREST CITY. LEFT ON
BOSTIC/SUNSHINE RD. LEFT ON CUDDLES LANE IN
SUNSHINE. 4TH HOUSE ON LEFT.
c-�
u
v
0
0'
0
•
I DO CERTIFY THAT THIS WELL WAS CONSTRUC1 Ell 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.
-a AT)
SI
Submit original to Division of Water Quali
(TING THE WELL DATE
water Section within 30 days
GW-1 REV. 12/99

Vorth 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 #:
a 51 r / 9 fl
a t)''i N
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: RUTHERFORDTON County: RUTH
214 LEE CAMP RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER LARRY STRICKLAND
Address 214 LEE CAMP RD/
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip (wie
4. DATE DRILLED 07/18/06Le
{
5. TOTAL DEPTH 39
6. CUTTING COLLECI .D ❑ YES ® NO ha
7. DOES WELL REPLACE EXISTING WELL? ® YES ❑ NO r
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 casing terminated allor below land surface requires a variance in accor-
dance with ISANCAC 2C.011S
10 YIELD (gpm): 18 METHOD OF TEST: S 1 b1tL TAPE
11. WA 1'ER ZONES (depth):
If additional space is needed use back of form
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING: LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. RT. ON COVE
RD. RT. ON HAMPTON RD RT. ON HAMPTON RD. RT. ON
J FP CAMP RD. 1n BRICK HOUSE ON RT.
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 39 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 FL in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 21 To 39 Ft 78M GRAVEL
From To Ft
17. REMARKS:
I DO CLRTIFY THAT THIS WF.1 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.
649
/t'xo ? /? - e 6
STRUCTING THE ,T .I DATE
ater Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

fTh
Qorth 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 UST (Check Applicable Box): ® Residential ❑ Municipal
0 Industrial 0 Agricultural ❑ Monitoring
0 Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FOREST CITY County: RUTH
WHITESIDE RD. DRILLING LOG
;Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER CHARLIE BROOKS
Address WHITESIDE RD.
(Street or Route No.)
FOREST CITY NC 28043
City or Town State Zip Code
4. DATE DRILLED 07/18/06
5. TOTAL DEPTH 52
6. CUTTING COLLEC fr.D 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 32 FT.
(Use"+" if Above Top of Coming)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing termimtcd at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: S I EEL TAPE
11. WA I ER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 9.2
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 52 Ft. 24 CEMENT
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT 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. SAND?GRAVEL PACK:
Depth Size Material
From 32 To 52 Ft 78M GRAVEL
From To Ft
17. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
n
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
BUS. 74 E. FROM FOREST CITY. LEFT ON
BOSTIC/SUNSHINE RD. LEFT ON PEA RIDGE RD. IN BOSTIC.
LEFT ON WHITESIDE RD. LEFT ON DIRT DRIVE ACROSS
FROM CHURCH 2 » ROUSE ON RT.
0
>.
c
t
L
0
m
• ,,
I DO OERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH 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.
e
SIGNATURE OF P
Submit original to Division of Water
TRUCTING THE WELL DATE
ty, Groundwater Section within 30 days
GW-1 REV. 12/99

4. WELL OWNER
OWNER'S NAME
ET ADDRESS
K tker r
City a Tam
• RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
t. DISINFE6TiON:Type chlorine Amount
326987
1. WELL COMRACTOR:
James W
W ell ConbeotoradWidual) Name
Camp s Weii ^•211P C Tnc _
Well Contractor Company Name
STREET ADDRESS P 0 Bok 429
Ellenboro
Cityor State
28) (8. 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tint spoilable)_
STATE WELL FERMIT#0rapplicabie)
DWQ or OTHER PERMIT #(S apntkable)�--
WELL USE {Check Applicable BOO: Residential Water Supply CI
DATE DRILLED--�--
TIME COMPLETED i - AMIIPMO
NC
2804
Zip
e
3. WELL TI!:
CITY: _ COUNTY .IA-
1
(SbeM aimNWrlbets Community. SubdlNl.dsion, _o., Parcel. Bp Cod?)
TOPOGRAPHIC 1 LAND SETTING:
CI Ma OValey OFtat ORidge Daher
(stock appropdalabm9 7
a • 2�
LATITUDE qry
LONGITUDELa
Latitude/longitude source: MOPS OTopographic map
(Walks? of wel must be shown on a USGS topo map end
attached to this fowl itnot using GPS)
e m Y
May be in depees,
mina seconds a
in a decimal format
y-O I*
SIRE 14ot as j}w g -a55
j2 T d)cn C- ()3�
State Zip Cede •
Area code - Phone number
5. WELL DETAILS: 0
TOTAL DEPTH: �
a
b. DOES WELL REPLACE EXISTING WELL? YES O NO d(
c. WATER
LEVEL Below Top d Casing FT`
('JUseas'v If Above Top d Casing)
1 FT. Above Land Surface*
d. TOT p CASING a etla below land surface may require
'Tap of nce in tcen ce With 15A NCAC 2C .0118.
avadanceMaccadan �+� ��
e. YIELD (gpm): METHOD OF TEST l Y'
g. WATER ZONES (depth):
From TO
From
Fran To
O. CASING:
Dept
Fran O
From To
From To
To
I%a cu0
To
ToT
To
Thickness/
FL 6# tCr SDR21
From•
Ran,
Ran
Ft
Ft
Material
VAC_
7. GROUT: Depth Material Method
Porn_ TO 2O FL Eackrete Hand
From To Ft
Fran__To Ft
S. SCREEN: Depth Diameter Shot Size .Material
From To Ft In. In..
From To Ft In. _ In.
From_ To Ft. In. __ In.
9. SANDIGRAVEL PACK: Sim MaterialDepth
Prom To FL
From To Ft
Fran To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Form •on Des jption
v
iNC
a o c `
I DO HERESY CERTIFYTHAT THIS WELL WAS DONSTRUCIED ai ACCORMNCE16A MAC 2C. WSH
WELL t+ STANDARD. AND MAT ACOPY OF. THIS
RECORD HAS BEPROVIDED TO
` DATE b.
ScTf URE OF CERTIFIED WELL • NTRACTOR
James W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mall Sery ce Center- Raleigh, NC 2 699 1617 e Division of Water slip within No. (9 9) 733 7015 ext 568.�on Mgt.,
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
Nor h Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well C.mtredor.(IndN)dual) Name
Camp's Well & Pimp ('o. Inc
Well Contractor Company Name
STREET ADDRESS P O Doi 429
Ellenboro NC
City orTom ' State
(828. 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Of applicable)
28040
tip node
STATE WELL PERMIT#01 appfeable)
DWQ or OTHER PERMIT#(It applicable)
WELL. USE (Check Applicable Box): Residential Water Supply IJ
DATE DRILLED l✓` _ D ' /
TIME COMPLETED Lf . 3 ° AM O PM th
3. WELL. LOCATION:.I.�yQ (_ Y
CITY: jo s) h c- }-cOuNTY i l'Le j%p Cl
Lot Li l SLIMDni r
(Street Name, Numbers. Community. Subdivision, Lot No., ParceEilp Code)
TpPOGRAPHIC I LAND SETTING:
litSlope DValley ['Flat ❑Ridge ❑Other
(die* wproPdatabox)
LATITUDE _a_ P 31
LONGITUDE f i e qq. oSl
Latitude/longitude source: OGPS OTopographic map
(location
et must be ## shownot n GFS) G Us ttopo map hjand
attached 4. OWNER'SLL
1 eke Sl de /31-Ll )de_rs
STREET ADDRESS P 0 &2X ri
%eke bet ye 74
City or Toen State Zip Code
May be M degrees,
minutia, seconds or
in a decimal format
Area code Phone number
5. WELL DETAILS:
s TOTAL DEPTH-
1k/0 S
b. DOES WELL REPLACE EXISTING WELL?(VYiES 13 NO
jk
c. WATER LEVEL Below Top dCasing 1 ? L1 FT.
(Use.V if Above Top d Casing)
d. TOP OF CASINO M 1 . FT. Above Land Surface'
'Top of casing terminated at/or below land surface muy require
a variance M accordance with 15A NCAC 2C .0118. ,
e. YIELD(gpm): tMETHOD OF TEST a) ✓
•326985
t. DISINFECTION: Type chlorine Amount ram% caps
g. WATER ZONES (depth): 1
From To From To
From To From To.
From To - From To
6. CASING:
From 0
Fmm_
From
TNclmessl
Depth. Minder Weight
To Ft. 6a SDR21
To Ft
To Ft
Material
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft.
Depth Diameter - Slot Size Material
To Ft. M. In.
To Ft. In. _ in.
To FL M. In.
S. SCREEN:
From
From
From
9. SAND/GRAVEL PACK:
Depth Size Matedd
From„ - To R.
From To Ft.
From To FL
. . •.. h7
10. DRILLING LOG
From .To Fopnati?n Description
Gt O S I C_ a /Ic o7
._e. 74 r
1 11 _ S>t7
17D6 . »tSoifdeCkd ire .
�
1 '3
70.
I"2006 . -c
11. REMARKS:
I DO HEREBY CERTIFY THAT THLS WELL WAS 15A WAG 2C. CONSTRUCTION STANDARDS. ANDDVATAf�OE 1.11$-DANCE H
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
URE OF CERTIFIECONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subm
Servl e eCenter — Raleigh, NC 2 699- 6117 inal to the Division of Water ality Ph ne No. (9 9) 733 TAttn: xInformation Mgt.,
t 568.
1617 Mall
Form GW-la
Rev. 7/05

City or Torn
Area code. Phase number
5. WELL DETAILS: 4 l
a. TOTAL DEPTH:
• RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
3269 4
1. WELL CONTRACTOR:
James W. Canto
Wd Contractor.(IndWldual) Name
Camp's Well & Pump Co. Inc
Well Contractor Company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City or Town State ZIP Code
(828. 453-7322
Area Lode- Phone number
2. WELL INFORMATION:
SITE WELL ID *Or opencabk) '
STATE WELL FERMIUM appllemble)
DWQ or OTHER PERMIT #(t applicable)
WELL USE (Check A»»plicab�Ie Box): Residential Water Supply CI
DATE DRILLED `� r -06
TIME COMPLETED IS AM I7 Mt/ `J 2. WELLL, Sake
c t� Ruc 1144)
CITY: "J� (,(-4l-fflQY is � lilt COUNTY �I \\
V105s
(Scent Nuns. Numbers. Commaeity. Subeleslon, Ld NO., Parcel ND Code) _
TOPOGRAPHIC I LAND S.EE/TT�,ING:
OSlape CIVeley anal jRidge Other
(µark sppropastaba,).
LATITUDE .... ° as • f _I
LONGITUDE ° 01. 8'1 3
Latitude/longitude source: PS ['Topographic map
pc to Mn be shown on lnot hg GPS)Gs topo map and
attached 4. WELL OWNER
OWNER'S NAME
IMay leIn deem,
miauke rocordi or
Ina decimal toner
Ski e_
STREET ADDRESS l 5S Kd .
Rat'te✓ State
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES Cl ND ❑
WATER LEVEL Below Top d Casing: 5-0 Fr,
(Use OAbove Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Top d casing terminated etlor below land surface may require
e variance In accordance with 15A NCAC 2C .0118. ,
e. YIELD (gpm): ?Sj METHOD OF TEST ot) r
t. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To 1)0 From To
From To From To
From To From To
5. CASING: amat«
Frain Q Depth
10 Ft 6#
From To Ft.
From To Ft
Theelclolmessl
SDRb21
7. GROUT: Depth Material
From 0 To 20 Ft. Sackrete
From To Ft
From To FL
a. SCREEN:
Ran
From
Depth
To
To
From To
Material
'PVC
Method
Hand
Diameter Skit Sire .Material
Ft. In In.
Ft. In. In.
Ft In. In.
S. SANDIGRAVEL PACK: She ManDepth
Fran To Ft
From To Ft
From To Ft
10. DRILLING LOG
From .To.
0• 110
tIo" 4-ID
Formation D
et-7 Set
rot sohdA_ e- k"7-J
LC)
UN [) n 200
11. REMARKS:
xi<
$ or,
n�
ti
I Do HEREBY CERIFY THAT TIES WELL WAS CONSTRUCTED N ACCORDANCE WITH
RECORD HAS BEEN 7 OVDFATOTHE WELL STANDARDS,
W ANDRICA COPY OE THIS•
ER
SI A URE OF CERTIFIED WELL NTRACTOR bATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water 1617 Mall Service Center— Raleigh, NC 2 6991617 Quality
Phone No. (9 9) 733 7 5 ext 568 Don 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 t1 21 3 8
1. WELL CONTRACTOR:
James W
Well ConbaGa.(IndNldual) Name
Camp We ina^^ Tn-
W all Contractor Company Name
STREET ADDRESS P O Poi 429
EllenborO NC 28040
City GTov m State ZIP Gode
t 828). 453-7322
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID *Or applicable)
STATE WELL PERMITMN apPBuhle)
DWQ or OTHER PERMIT 401 applicable'I WELL USE {Chock Applicable Box): Residential Water Supply ❑
DATE DRILLED_
pp
TIME COMPLETED I o' h 0 AMP PM
2. WELLLQFA N: f Ll. er id
r ✓d DIL COUMTY
Laco c — 93
(Swat alms. Numbers. Community. Subavkbn, La No Parcae
WPOGRAPHIC I LAND SETTING:
lope oVallelr oFlat ❑Ridge ❑Other,
h 004
LATITUDE � .�'' 968
LONGITUDEI 2--ci
latitudellongitude so Topographic map
(heath; dwel' must be shown on a USGS tape map and
attached to fhb Mon 1 not ushg GPS)
4. WEU. OWNER
OWNER'S NAME
STREET ADDRESS
LAKe Litre
or Tam
Atoa codePhone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NO
c. WATER LEVEL BelowTop d Casing
D FT.
Cods)
May be In degas,
minutes seconds or
in a decimal bract
urce: GPS ❑
(Use+•if Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Lend Sudece°
;Top 01 casing terminated eVa below land surface may require
a ice In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):.._�O METHOD OF TEST A,) Y
�
3 2 6 9 8 3
t. DISINFECTION: Type chlor ine Amount
g, WATER ZONES :
From To From
Ran To From
From To Ran To
6. CASING: - TI' sl
Weight De
Fran 0 T Ft We' SDRh21 PVC
From To FL
Ran To Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To FL
From_. — To Ft.
B. SCREEN: Depth
From To
Fro To
From To
To
To
Diameter Slot Size .Material
Ft In. .__ in.
Ft in. _ in.
FL In. _ In.
9, SANWGRAVEL PACK: Depth Size Material
From ' TR— Ft
Fran To Ft
From To FL
10. DRILLING LOG
From .To
•
11. REMARKS:
Forms
Ave
n DgSCtiptlon
I DO HEREBY CEmFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
RECORD HAS BEENP WIDEDTOTHEA RDS. AND MATACOPY OF. THIS
ER
R C
\Eli
apb
SI • , • RE OF CERTIFIED WELL CO RACTOR DATE
James W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
s.
Submit
Serrvi original
Center - Raleigh, NC 27 99.16117 e Division of Water Quality
Phone 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 # 21 3 8
t DISINFECTION: Type Ch lori ne Amount calls
g. WATER ZONES (depth):
From To From To
From To From To.
From To From To
1. WELL CONTRAOTOR:
James W. Camn
Well Contractor(Individual) Name
Camp's Well & P_umn
Well Contractor Company Name
STREET ADDRESS P 0 BOX
Co . Inc
429
Ellenboro NC 28040
City orTown State Zip Code
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Of apsOeabb)
STATE WELL PERMITM(d applicable)
DWQ Of OTHER PERMIT /0 apPBeable)
WELL USE {Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 5-1- o 6
TIME COMPLETED Q. - O AM ❑ PMf(" ( 1 S. CIITLLLOChp571 L COUNTY RU. I beYJDY(1
%4" 6'1 S ariev ; f
(Street Name, Numbers. Community. SubdMaion.Lot No., Parcelalp Code) -
TOPOGRAPHICILAND SETT G:
❑Slope oValley °Flat e Daher
(child( apptopnetabox)
LATITUDE „-S �fry
LONGITUDE I 4 c. 9: 3
Latitudedlongitude source: pGIPS °Topographic map
(lattached to fhb lam not using GPS)GS topo map and
4. WELL OWNER'S
ER T I c._L_ J
OWNER'S NAME To ,C 1GLSaL`
STREET ADDRESS 2.1 3 �^)) Z.A% e tr A ✓e .
l MYP6I (';±1 Nc- 2Sv4/3
City orTown tate Zip Code
•
May be N depea,
minutes, woods or
in a decimal bunt
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES l7 NOX
c. WATER LEVEL Below Top of Casing: FT,
(Use'+" 8 Above Top of Casing)
d. TOP OF CASING 1S 1 FT. Above Land Surface'
'Top of casing terminated agar Warn land surface mey require
a variance in accordance wah 15A NCAC 2C .0118.
e. YIELD Wpm):METHOD OF TEST a» / ✓
32698
6. CASING:
Depth
9 To
From To
From To .
Thickness/
6tanec S
Material
1 Weight
VC
Ft
Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
Fran To Ft.
Front__ To Ft.
S. SCREEN: Depth Diameter Slot Size .Materiel
From To FL in, In.
Fron, To Ft. In. In.
from To FL in. in.
S. SAND/GRAVEL PACK: Size
Depth Material
From To-_ Ft.
From To Ft.
Fran To Ft
10. DRIWNG LOG
From To.
. 0 • ,.,3
Form�atlon;Description
SAHQ tick/
(Po5 (1vn:sob dale- d roc-k
JUN () F. 2006
11. REMARKS:
a
(3 ter_
ti
I DO HEREBY CERTIFY MATINS WELL WAS CONSTRUCTED N ACCORDANCE Wmt
16A NCAC 2c, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ditkik T
RSERFWELLCONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Soriginal to the alQuality
ln5 information Mgt.,
1617 Mali Service Center - Raleigh, NC 2 99- 6117 P Phone No (919)7337Attn:
ext 68.
Form GW-la
Rev. 7/05

City aTawn ' State
(828). 453-7
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID apt aNalaWe)
' RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality 32,69 8 I
WELL CONTRACTOR CERTIFICATION N 21 3 8 ' .
1. DISINFECTION: Type ch1orune Amount I ear
g. WATER ZONES (depth):
From To t h0 Ram _ To
From To From To
From To From to
1. WELL CONTRACTOR:
James W. Camn
Well Coniraaar.(IndMWual) Name
Camp 's We11 It P.imr Co, ?Dr _
Well Contractor CanpantName
STREET ADDRESS P O BOX 429
EllenborO NC 28040
tode
STATE WELL PERMTTIGaPPaaable)
DWQ a OTHER PERMIT d(e aPPlicabla)
WELL USE (Check Applicable Bag: Residential Water Supply V
DATE DRILLED C6
TIME COMPLETED 2- - AM PM
a. WELL LOCATION: u_U Yd
FY I
CITY: Qos -7
fr _ COUNTY I'` ) It
L-ot .263 1 Effc )±oP Nth
(Street Name, Numbers. CanmuI$y, Subdlvkien. Let _o., PercN: Code)
TOPOGRAPHIC / LAND SE ..ING:
❑SICPa OValley OFlet & •1dge inciter
oho* e-Pr-P lasisr4
LATITUDE p5 1I
6 1113 (le
LONGITUDE
Latitude/longitude source: PS OTopoBaphic map
ofwalnut(
alnut(be shown on a USGS Alpo map end
attached form I no using
4.WELLOWNER t
D
OWNER'S NAME Dt tvT77✓eta vtsl
BT ADDRESS 0 ,0 X 2,
t705fit C-- ASolg
IMay lain J
minutea,secodsor
Inc decimal format
Clly or Tavn State Zip Code
Area code Phone number
5. WELL DETAILS: .3 O
a. TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL?? YOESp NO X
o. WATER LEVEL M TodCasing: d ) "' o FT,
d. TOP OF CASING IS 1 FT. Above Land Sudece'
'Top d casing terminated aUa below lend surface may require
a variance In accordance With 15A NCAC 2C .0118.
e. YIELD (gWn) `� METHOD OF TEST A...;
r
IL CASING:
DiameterDepth
'Fran 0 I Io FL
From To FL
Fran To •Ft.
7. GROUT: Depth Material Method
FrontO _To20 Fr. Sackrete Hand
From To FL
Front__,___Tci FL
IL SCREEN: DepthFL_i- Slot Sim .IAateal
From
Fran To FL In. In.
From__ To Ft_in — In.
9. SANDIGRAVEL PACK: Depth Size Material
Fran„__,L_.To_ FL
Fran To FL
Fern 'T2 FLU_
Thatcglomsd
Wht
Material
10. DRILLING LOG
Rom
Iio_
Formation Description
Sand cIa/) A raUel
J
II6 33o ' (ovt5o)ida-feA Y'DGK=
UIN ne 2006
11. REMARKS:
-c
o C -
I DO POESY CERLFYnornie was WAS oa11STR AACCmmu COPY 5E Wml
1 as MCC2C, WELL CONSTRUCTIONSTANDARDS,
: RECORD HIS BEEN PROVIDE) TOTHE WELL OWNER.
IQ3ATUREIO 1ER IEbWE . (0
SI TURE OF CERTIFI W ELL CONTRACTOR bA E
James W. Cam_
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit fty
18 7 Mall the
original
Center- Raleigh, NC 27 99- 617 e Division of Water al Phone No. (9 91,733 Y 5 ext 568.0on Mgt,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION g 21 38
1. WELL CONTRACTOR:
James W. Camp
Well contractor (Individual) Name
Camp's Well & PIMA
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 #pr applicable)
STATE WELL PERMRII(Bapplicable)
DWQ or OTHER PERMIT Elf applicable)
WELL USE (Cheek Applicable``''Bar: Residential Water Supply ❑
T
DATE DRILLED 7 �/✓Zo`,04 r
TIME COMPLETED : Y 5- AM O PM llr
Co. Inc
3. WELL LOCATION: ((i,
CITY: Kty)te✓1or0/VrCOUNTRatite
r r
lV2 gel. fiAy07 rl CI-6 re RA .
(soest Name, Numbers, community, SubdMslon, Lot No., Parcel, Zip Code)
T OGRAPHIC I LAND SETTING:
Slope °Valley O.FId ❑Ridge ❑Other
(check appropdateboA)
LATITUDE _ e a7 90 * d
LONGITUDEi a©. OS: //06# 141
Latitude/longitude source: VMS °Topographic map
(beatbn W we/ must be shown on a USGS topo map and
attached to thls Iona lnot ushg GPS)
4. WELL OWNER I ,
OWNER'S NAME Vt7 Li 6 Co p%&
STREET ADDRESS ,2 I W 4 t � I3
ki Pv -n r c lv V\
City or Town Sta Zip Cab •
(_i. `18a-2SS�i
Area code- Phone number
May ha in dogma,
minutes, seconds or
in a decimal brmat
5. WELL DETAILS: 3QS
a. TOTAL DEPTH: lr
6'
b. DOES WELL REPLACE EXISTING WELL? YES NOEI
e. WATER LEVEL BeSSW Top of Casing: o FT, 111
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated d/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):_l— METHOD OF TEST (t-I C
.326980
t. DISINFECTION: Type Chlorine Amount )� Gat
g. WATER ZONES( ):
From To V From
Fran To From
From To From
6. CASING: Thidmesa/
Depth Weight WeiMaterial
From 0 �To Ft 6g SDR21 PVC
From To Ft.
From To Ft
To
To
To
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
Fran To Ft
a. SCREEN: Depth
Fran To
From_____
From To
Diameter - Slit Sim
Ft. In. In.
Ft. In. h.
Ft In. b.
.Material
8. SAND/GRAVEL PACK:
Depth Si193 Material
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To.
0' 4-5
3os
11. REMARKS:
Formation Dgscriptbn
C.) ) Sarnd
Covtselldated rocK
0
Ca
--c
[OOb
-Cr•1
3 itrtf
l
r-
-1
-c
1 DO HEREBY CERTIFY THATT(BS WELL WAS CONSTRUCTED IN ACCORDANCE Wtm
15ANCAC 2C. WELL CONSTRUCTION STANDARDS, AND 1HATACOPY OF THI$
RECORD HAS BEEN PROVIDED
/�TOO{THE WWELL OWNER.
SI ATUURREOF RTIFIED'WELCCONTRACTOR �DA E U6
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water
1617 Mali Service Center- Raleigh, NC 276994617 Duality information Mgt„
Phone No (9 9) 733 7015 eat 68.
ram GWla
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3
26978
1. WELL CONTRACTOR:
James W. Camp
Weti Contractor.(IndMdual) Name
Camp's Well & PIMP Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 Bo) 429
Ellenboro NC 28040
City or Town State ZIP COde
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #f applicable)
STATE WELL PERMIT#(aapplicable)
DWQ a OTHER PERMIT NW applicable)
WELL USE (Cheek Applicable Box): Residential Water Supply
DATE DRILLED 4'a.7-02,
4
TIME COMPLETED • 30 AM 0 PM
1. WELL Lp/RMON; r (' JI
CITY "KtA.the✓'i4YQ TO 11 COUNTY gvittc riCYu
yree&fuI (raymm. —Fu:y )4s
(SOW Name, Numbers, Community, Subdivlslon, Lot No., Parma, Zip Code)
TOPOGRAPHIC /,L�,A,�NlD SETTING:
D Slope OValey V 'Iat ORidge ❑Other
(died( appropdatebt i •
LATITUDE _aZ.6Dt/Y
LONGITUDE, a° D. t.641 d
Latitude/longitude source: IA GPS OTopographic map
(location of we I must bo shown on shaded to this krm Inot ushg P)GStopo map and
May be in degrees,
minutes, seconds or
in a decimal tonal
4. WELL OWNER
OWNER'S NAME
STREET. ADDRESS
�t17 EMU" r1'DY
!!! City or Town
AreaAreacode • Phone number
(reeve )1 i) £ere✓a) Store
g7SI 1.15 64-.7�Ati
c- ai,ci
Zip Cede
State
5. WELL DETAILS: �� /
a. TOTAL DEPTH: �j .,
b. DOES WELL REPLACE EXISTING WELL? YES p NO
o. WATER LEVEL Below Top of Casing: - So FT,
(Use '+'.If Above Top d Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Tap et casing fin ed at/or below land surface mtfy require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2_ METHOD OF TEST_
f. DISINFECTION: Type chlorine Amount aYa cagy
g. WATER ZONES (depth):
From To From To
From
From
B. CASING:
To From To
To From To
DrWeight
Thtccknessl
Frar_O Depth
/06 Ft. SDR21 PVC
From To Ft
From To .Ft
7. GROUT: Depth Material
From 0 To 20 Ft Sackrete
From To FL
From . To Ft
Method
Hand
8. SCREEN: Depth Diameter Slot Size .Material
Front_ To Ft._In. In.
From To Ft In. In.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth She Matar d
From - Tq Ft.
From To Ft
Fran____To Ft
10. DRIWNG LOG
From .To.
0• IOD
100 . 905
Formation D sedption
Ally .5.trtd1 j ravel
dated rpe1G ,
JUN Ora 2006 •
11. REMARKS:
u-.7
N
1 DO HEREBY CERTIFYM T7HIS WELL WAS CONSTRUCTED NACCORDNICE WIN
HA NCAC 20. WELL CONSTRUCTION STANDARDS, AND 111ATACOPY WOO
RECORD MS BEEN PROVIDEDTOTHE WELL OWNER.
ti &L* L. c r9 -06
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30days. 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 3 2 6 97 6
North Caroline Departnent of Environment and Natural Resources- Dlvllon of Water Quality
WELL CONTRACTOR CERTIFICATION 0 21 3 8 '
1. WELL CONTRACTOR:
James W. Camp
Well Conhaeta.(Individual) Flame
City a Tam State
( 828>_ 453-7322
Area code• phone number
2. WELL INFORMATION:
SITE WELL ID 00f applicable)
Camp's Well & Puma Co. Inc_
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429.
Ellenboro NC 280400
ZCollie
STATE WELL PERMIT001appOubb)
DWQ a OTHER PERMIT gat applicable)
WELL USE(Cheolt Applicable Sac): Residential Water Supply iv(
DATE DRILLED 4- 2 I- D h
TIME COMPLETED I lAM CI PM
3. WELL LOCATION:
, PtlN Y� id
CITY: ,Y>o5�lc COUNTY
Lot 1'16 ye I�iI.Jfok, fait r, Cods)
(SOaN Nams. Numbs!. ..
�T/p POGRAPHIC/LAND SETTING:
',Slope Maley OFlat ORIdge ❑Other
(shed: eppropdahboa)
LATITUDE _a_i-2 5. I gco
LONGITUDE LL 5-0,. (Al
TatitUdcfongitude source: IyvPS OTopographic map
�
shown
tchedtothisform/nous'g PS)GStopomapand
OWNERS NAME .Del Greco fist
STREET ADDRESS Pp g° X 3 '
Bos`i-rc C. :�So)�
City a Torn State Zip Cede
Area wde- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: j 1�---
b. DOES WELL REPLACE EXISTING WELL? YESp NOA
c. WATER LEVEL BelowTop of Casing: U 0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING 1S 1 FT• Move Land Sudan*
'Top of casing terminated al/or balm late stelaoe may owls"
a variance in accordance with 1SA NCAC 2C .0115.
e. YIELD(gpm): METHOD OF TEST al Y
Maybe Indew n.
Sato, seconds a
in a deebml format
WELL OWNER
4.
t DISINFECTION: Type chlorine Amount ) cat
g. WATER ZONES (depth): From_ To
From To 1 R
From To From To .--
From To From _ To
6. CASING:
jeer Thlbla*sel
Fra0n DToh xg Ft. b# Mill mPVC
Fran To Ft
From To Ft
7. GROUT: Depth
From 0 To 20
From To
Frog_, To
Material
Ft. Sackrete
Ft
Ft.
Method
Hand
S. SCREEN: Depth Diameter slot Size .Material
From To Ft_In. __ h.
Fran__ To Ft. In. __ In.
From To FL In. ____ h.
S. SAND/GRAVEL PACK: Size Matslal
Depth
FT_To Ft,
Fran To Ft.•
Fran..` To Ft,
10. DRILLING LOG
From To .
. 0 • a
g. alo
•
Formation Dggscriptbn
GI A)f t 5 d. rv11 G Tad e.
[2cnsol;dated rock
a. o
� n
.{li? n 2006 n
• ' L0 n-, f"*'I
OC3
11. REMARKS:
100 HEREBY CERTIFYTHATTHS WELL WAS OONSIRUCTEDNACCORDANCE Wrm
A NCJ
JHRE O
2G.AS WELL
BECONSTRUCTIONCONSTRUCTION�PROVIDED STTTANDS,OWNER.
RDMD R T:UTACOPY PE THIS •
RECORD
SAT F CERTIFIEDWELI_'CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to 1617 Mali Service Center — Raleigh, NC 27699-1617 Division of Water Quality
al Phone No. (9 9) 733 i 6 ext 68.Bon Mgt,
Informa
Form GW-la
Rev. 7105

• RESIDENTIAL WELL CONSTRU.CITONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38'
L DISINFECTION:Type clllorine Amount 1 Getp
1. WELL CONTRACTOR:
James W. Camp
Wel Contractor.(IndMduaq Name
Camp 's Well & PumD Co. Tnr
Well Contractor Cornpan9.Ntene
STREET ADDRESS P O BOX
Ellenboro NC
429
28040
City orTo.vn ' Stale 1I ode
e
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 60f soollabk) •
STATE WELLPERMRlQI.P able)
DWQ or OTHER PERMIT 8(t applicable)
WELL USE (Check Applicable Box: Residential Water Supply
gel
- ao -D4
DATE DRILLED
TIMECOMPLETED I AM 0 PM (Q"
]. WELL LOCATION: iI y� �(`
CITY: ae✓ ✓JPh COUNTY RIftiteYTtVA
)4popk f Dew; it °Idols Rd.
(Sent Naaei, NumMts, Community. Subdhlsbn. I.d No., Porcelain code)
TO OGRAPHIC / LAND SETTING:
lope OVaaey rifled DRldge CIOther
(chair aPP 0 �aS
LATITUDE _a_
LONGITUDE I J_ ,SG' • D5.'Z
Latitude/1ongiWde source: MdPS °Topographic map
(bcalbn of well must be sham on a USGS topo map and
attached to this faro Snot using GPS)
4. WELL OWNER
el'
OWNER'S NAME I���C"1�u�
STREETSS r j+cK C- G au 131
city or Tam State ZIP Cade
Ar � Pharr* number
6. WELL DETAILS: r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?YES CI NO,
?
C. WATER LEVEL Belo/Top d Casing: J S FT
(Use'+• ITAbove Top d Casing)
d. TOP OF CASINO IS 1 FT. Above Land Surfs*
*Top d acing tarmBia ed ate belay land surface spy require
a variance 01 accordance wdh 15A NCAC 2C .0116.
e. YIELD(gpm):METHOD OFTEST Q%(
May be adegrea,
minutes, seconds or
in a decimal format
g. WATER ZONES Myth):
Fran To veh O
Fran To
From To
6. CASINO: �. Thickness/
'Fran 0 Depth D /DOFt b* SD_21 mit Weight PVC
From To Ft
From
From,
From
326975
To
To
To
Fran To
7. GROUT: Depth
Fran( L To 20
Frarj_ To
Fran, To
8. SCREEN: Depth
Fran To
Fran To
Fran To
P. $ANDIGRAVEL PACK: Depth Sim Material
Fran ' To Ft.
Ft.
Material Method
Ft Sackrete Hand
Ft.
Ft.
Diameter Slot Styx .Material
FL —lit. _._ In.
Ft. In. __ in.
Ft. In. In.
Frain To Ft
From To Ft.
10. DRILLING WO
From •To.
0' ID
Fomlatbn Depuiptbn
Dad Set
iD17 45, • roit.so',dated ✓ocic
119N !d<, Wifh
11. REMARKS:
y sin
_c F•i•i
100 HEREBY CERTIFY TNATTNe WELL WAS CONSTRUCTED!' ACCORDANCE WIN
15A
1 NCAC
20. BEEN p N ThA TNNSWEµ STANDARDS,
AN THATACOPY OE TIES
RECORD
tA) C FDA
' EIA: O
4r3�p7U F CERTIFIEDNTRACTOR GATE
vJames W. Camp•
PRINTED OFE PERSON CONSTRUCTING THE WELL
Subit the oriinal to with n,30. days.
1617mMall Smilee Center- Raleigh, NC 27 99-1617 Divialon of Water Quality hone No. (9 9) 733A0 5 ext 568. . Mgt„
Form GW-la
Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Wed Contractor (individual) Name
Camp's Well & Rump Co,. Inc_
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town • State
( 828)_ 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#Or'pen eN°)
STATE WELL PERMIT#(sappbcable)
DWQ or OTHER PERMIT #(a applicable)
WELL USE (Check Applf le Box): Residential Water Supply lg
DATE DRILLED 6 - D /o �/
TIME COMPLETED AM 0 PM IV
Zip Code
3. WELL LOC,(Lail eY-Ie Ya+01+ COUNTY IA-1 teY'tm YQ
CTIY: �,fr��// rrt
Lot" 23 g k Rn-k
(Street Name, Nunn. unity, Subdivision, Lot No, Parcel .zip Code)
'STOPOGRAPHIC /LAND SETTING:
Iope OVafey O)7at ORIdge ❑Other
(cMdc appropdatebox)
LATITUDE Spp L!° a4I23. 431 1�^,
LONGrTUDE,g ° 64. I c')
Latitude/longitude source: erdPS oTopograpbic map
(boation
ust he shooffinoon GG U GS topo map and
attached this
4. WELL OWNER
OWNER'S NAME ke5l e. k/a I'1e1�5
STREET ADDRESS P D Box 541
l c�lie LAre NI (-
City or Town State Zip Code
May be. N
minutes, seconds or
in a decimal @nett
Area code Phone number
6. WELL DETAILS: .�� tJ
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES (7 NO 0
c. WATER LEVEL Below Top of Casing: go FT.
(Use '+'B Above Top d Casing)
d. TOP OF CASING 1S 1 FT. Above Lead Surface'
'Top d casing terminated aVor below land surface may revive
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a.O METHOD OF TE$T Q 1 r
f. DISINFECTION: Type chlorine Amount g aids
g. WATER ZONES (depth):
From To 5 D 0
From To
From To
From To
From To
From To
6. CASING: Thickness)
D�a�neter We�M 11 tit'
From 0 •Toh�0 Ft 6# , SDR21 'PVC
From_To Ft
From To -Ft
7. GROUT: Depth Material
From, 0 To 20 Ft Sackrete
From_ To Ft
From To Ft.
Method
Hand
a. SCREEN: Depth Diameter Slot Size .Material
From To Ft. in. In.
From To Ft. In. In.
Fran To Ft In. in.
9. SAND/GRAVEL PACK:
Depth Sim Material
From Tin_ Ft
From To Ft,
From To______ Ft
10. DRILLING LOG
From .To
0' lob
Formation Descdptbn
clay
I
0
ID-3 585 /.vnsoi'Aated VcS1C
0
m
Its
—C r
_ DYE
to con
37 <
JUN O q 2006
11. REMARKS:
r-
1 DO HERESY CERTIFY THAT T IS WELL WAS 009STRUCTED N ACCORDANCE WflH
MA teed
ee BEEN
2C, WELL PROVIDED CONSTRUCTIONS TION STANDARDS,
DARWELL RD END THATACOPY OF VS •
• RECORD HAS
T ;TDREO ` C1um-P BOG
SI RE OF CER IFIEDWELLC 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: InforatIon Mgt.,
1617 Mall 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. Camp
Well C.ontractor.(IndMdual) Name
Camp 's Well & Pump Co. inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX
Ellenboro NC 28040
City a Tam State Code
( 828 - 45�322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID CV appllesble)
STATE WELL PERMIT/RV appaeabte)
DWQ or OTHER PERMIT W(tt appflcable)
WELL USE (Cheek Applicable Box): Residential Water supply
DATE DRILLED —/
TIME COMPLETEDT--- AMC `-`�',��-(y, J. WELL LOCATIO!: (Y iv COUNTY ga I f`ey�wol
CITY: w e 0(
429
Zip
e3p7o U6 ft- 't
(Street Name. Numbers. Community, Subdhlslon. Lot No.. PercetMp Code)
TO OGRAPHIC / LAND SETTING:
tope DValsy anal 0Ridge ID Other
(cheek appropdsiebag
•
LATITUDE
LONGITUDESL
Latitude/longitude source: 'GPS oTopogaphic map
(location of we/ must be shown on a USGS topo map and
attached to fhb fame tnot ushg GPS)
IMsy be. In degrees.
•
aiartn, seconds cc
in a decimal format
/
4. WELL OWNER +
OWNER S NAME IVA �-)Vtill
c aR131
State5
) Zip Code
ST ADDR S.
4Ec (er'kV
City or Tam
Area code Phone number
5. WELL DETAILS: [� n
e. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NO
tit
C. WATER LEVEL Below Top el Casing FT'
(Use '9If Above Top el Casing)
d. TOP OF CASING IS 1 FT. Above Lend Su ear
'Top d easing terminated et/or below land surface may require
overlent* In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
Fran
From
Fran
6. CASING:
RESIDENTIAL WELL coNSTRUC11oNRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
2138
2697
f. DISINFECTION:TVP. Chlorine Amount 17a cu_i
g. WATER ZONES (depth):
To From To
Tor From ToT_
To From To
r Thickness/
From 0 -To 0 Ft. Dbt SD MaterialN21 PVC
Fran To Ft
From To .Ft
7. oROUr: Depth Materiel Method
From 0 To 20 Ft Sackrete Hand
From To Ft
From _ _a_To FL
8. SCREEN: Depth
Fran To
From T?
From To
9. SANDIGRAVEL PACK: Depth Size Material
Fri" Ttl__ FL
From To Ft.
From To Ft._ _
10. DRIWNG LOG
From 0.
. 0 •
Diameter - Slot Size _Material
Ft. In. __ In.
Ft. In. __ In.
Ft In. _ In.
•
.b to
.C.Un ��-rD /'k-� �n
ci*'h 9Pal
!� �F 2006
11. REMARKS:
0
.o r
r
I DOIEREBY CERTIFY THAT THIS WELL WAS CONSrRUCiED NACCORDANCE WIN
16A / CAC20, WELL CONSTRUCTION STANDARDS, AND THATACOPT OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SI TURE OF CERTIFIED WELL CONT CTOR BATE
ames W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mall Seroriinal to vi ee Center the
Raleigh, NC 276994617 Quality
Phonewithin
No. (9 9) 733 7015 ext 568.gon Mgt.,
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
James W
Wee Contractor (Individual) Name
Camp' s Well & Pl1mn f o TnY _
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro
City cc Town She
(828} 45 3-7322—
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 8Nap0ecabie) '
STATE WELL PERMITS(, applicable)
DWQ or OTHER PERMIT Sot applicable)
WELL USE (Check Applicable Bo:Q: Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED� ay0 AMO PM W
3. WELL LOCATIO I: •
CITY: e d e Yl COUNTY 0l F r V
(Sleet Norma, N_umbers,ommunity. SubdlNslen:Ld Na, Perot Code)
TO OGRAPHIC / LAND SETTING:
ic:e DValley OFtat ORklge OOther
Oho* appmpriarebet)
LATTTUDE io
LONGITUDE a.` 21.1LS
Latitude/longitude source: O GPS OTopogaphie map
(loatation of tached dpel form not shown must be oo a U
GS Woo map and
thi
ESIDENTIAL WELL CONSTRUCTIONRECORD
North Carolina Department of Envbonment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION g 21 3 8
280
Zip
ode
May be in degrees,
minutes, seconds et
in a dedmal Ramat
4. WELL OWNER
OWNER'S NAME
STR ET ADDRES
.wtlley - — Zip Code
City a Tarn She
A Phone number
NC
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NOO
c. WATER LEVEL Below Top d Casing:
(Use a If Above Top d Casing)
d. TOP OF CASING IS 1 _ FT. Above Land Surface*
'Top d casing temihtated et/or belay land surface may roMuirc
a variance In au ce Wlth 15A NCAC 2C .0118. e. YIELD (gpm): X. -- METHOD OF TEST at
7o S
�26966
1. DISINFECTION: Type chlor ine Amount o& caps
g. WATER ZONES �(de�p�t��hhp)�:__ ������
From Tow�/s^n Amoco To
Fran To From To
From
To From To
6. CASING: Depth a
D
'Fran 0 To -
From To
From To
7. GROUT: Depth
From_2_, To 20
From To
Fran_•_._. To
�ynet Thickness/
Material
Ft 6# SDRk21 PVC
Ft
Ft
Material Method
Ft Sackrete Hand
Ft
FL
8. SCREEN: Depth Diameter Slot Size .Material
Fran To Ft. In. In.
From To Ft. in. .__ In.
From To Ft In. __ kt
9. SANDIGRAVEL PACK: Depth Size MtledA
From To Ft
From To Ft.
From To Ft.
10. DRILLING LOG
From .T .
O D
� Sri
!V 'n.
_
c
1-- 006
11. REMARKS:
0
1 DO HERBY CERTIFY TWINS WELL WAS SSR57UC7E8 N ACCORDANCE wad
16A NCAC 20, WELL CONSIRUG7ION STANDARDS, AND 1)WACOPY OE TNIB
•
RECORD HAS BEEN CROWDED TOSS WELL OWNER.
6r1)9 G6
S TORE F CERTIFIED W LCCONTRACTOR DATE
James W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mall Seroriinal to the Division of Water vicge Center- Raleigh, NC 27 991617 Quality Ph ne No. (9 9) 733 7Attn: ext 568.gon Mgt.,
Form GW-la
Rev. 7105

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM
Page 12 of 12
326
STATE WELL CONSTRUCTION PERMIT #
(if applicable)
1. WELL USE (Check Applicable Box): Residential
Recovery ❑ Heat Pump Water Injection 0
2. WELL LOCATION:
Nearest town: HARRIS County RUTHERFORD
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
TT CERTIFICATION # 2584
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCO.. _---
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. NE # [phone]
ASSOCIATED WQ PERMIT #
(if applicable)
Municipal 0 Industrial 0 Agricultural ❑
Other ❑ If Other, List Use:
358 CREEK RD
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
3. OWNER RANDY GREGORY
ADDRESS 358 CREEK RD
(Street or Route No.)
RUTHERFORDTON
city er Town
828-863-4677
NC
State
Area Code - Phone Number
4. DATE DRILLED 5/11/06
28139
Zip Code
5. TOTAL DEPTH 210
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
El
7. STATIC WATER LEVEL Below Top of Casing: 30 FT
(Ilse "a^ 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 vanance in
accordance with 15A NCAC 2C.0118
9 YIELD (ppm): 40 METHOD OF TEST ARDM
10. WATER ZONES (depth): 210
it DISINFECTION: TYPE HYPOCHLORITE Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
To 73 Ft 61/4" SDR21 PVC
Monitoring 0
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley 3 Flat
Latitude/Longitude of well location
35 12.360 / 81.57.725
(degrees/minutes/seconds)
Latitude4ongitude source: El GPS 0 Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 68 Clay
68
210 Consolidated Rock
10 Oz
From 0
13. GROUT:
Depth
From 0 To
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
NA To
From
16. REMARKS:
Material Method
20 Ft GRAVEL MIX GRAVITY
Diameter
Ft 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.
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.
5/12/03
SIGNATURE OF PERSON CONSTRUCTING THE WELL Dale
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
O

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 Time: 8:58:08 PM Page 8 of 12
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]
ONE WQ PERMIT #
STATE WELL CONSTRUCTION PERMIT # ASSO(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box) : Residential ® Municipal 0 Industrial 0 Agricultural 0 Monitoring
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION: Topographic/Land setting
Nearest town: LAKE LURE County RUTHERFORD ❑ Ridge 0 Slope ❑ Valley El Flat
LOT 29 WOLF LANE , RIVERBEND SUB Latitude/Longitude of well location
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
35.25.019/ 82.10048
3. OWNER NEAL TOWNSEND (degrees/minutes/seconds)
ADDRESS 456 NC 210 E. Latitude/longitude source: ® GPS ❑ Topographic map
(Street or Rome No.) DEPTH DRILLING LOG
HARRELLS NC 28444 From To Formation Description
City or Town State Zip Code 0 35 Clay
910-990-7565
Area Code - Phone Number
4. DATE DRILLED 4/27/06
5. TOTAL DEPTH 440
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 85 FT.
(use "+" If Above Top of Cuing)
8. TOP OF CASING 1S 2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gran): 5 METHOD OF TEST ARDM
la. WATER ZONES (depth): 415
DISINFECTION: TYPE HYPOCHLORITE Amount 20
12. CASING:
Depth Diameter
From 0 To 40 FL 61/4"
13. GROUT:
Depth
From 0 To
14. SCREEN
From
Depth
NA To
35
440 Consolidated Rock
Wall Thickness
or Weight/Ft. Material
SDR 21 PVC
oz LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Material Method
20 FL GRAVEL MIX GRAVITY
15. SAND/GRAVEL PACK:
Depth
NA To
From
Diameter
FL in.
Ft,
Slot Size Material
in.
Size Material
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
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.
GW-1 REV, 07/2001.I
JUN1 0 6 2006
3 2 6 8 E /

From: Scott Gantt To: Stephenie Wilson
Date: 5/14/2006 lime: 8:58:08 PM Page 6 of 12
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - GroCoundwater aCATection
ON # 2584
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # (704) NE WQ 4ERMIT77
STATE WELL CONSTRUCTION PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ® Municipal 0 Industrial 0 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE
LOT 227 OLD CROW RD, RIVERBEND SUB
County RUTHERFORD
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
3. OWNER JOHNNY WATKINS
ADDRESS 1001 CAMP HILL RD
(Street or Route No.)
MILL SPRING NC
City or Town State
828-625-1311
Area Code - Phone Number
4_DATE DRILLED 4/18/06
5. TOTAL DEPTH 240
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO
120 IT.
(Use +" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of easing terminated at/or below land surface requires a vaiance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 5 METHOD OF TEST ARDM
1o. WATER ZONES (depth): 220
It. DISINFECTION: TYPE HYPOCHLORITE Amount 6
12, CASING:
Depth
From 0 To 60
13. GROUT:
Depth
From 0 To
14. SCREEN
Wall Thickness
Diameter or Weight/Ft Material
Ft 61/4" SDR21 PVC
Zip Code
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley Flat
Latitude/Longitude of well location
35.26.378 / 82.10.830
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 52 Clay
52
240 Consolidated Rock
oz LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Material Method
20 Ft. GRAVEL MIX GRAVITY
Depth Diameter
From NA To Ft in.
15. SAND/GRAVEL PACK:
Depth
From NA To Ft,
16. REMARKS:
Slot Size Material
in.
Size Material
in 0 ; LUUb
ZG
�.i
0
O
U
m
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.
5/1/06
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.
ei 6 8
GW-1 REV. 07/2001

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STAR will OOIIBIAuc11011
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911 Noy. Business 74
Bostic, NC 28013
828.247-177S
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was. a 13S
WELL CONSTRUCTION RECORD
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UMW WILL CONSTRINW10AMINIM
ASV WELL DRIWNG
AND PUMP SERVICE, PC
911 Hwy. Business 74
Bootie, NC 28013
828-247-1773
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JUN 06 2006

From: Scott Gantt To: Stephenie Wilson
Date: 5114/2006 Time: 8:58:08 PM
Page 3 of 12
326882 Av u
2. WELL LOCATION:
Nearest town: RUTHERFORDTON
275 ROY GOINGS RD
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - GrCoRTIFaCATeON # 2554
oundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC.PHOONE # [phone]
WQ PERMIT #
STATE WELL CONSTRUCTION PERMIT # ASSOCIATEDf applicabl
(if applicable) (iA icable) ❑
Municipal ❑ Industrial ❑ gF
1. Recovery
USE (Check Applicable t ox) : a Residentialnje® Otherp❑ If Other, List Use'.
Recovery ❑ Heat Pump Water Injection 0
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.26.178 / 81.55.095
(degrees/minutes/seconds)
Latitude/longitude source: ® GPS ❑ Topographic map
DRILLING LOG
Formation Description
County RUTHERFORD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER JOHN MEADOR
ADDRESS 309 BARTLEY ST
(Saco or Route No.)
SPINDALE
City or Town
828-4403217
NC
State
Area Code - Phone Number
4. DATE DRILLED 4/7/06
5. TOTAL DEPTH 220
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 55 FT
(Use "+" If Above Top of Casing)
S. TOP OF CASING 1S 2 FT. Above Land Surfaces
'Top of casing terminated at/or below land surface regmes a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 5 METHOD OF TEST ARDM
10. WATER ZONES (depth): 120 200
28160
Zip Code
DEPTH
From To
0 105 Clay
Monitoring 0
105 220 Consolidated Rock
11. DISINFECTION: TYPE HYPOCHLORITE Amount 8
12. CASING:
Depth
From 0 To 114
13. GROUT:
Diameter
FL 61/4"
Depth
From 0 To 20 Ft.
l4. SCREEN
Depth
From NA To
1s. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Wall Thickness
or Weight/FL 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 m miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
LAN
o �:
J
2055
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.
5/1/06
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.
A
—t
J
0
0
v+
IGW-1 REV. 07/2001
rc
O
,`1 3
t?l
>0
—irn
rT1
O Frl
F

From: Scott Gantt To: Stephenle Wilson
Date: 5i14/2006 Time: 8:58:08 PM
Page 2 of 12
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater CERTIFICATIONSection
0 2584
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS,
INC.PHONE
ERMIT77
STATE WELL CONSTRUCTION PERMIT 0 f ASSOCIATEDapplicable)
WQ 4
(if applicable) ❑ Agricultural ❑ Monitoring ❑
1. WELL USE (Check Applicable Box) : Residential ❑ Municipal ❑ Industrial
Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use:
Topographic/Land setting
2. WELL LOCATION: e Sloe ❑ Valley 0 Flat
Nearest town Rid
LAKE LURE County RUTHERFORD ❑ g ❑ P
Latitude/Longitude of well location
LOT 33 SWEET BRIAR ST, RIVERBEND SUB 35 og 790 / 82.07.074
(Street Name, Numbers, Community, Subdivision LotNo,. Zip Code) (degrees/minutes/seconds)
3. OWNER RIDGELINE DEVELOPMENT CORP.
ADDRESS 112 COCOPLUM CIRCLE
(Street or Route No.)
ROYAL PALM BEACH
City or Town
561-798-2729
Area Code - Phone Number
4. DATE DRILLED 4/4/06
FL
State
33411
Zip Code
Latitude/longitude source: ❑ GPS 0 Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 75 Clay
75
3 2 6 8 1
165 Consolidated Rock
5. TOTAL DEPTH 165
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
El
7. STATIC WATER LEVEL Below Top of Casing: 65 FT
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 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): 15 METHOD OF TEST ARDM
lo. WATER ZONES (depth): 90 155
u. DISINFECTION: TYPE HYPOCHLORITE Amount 5
oz LOCATION SKETCH
12. CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or W eight/Ft. Material twohSt t ers aRoand d�County � . Include the road
From 0 To 82 FL 61/4" SDR 21 PVC
l3. GROUT:
From 0
Depth Material Method
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:
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.
5/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Dale
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.
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1GW-1 REV. 07/2001

• Uiviche el Water (l,rility - Greundwmer fir-1i,.i�l Y 1
(forth Carolina • OPparimenl of 6wh ommerl nod IJnlur al I IPanw Cn : SkQVL cO rcui+- _ 2 6 6 w
WELL CONSTRUCTION RECORD (04
WELL CONTRAC O11OW nl�ir c1l�ltieil can
j `
SIP]E WELLCONSRIUC1TOri PERMilll: _ __-
1636 Mail Service Center • Ralelgh, N.C. 27699-1636 Phone [phone]
1. WELL USE (Check Applicable nos):Resld0ntinl _i Municipal hokum Agticullulal11
Recovery ❑ Heal Pump Water Injection [J Other ❑ II 011hl, LI•a We:
2. WELL LOCATION: (Show sketch of (Ire location below) ��1 �Q V t0 j iUl�
Nearest Town: ryhrfrS a " ("uinly i
11 c,,r r c 1?1 a.t^\ Ci r -
(noad Name and numbers. Catmin fly. or Subdivision and for Ito.)
3. OWNER --1 G' 144j i e cci, e-ot
r`•5
Address /�� X 2-D : 7 Q
/%!`% (� jsl ei osoula Tle.l /
Ca z?3
City or Town Stale 71p Curio
4. DATE DRILLED 5" I(-aQ
5. TOTAL DEPTH 1-10 o
6. CUTTINGS COLLECTED YES (_ I N(.ij
7. DOES WELL REPLACE EXISTING WELT.? YES Ili 1401 j
8. STATIC WATER LEVEL Below Top al Casing: _5 S rr.
` (Use -4- II Ahovo Inn or Canino)
9. TOP OF CASING IS -4-7/ rr. Above Land Surface*
'Top of orally terminated .Vor below lend nudacn rnquire• n violence In accor-
dance with ISA NCAC 2C .0110 r
10. YIELD (gpm): fa METHOD OF TEST A 1 r
11. WATER ZONES (depth): 490 -a00 - —
111111 OHM LOO
rrnui ro
Dr ao/
40 1 y,o,
gat -
- a'
Lk) 4011
Monitoring J
12. CHLORINATION: Type LIA 1•'1' Amount 4 •f Off 11 additional space h needed 117n bn k of born
13. CASING:
Depth r �)
From + \ To
From To rt
From To FI
14. GROUT:
From 5
Woe 1M^4nr:9
Dkyrietor er WnighVrl. Almeria!
Vt
Depth Maierl?*- Pif rod
To 6�--� n �CL10�Jn
From To Pt.
15. SCREEN:
Flom:$:
rt in in.
From rl _ In. — In
From To Ft In
16. SAND/GRAVEL PACK:
Mpg'
Frorn--\ To PI
Frorn
17. REMARKS:
I DO HEREBY GEM ice -HAT ruts wrt I VIA corm -mom) III ACC(IRUAI ICE WIII I ISA MAC 2C. v.EI
CONSTRUCTION STANDARDS, ANU 11IAI A COPY OF 1ITS UECORIaHAS DEED- TIOVIDED 101I IE 17rft OWNED
Diameter Slut Slza Materiel
Size. Malotlal
LCIGAI is 11 ,rH_i i11 I_
(Show direraion find distance how nl Inns! Iv.n Sint?
Hondo, or oilier reap releroire
fictrri S
—v k
4 h.
ewe`
To PI
F
s
1
FOR OFFICE USE ONLY
Ouad No:
!Indnl rn.
slctim unE or rE FIS0I1 COI1SI1uuc tiro TIIF- Wrl. 1.
Submit e'luinal Io Division of Water 071011Y. Cruandwaler Seclie° Within 30 day^
DATE
G 1 I I IE':. 17,77

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 #:
326126
1. WELL USE (Check Applicable Box): 0 Residential ❑ Municipal ❑ Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: LAKE LURE County: RUTH
OLD MILL RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER JAN POLLACK
Address OLD MILL RD.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
4. DATE DRILLED 04/19/06
5. TOTAL DEPTH 185
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ 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): 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 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 distance from at least two State
Roads, or other reference points)
HWY. #64/74 FROM RUTHERFORDTON. RIGHT ON BILL'S
CREEK RD. RIGHT ON OLD MILL RD. GO TO END OE
PAVEMENT. TAKE LEFT FORK STAY STRAIGHT ItTNEW
GRAVEL DRIVE ON RIGHT. CI
-n77
rl
>0
G r?
N Fl
r0
Cr,
_L-
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.
-Lug,. &TI �
SIGNA OF PERS N CONSTRUCTIN THE WELL DATE
Subrgit�original to Division of Water Quality, Groundwater Section within 30 days
viv jU tuJ
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 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: BOSTIC County: RUTH
449 PUZZLE CREEK RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER SHIRLEY JONES
Address 449 PUZZLE CREEK RD.
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
4. DATE DRILLED 04/18/06
5. TOTAL DEPTH 145
6. CUTTING COI.I.FCTED ❑ YES NO
7. DOES WELL REPLACE EXISTING WFI 1'7 ® YES 0 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 I5A NCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3
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 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
326125
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
FROM FOREST CITY GO DOWN HWY. BUS. 74 E. RIGHT ON
PUZZLE CREEK RD. 1-1/2 MILE ON LEFT.
0
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.
ATUR-. 0 ERSON O S CTING THE WELL DATE
Submit orig to Division of Water Quality, Grondwater Section within 30 days
GW-1 REV. 12/99

326119
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 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHLRFORDTON
PARRIS RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: NORRIS HILL
Address PARRIS RD.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
Mg) — 287-3713
Area Code Phone number
4. DATE DRILLED 04/11/06
5. TOTAL DEPTH: 80
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 STEEL TAPE
10. WATER ZONES (depth):
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 __,__ Ft
From _ To _ Ft _
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To _ Ft
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ From _ To _ Ft _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 60 To 80 Ft 78M GRAVEL
From To Ft
County RUTH
Topographic/Land setting
❑ Ridge 0 Slope 0 Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degreeshninutes/seronds)
Latitude/longitude source: ❑ 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 GILKEY TO UP PAINTERS GAP RD.
LEFT ON PINEYKNOB RD. LEFT ON PARRRERD.
GO 1 MILE. (584 ON BOX ON LEFT)
0
3 Yid
sr
>n
co rnrri
N Qri
o F0
a
r—
U 06
reJ .;C,`„
.. Lie
16. REMARKS -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS CTION STANDARDS, AND THAT A COPY OF TM RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�a '& 4'�- a LZ /,'- 6 6
GNA OF P$R INS UC 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

326117
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 ig Municipal/Public ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON
104 SEASON'S DR
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MIKE & DIANA BROWN
Address 104 SEASON'S DR
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
8( 28) — 245-1335
Area Code Phone number
4. DATE DRILLED 03/07/06
5. TOTAL DEPTH: 63
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 51 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-112 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): 12 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CBLORYTE Amount 5_52
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 63 Ft 24" CEMENT
From To Ft_ _
From To _ Ft
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To ____ Ft
14.SCREEN: Depth Diameter Slot Size Material
From To_Ft_ is _ in.
From ToFt. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 51 To 63 Ft 78M GRAVEL
From ____To ____Ft ____
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 mad
number and common names
FROM SILILOH GO DOWN CLEGHORN MILL
RD. LEFT ON EPPLEY RD. LEFT ON SEASON'S DR
1n HOUSE ON LEFT. <
0
z -n-✓
>co CD r -
N C rr
0
r
16. REMARKS:
I DO HEREBY OERTIFY THAT THIS WELL WAS CONSTRUC 1'hD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS$UCTIO(N STANDARDS, AND THAT A COPY OF THIS ORD HAS BEEN PROVIDED TO THE WELL OWNER
SId� �
GNATURE 0 PERSOJQUNSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center — Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

Drth Carolina — DX.pmtment 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 RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
WELL USE (Check Applicable Box): N Residential ❑ Municipal
0 Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
earest Town: RUTHERFORDTON County: RUTH
IEADOWS RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER LESLIE HIGGINS
.ddress MEADOWS RD.
itreet or Route No.)
UTHERFORDTON NC 28139
'ity or Town State Zip Carle. DATE DRILLED 06/30/06
. TOTAL DEPTH 345
. CUTTING COLLECIE"D ❑ YES ®NO
. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
. STATIC WA that 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 accor-
mce with 15A NCAC 2C.01I8
0. YIELD (gpm): 4 METHOD OF TEST: ARD
1. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 9
3. 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.
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
LOCATION SKETCH
(Show direction and distance from at least two State
Roark, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. LEr 1 ON
MAPLE CREEK RD. RT. ON STARVIEW RD. RT, ON
MEADOWS DR. 1ST LOT ON RT.
ca
C
L 7-1
r -
a' rn
-
N c r
O
m -
DO CERTIFY THAT THIS WELL WAS CONSTRUL 1ED IN ACCORDANCE WITH 15A NCAC 2C, WFJ.T �<
:ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
GNA OF PERSON ONSTRUCT1NG THE WE I DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

A&C WELL DRILLING
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•
RESIDENT AL WELL CONSTRUCTIONRECORD
North Carolina Department of Environment sad Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2138 '
twos CONTRACTOR:
James W. Camp
we Contractor (Individual) Name
Camp's Well & PUTRID Co. 7nr
Well Contractor CompanyName
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City a Town State - ap Cory
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID SOr appaeable) .
STATE WELL PERMR#(Bapplicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Cheek Applicable Bo): Residential Water Supply 0
DATE DRILLED f S le /
TIME COMPLETED 3 A AMP PMi�'
1. WELL LOCATION:
CRY: 01C Qp IAA COUNTYSi
(Shaft Name NuoUws, Canmunity, SnWBNsion _Lot No.. Parear tip Cods)
'STOPOGRAPHIC / LAND SETTING:
Icpe Malley oFlat ORldge ❑Other
(Wok sppropdstaba)
LATITUDE _, S 64'3 1.1
LONGITUDE g �° 10• otg2 I'd
Latitude/longitude source: 976PS DTopographic map
*am of wel must be shown on a USGS topo map and
attached to this tom l not ushg GPS)
4.WELLOWNER �. , ' 1
OWNER'S NAME ICi1Y1 WI (COX
STREET ADDRESS S CSprey 1..)0.J
G-6 KP l.tkry NC_
f l
May be in depea,
mywte%woods a
in ■ dalmal format
City orTavn State Zip Cede
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Lk f")
b. DOES WELL REPLACE EXISTING WELL? AYES 0 NO 0
c WATER LEVEL Below Top atCasing: 1. 2Q Ff,
(Use+•.S Above Top of Casing)
d. TOP OF CASING IS ' 1 . FT. Above Land Surface•
. 'Top of casing teenlmled ado below land soda* may requbs
a variance in aoeordance Wllh 15A NCAC 2C.0118.
e. YIELD (gpm): \ METHOD OF TEST 01 K
t DISINFECTION: Typo Chi Orine Amount i 3/4 car
g, WATER ZONES (depth):
From To From To
From_ To From To
From To From To
B. CASING: a�ne� TNCWbs/
From 0 I Ft Db# r All
Fran To Ft
From To .Ft_
7. GROUT: Depth Matedal Method
Fran 0 To 20 Ft Sackrete Hand
Ran To Ft
Front To Ft
S. SCREEN: Depth Diameter . Slot Size .Material
From To Ft.i jn. yr.
Fran To Ft in. ki.
From To Ft. In. In.
9. SAND)GRAVEL PACK:
Depth Size Material
Fran To Ft
From To Ft
Fran. .To Ft
10. DRILLING LOG
From ..To,
0• \1S
11. REMARKS:
Formation Description
0
r—
rV —.
0
I DO HEREBY CERTMHATTAS WELL WAS OONSIRUCIED NACCORDANCE WTIH
1a1NcAC 2C, WELL CONSTRUCTION STANDARDS, AIM MIA COPY GEMS •
RECORD HAS BEEN PROJIDEDTOTHE WELL OWNER.
0mIp up CA
SI6NATORE OF CERTIFIED WELL"CO RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within SO. days. Attn: lnfonnatfon Mgt.,
1617 Mall Sarvi* Center- Raleigh, NC 27699-1517 ' Phone No. (91917334015 ext 568.
Form GW-la
Rev. 7/D5

• RRSIDENTLAL wEIL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION A 213 8 '
1. WELL CONTRACTOR:
James W. Camp
Well Cantradar.(IndMdual) Name
Camp's Well & Pump Co. Inc -
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
E1lenboro NC 28040
City orTown • State -' Zip Code
(828} 453-7322
Area coda. Phone number
2. WELL INFORMATION:
SITE WELL ID do(applluble) •
STATE WELL PERMR#(Bapplkable)
DWQ or OTHER PERMIT #Qf applicable)
WELL USE (Check Applicable Bag: Residential Water Supply 0
DATE DRILLED 1• 1 . V
TIME COMPLETED ) 14 S
3. WELL LOCATION:
CITY: F(:\kt
(Sbts Numbers..Ccatmurg' ion,_LotN P
TOPOGRAPHIC / LAND SETTING:
o Slope takey °Flat °Ridge ['Other
Naar ePProPrib90
LATITUDE 30 0l�I]
•
LONGITUDE. CAI mci o!11 ��Q 1e
Latitude/longitude source: fp6PS °Topographic map
(Saban onset must be shown one USGS topo snap and
attached to thb form Inot usbg GPS)
4, WELL OWNER
OWNER'S NAME (5Ntr. �nakfkA
STREET ADDRESS 19 I y�-0. CI YtM Kr1
EIIPl.bcvV-b
Chy or Yam State Zip Cede
Area code- Phan number
AMdPM❑
GOUNTY_J__
itaW
Code)
•
May be le depsa,
minutes, *monde or
in a decimal treat
6. WELL DETAILS: �^
a. TOTAL DEPTH: VA J
b. DOES WELL REPLACE EXISTING WELL? YES b" NO 0
c. WATER LEVEL Beim Top d Casing: • e2 0 FT,
(Use if Above Top dCasing)
d. TOP OF CASING 19 1 . FT. Above Land Surface
. 'Top dossing terminated at/Or belay land surface may require
a variance In accadswe WRh 15A NCAC 2C .0116.
e. YIELD (gpm): I (iv'i- METHOD OF TEST Q) r..
I. DISINFECTION: Type chlorine Amount / ca%
g. WATER ZONES (depth):
From To • From To
Fran To From _ To
Ran To Fran
6. CASING:
Fran 0 DepthTooyJ Ft ter
From To Ft
From To .Ft
To
TNcbase/
Weight MMedd
SDR21 _PVC
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
Fran To Ft.
From To Ft.
a. SCREEN: Depth
From_ To
From To
From To Ft.
Diameter Slot Size .Material
Ft In. In.
Ft in. In.
IR Ia.
9. SAND/GRAVEL PACK:
Depth Size Material
Fro n..__ To Ft.
Ran To Ft
From Tq Ft
10. DRILLING LQG
From To.
0' WrIs-
11. REMARKS:
Foronabon Description
r
N r_
c
I WHEREBY CERTIFY THM GS WELL WAS CONSTRUCTED NACCORDANCE WRH
IM1CAC2C, WELL CON5mUdnDN STANDARDS, AND RATACOPY oryI S.
RECORD HAS BEEN PROVIDED TOTHE WELLOWNER
RE F CERTIFIED WELL CTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submttthe original to the Division of Water Quality within 30.days. Attn: tntonnatlon Mgt,
1617 Mall Service Center — Raleigh, NC 27699-1617 ' Phone No. (9191733-7015 eat 568.
Fonn GW-1a
Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environmem end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
V Cf
1. WELL CONTRACTOR:
James W. Camp
Well Contract:.(IndMdual) Name
Camp's Well & Pump Co. Inc-..
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
City or Tam ' State ZIP bode
( 828)• 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID/Orappncable) •
STATE WELL PERMTURYapplicable)
DWI) or OTHER PERMIT Cif applicable)
WELL USE (Cheek Arable Bca): Resldenld Water Supply
DATE DRILLED I O - D%
TIME COMPLETED %O
� 2:0 AM�7 ,Psi
3.WELL
: LOCATION:
CITY: Iir COUNTY Path e "TOr rllf
Sa_winait Min'.- Lot )6
(Shoe Noma, Numbers. Community, SubdMsion, Lot No, ParcaLRlp Code)
(TOPOGRAPHIC! LAND SETTING:
Slope DVPIOY DFIat DRldpe CI Other
(chimes ppopd abox)
LATITUDE 1.° 5-10
LONGITUDES 1 ° 47• ri 37
Latitude/longitude soma: O GPS °Topographic map
(beatlon of welmust be shown one USGS topo map end
trod to the tom /not using GPS)
4. WEU. OWNER
OWNERS NAME
STREET ADDRESS
Ma r,o),A,
City aTam State Zip Code
Mry be b derma,
minutes, secmda or
in a decimal format
Xi i/Jilooet^ Pens±
13'7 itXusel Dr..
N c'rs�
Area code • Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES Q
e. WATER LEVEL Below Top dCasing: • , 0
(Use '+'.IAbate Tap d Casing)
d. TOP OF CASINO IS 1 . FT. Above Land Surfs*
. , Tap of casing temdnded aka below land surface may require
a variance In accordance wlfh 15A NCAC 2C .0118.
e. YIELD(ppm): (.0 METHOD OF TEST Q.1 f
N00
FT.
. t. DISINFECTION: Type chi orine Amount /4 r���j
g. WATER ZONES (depth):
From To • From To
From_ To From To
From To From To
6. CASING: Thickness/
From 0 Too ,16 FDepth /0 •Dt� SDR21 .PVC.
From To Ft.
Fran To .R.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft,
From To FL
B. SCREEN: Depth Diameter . Slot Sloe .Maeda!
Fraq_To FL M. YL
From_ To Ft In. h.
From _To FL In. In.
9. SANDIGRAVEL PACK:
Depth Slur Material
From ' TQ , FL
From To Ft
Frorn_ To Ft
10. DRILLING LOG
Fromg.
.0• ASS
at
5R ll�� �SI AM,X1
11. REMARKS:
CI _
-o
I W HEREBY Calif YMATINS WEU. WAS oa1smUCIED INACCORDANCE WTIH
16A NCAC 2C, WELL CONSTRUCTION STMIDAROS.A1 D TATA COPY QFTFNS •
RECORDHAS BEEN PROMDEATOTHE WELL OWNER
SI 9knla W ` LC NT
SI EOFC TIFlED�WELL'CONi
TACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: information Mgt,,
1617 Mall Service Center — Raleigh, NC 27699-1617 ' Phone No. [phone] eat 568.
Form GW-1a
Rev. 7106

d
•
RESIDENTIAL WELL CONSTRUCTION' RECORD
North Carolina Department of Environment and Natural Resources- Mahlon of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8 '
1. WELL CONTRACTOR:
James W. Camp
Wee CmtraGar.(Individual) Name
Camp's Well & Pump Cb. Inc.
Well contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tavn ' State - Zip bode
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL IDalit applicable) .
STATE WELL PERMIT#(9eppfabIe)
DWQ cr OTHER PERMIT #(B applicable)
WELL USE {Check Applicable Box): Rdsldenud Water Supply ID
DATE DRILLED .l .- I A - D U —
TIME COMPLETED AM (2/ PM O
3. WELL LOCATION:,,pp..__ (�
CITY: t}Lk1:J. COUNTY \ 1 Ay
(SfteNNanu, Numbers. Caiimwk. Su
TOPOGRAPHIC / LAND SETTING:
Slope DVaIey DFlat Midge ❑Other
Oh.rkaww Mt)
LATITUDE 3C lg \V) •
LONGITUDE_
Latiwdellotgitude source: GPS OTopograpbic trap
(bacon dwel must be shown on a USGS topo map and
attached to thb tone lnot ua➢rg GPS)
4.WELLOWNER
OWNERS NAME tfl�I /' I'�� /'-
STREET ADDRESS G+ 5Q m I1 r a- c-e
D,-wtw.td J3e&ck , EL 3 1'76
City or Tavn State ' Zip Cede
Area wale. Phone number
n:Let No.. Paroefellp Code)
May be m derma,
mlmna, aeoced, or
Inc dolmal format
5. WELL DETAILS:
a. TOTAL DEPTH: S
b. DOES WELL REPLACE EXISTING WELL? YES p NO 0
a WATER LEVEL Below Top dCasing '4U FT,
(Use W.B Above Top d Casing)
d. TOP OF CASINO IS • 1 . FT. Above Land Surface*
. 'Tap d casi g Wntated aver below land surface may require
a variance F accordance with 15A NCAC 2C .0118.
e. Yg3D(gpm): '\ METHOD OF TEST l &,..
f. DISINFECnoN: Type chlorine Amount
g. WATER ZONES (depth):
From To From To
Fran To
From To
6. CASINO: j�nete
From 0 Deppth' I o Ft. Db # r
From To Ft.
From To Ft
1 :�4 c u�g
From To .
Fran . To
.ThIccgkneni
Seiht Material
DR21 PVC
7. GROUT: Depth Material Method
From 0 To 20 Ft. Sackrete Hand
From To Ft.
Front„__ To Ft._
B. SCREEN: Depth Diameter . Slot Sire .Material
From To Ft. In. In.
From To Ft. In. In.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Front ' To Ft
From To Ft.
From To Ft
10. DRILIJNG LOG
From To . Fo tion
0 CIU S(y J°"(° RA
•
t, v - • L,.r )t. CA-tUt .
11. REMARKS:
m
0
I DO HEREBY GERM THAT TW¢ WELL WAS CONSTRUCTED NACCORDANCE WRH
154 NEC 70. WELLCONSTRUCTION STANDARDS, NOVATACCPYPEWS •
RECWIDHAS BEEN PROMDEDTOTNE WELL OWNER.
l Cam. ,1
6
SIG 0 CERTIFlEDIN CO RACTOR BATEE
antes 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 27689-1617 ' Phone No. (9191733-7015 ext 568.
Form GW-la
Rev.7/05

CilyaTavn Slate
( 828). 453-7322
Area code- Phew number
2. WELL INFORMATION:
SITE WELL ID earapplicable) '
,RESIDENTIAL WELL CONSTRIJCTION'REcoRD
North Caroana Department of Envhoomem and Natural Resources- Division of Water Quaky
WELL CONTRACTOR CERTIFICATION # 2138.
1. WELL CONTRACTOR:
James W. Carol
Well Contrada.(krdMdS) Name
Camp's Well & PunD Co. Tnc.
Well Contractor Company Name
STREET ADDRESS P 0 Bok 429 .
Ellenboro NC 2%Si0
4iP t%�
STATE WELT. PERMIT#(6appDeabls)
DWQ or OTHER PERMIT #(S applicable)
WELL USE (Cheek Applicable eo:q: Residential Water Supplyp
DATEDRILLED `! -/G% - D 6
TWE COMPLETEDy/� .•-' /0 AND PM�,I
3. WELL LOC1103 1 C--,(+ coming -Life /``I Yd
cirt
6LCItin/11 V 111t Lo f too
(StraailiamA NwNws,.Camnus*. SubdWelory Lot No.. ParcoLZIp Code)
T OGRAPHIC / LAND SETTING:
Slope OVafey DFlat DRldpe ❑Other
Oho* appmpaa tbe)
LATITUDE _C a9.gv7A/
LONGITUDE j. .L 41fi. 0 I % Pt)
Tatituddlongitude source: 11/C S OTopog apbio map
(bcafbn cling must be sham on a USGS topo map and
attached to thb tone 7not using GPS)
OWNER'S NAME
4.WELLOWNER.� ,h1
e-S C' ul ers
STREET ADDRESS 0 0X 5-44
LQKc L.cre L gg'74G
Oily orToan State Zip Code
MAY t:o minutes, a � dsa•
in • decimal format
Area code. Phone number
6. WELL DETAILS: /t,.0 5
a. TOTAL DEPTH: ((
b. DOES WELL REPLACE EXISTING WELL? YES CI NOJK
e. WATER LEVEL Wow Top el Casing: .D-t FT,
(Use'+1f Above Top of Casing) '
d. TOP OF CASING IS ' 1 . FT. Above Land Surface'
. 'Top d easing taminted tics belay land surface miry wars
■ va lane el 7eadancewI h 15A NCAC 2C .0118.
e. YIELD(gptn) METHODOFTEST 4ir
1. DISINFECTION: Typo ch1ori ne Amount �, Cc,'s
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From . To
6. CASING:a Depth
From 0 To ` ,& F1
From To Ft
From To Ft.
D0* all
7. GROUT: Depth Material Method
From 0 To 20 Ft, Sackrete Hand
Fran To Ft
From To FL
a. SCREEN: Depth Diameter . Slot Size .Matedal
From__ To Ft`_In. N.
From To Ft. In. In.
From To Ft In. In.
9. SAND/GRAVEL PACK:
Depth Sim Material
Front ' To FL
From To Ft
From To Ft.
10. DRILLING LOG
From0' '
• -! O S
11. REMARKS:
connrdlon Des tion
O.V�
C
1 DO HEREBY CERTWYswims WELL WAS OORSIRtICTED NACCORDANCE WITH
15A NCAC2C, WELL CONSIRUCIION STANDARDS.AND R ATACOPTOET I$ •
RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER
tA) C b
RE OFCERTIFEDiNELI"CONTRACTOR OATE
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 MO Service Center- Raleigh, NC 27699-1817 ' Phone No. (9191733-9015 ext 566.
Form GW-la
Rev.7105

1/4124)
North Carolina Department of Environment and Natural Resources -Division of Water Duality-Groundwa er Section
1636 Mall Service Center - Ralelgh,N.C. 27699-1638-Phone [phone]
329451
WELL CONSTRUCTION RECORD
WELL CONTRACTOR- /' O t'g' Aid QA r t" L. /At S
WELL CONTRACTOR CERTIFICATION # : 0.73749
STATE WELL CONSTRUCTION PERMIT # :
1 WELL USE (Check Applicable Box): Residentiallti Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring n
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other. List Use:
2 WELL LOCATION how sketch of the location below)
Nearest town. Gi IS'f.f ,ea/'i°N County
FFEC-w,ic 84hj,'src4&Kh ad sa r-oa
�uTbtFbFaFd TaN
/Road Name and Numbers Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3 OWNER PO 1 /4CFI ink' From To Formation Description
Andress Po /3ow 51)/
(Street or Route No.)
MTh EAni,lJ'i�.r N,[. "si89
City or Town State Zip Code
a DATE DRILLED G-S�OL
5 ' C.'AI DEPTH /S.
5 ObTTINGS COLLECTED YES n NOIY
DOES WELL REPLACE EXISTING WELL? YES n NOV
9 STCT.0 WATER LEVEL Below Top of Casing. 5% FT .
(Use `+' if above Top of Casing)
9. TOP OF CASING IS /L �� FT. Above Land Surface'
•Top of tasing terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C 0118 s�
1C YEILD (GPM): 2O METHOD OF TEST %q$Q,LZ,'h
WATER ZONES (depth):
12. CHLORINATION: Type
�T>+
13 CASING
Depth Diameter
t-rom To 41e- Ft
To
To --Ft
12 ;PC!.JT
15 SCREEN
Amount If additional space is needed use back of form
Wall Thickness
or Weight/Ft Material
X% L .n Sr,Ca LOCATION SKETCH
(Show direction and distance from at least two State
Roads. or other map reference points)
Depth Material Method
To rt
To Ft
Depth Diameter Slot. Size Material
�•om To Ft in in
P-orn _ To Ft in in
Prom _ To Ft in in
1E SAND/GRAVEL PACK:
Depth Size Material
L•om To Ft
-om To Ft
17 REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No
SIGNATURE O��RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

• 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. Camp
Well Caihactor.(IndhAdual) Name
Camp's Well & Pump Co. Inr_
Well Contractor Company Name
STREET ADDRESS• P D BOX'. 429
Ellenboro NC 28040
Zip bade
CltyorTwm Stale
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 'DIN applicable)
STATE WELL PERMR#(aappfable)
DWQ or OTHER PERMIT 11(6 applicable) Si
WELL USE (Check Applicable Sac): Residential Water Supply
DATE DRILLED aeo --b6'
TIME COMPLETED I AM ❑ PM
3. WELL
LOCAnoN: -, 1
CRY: COUNTY RN /,.J.t ll e ice r0
irlttrsertion in H o4 d-PfttRideir
(Strew Nam*, Numbers, Community. Su , Lot No., Parat: in Cod
TOPOGRAPHIC /�1A,�p,�J SETTING:
CI Melee OValey tflW ORidge ❑Other
(check
LATITUDE _ it' a7, 3554
LONGITUDE i .L 573, IV W
Latitude/longitude source: v( s fTopovaphic map
(bastion fhb long be I not using Gon PS) GS topo map and
4. WELL OWNER i� �
OWNERS NAME Day- Craw -For
STREET DRESS 14 (' f o rL ia 61
/rita.fe NL `-'agI(oo
City orlfavn State Tip Cede
Ar�-code-code Phone number
IMay be in depart,
minutes, second'or
in a decimal format
6. WELL DETAILS: a. TOTAL DEPTH: I G1 ` O
b. DOES WELL REPLACE EXISTING WELL? IV
YES NO NO
el WATER LEVEL Bea mTop of Casing: `i- 0 FT,
(Use •+'.If Above Top of casing)
d. TOP OF CASING IS 1 Ff. Above Land Surface*
Ica cf wing tamhlated at/or belay land sudaos may require
a valance 6 accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):iP P METHOD OF TEST rX i
1. DISINFECTION: Type Chlorine Amount 1 rail
g. WATER ZONES (depth):
From To From To
Fran To From To
From To Rom To
6. CASING:
•
From 0
From
From To
Deth 4
To
7. GROUT: Depth
From 0 To 20
From To
Fran . To
8. SCREEN:
From
From
From
Depth
To
To
Ft D7 b
Ft.
Ft.
Thfopuesal
Weight Material
SDR21 PVC
Material Method
Ft Sackrete Hand
Ft
Ft
Diameter Slot Sim .Material
FL In In.
Ft. In In.
Ft. In. In.
9. SANWGRAVELPACK:
Depth Size Material
Rom ' Tct_ FL
Fran To Ft
Ran To Ft .
10. DRILLING LOG
From To
o• /r4
11. REMARKS:
clFormation Des c, Description ,
a f. a rA✓e
CDn ohria ter
ro
G
WAS
N ACCORDANCE
1SA RCAC2C. W OONSTRUODONSSTANDARDS.A TA W�
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
am,1A (k) CA
SIGN TURE OF CERTIFIED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mall Service Centeriginal to -RDivision of Water aleigh, NC 27699-1-1617 Phone No. (9 91733-7Attn: ext 568.�on Mgt.,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Camp
Well Contredor.(IndMdUal) Name
Camp's Well & Pump Co. Inc
Well Contractor Company Netre
STREET ADDRESS P 0 BOX 429
Ellenboro NC 2$040
mod
City or Tom State ZIP e
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(N applicable)
STATE WELL PERMR#(eappliable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Apppyatblee Bar): Residential Water Supptp 0
DATE DRILLED GJa °� lO
TIME COMPLETED jI.3o AM/PM❑
3. WELL LOCATION: II � y('
CITY: )'1�^ �`e Lk'Y(f COUNTY leVIdV
VIS A_(X)B;llhCYecK- flat
(Shia Name Numbers. CommuNly, SubdlNslon. Lot No.. ParCel ilp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVakey OFbt 0Ridge ❑Other
(chair sppropdetabTO "" II
LATITUDE L �v- 1r v
LONGITUDE S '�_C 4q,
Latitudellongitude source: D GPS ['Topographic map
(ba0m of;almost be shown on a USGS topo map and
attached to this lone Ind ushg GPS)
Maybe. In dogma,
minutes, seamds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
I-eUtifu5 E vl(cje Vs
STREE�ADDRESS U O RD X 99✓<
r4 n(.)cta-) o f Off- N L 2 758
City or Tam Zip Cede
Area e Phone number
5. WELL DETAILS: 0
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL'? YES p NO 0
c. WATER LEVEL Below Top d Casing FT,
(Use '+•1I Above Top d Casing)
d. TOP OF CASING IS - - 1 . FT. Above Land Surface'
. 'rap d casing laminated at/or below land surface may require
a wine In accordance With 15A NCAC 2C .0118.
a. YIELD (on)*,k D METHOD OF TEST DI) r
t DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To
Frain To
From To
6. CASING:
Frmt_0 Tom I b Ft 6Mer
From To Ft.
From To .Ft.
I c-Y5
From To
From To
From To
Thldmessl
Weight
PVC
7. GROUT: Depth Material Method
Ram 0 To 20 Ft Sackrete Hand
From To Ft
Fran To Ft
e. SCREEN: Depth Diameter Slot Size .Material
Ran To Ft. In. In.
From To Ft. in. In.
From To Ft in. In.
9. SANDIGRAVEL PACK:
, Depth
From____To Ft.
Size Material
Fran To Ft
Fran_To FL
10. DRILLING LOG
From .To.
.0• 70
11. REMARKS:
. Formation Description
5an'.) gKm/el
(,O v\sof i dam,
VD
Cr.
I DO HEREBY CERTFYIMAMS WELL WAS OONSTRUC1ED 11 ACCORDANCE WITH
15A NW020, WELLCONSTRUG'ION STANDARDS, AND THAT ACOPY OEMIS .
RECORD HAS BEEN RROVIDEDTO THE WELL OWNER.
_ \WCX IA CC.{kmr.$ -23 Olp
S��GRAATURE OF CERTIFIED EL.LC 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: infonnatlon Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 ' Phone No. (9191733.7015 ext 568.
Form GW1a
Rev. 7/05

• RESIDENTIAL WELL CONSTRUCTION -RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTffICATION k 21 3 8
1. WELL CONTRACTOR:
James W. Camn
Wee Contractor (Individual) Name
Camp' s Well & P11mD Co. Inc -
Well Contractor company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City orTonn State Cod
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID act applicable)
STATE WELL FERMIUM, appecabte)
DWQ or OTHER PERMIT it(t applicable)
WELL USE {Check Applicable Box): RBsldental Water Supply
DATE DRILLED 6-. 7 0 C' /
TIME COMPLETED g AM 0 PM dY
Zip e
3. WELLL 7OJ+ �• I4 1)
cry: Kai hey%r6 kr�. couriitypRther-Cri
17W — Catke K. Cow�m•
(Saeel Name,Numberrs, Cone moon, SubdMslon, Lot No., Parcel,2ip Code) .
TOPOGRAPHIC / LAND SETTING:
[Slope [Valley [Flat [Ridge [Other
(c &appropdamlwt
•
LATITUDE 16 2A. R aa N
LONGITUDES ( 5�•b,_5 tJ
Latitude/longitude source: t36PS [Topographic map
attacchhed � forsm f noa�ng PS)GS top[ map end
4.WELL OWNER r I
OWNER'S NAME 'Ire- R c-/ rts al
STREET ADDRESS 971 old jro✓aanfon /n`y
G..ttan Mi(ity or Ton SsI\C- IZip U7
e
Area cads Phone number -
Ma be in deyees,
minuta, seconds or
in a decimal brmat
5. WELL DETAILS: I D
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
c. WATER LEVEL Below Top of Casing: 4 5 FT,
(Use'+' f Abo✓8TCp of Casing)
d. TOP OF CASINO IS 1 • FT. Above Latta Sudan?
:Tap el carp terminated atlor belay land what may require
a variance In accordance with 15A NCAG 2C .0110.
e. YIELD(gpm): two METHOD OF TEST cu Y
1• DISINFECTION: Type Chlorine Amount I /1 cup
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From To
6. CASING:
TMOWuess/
Depth D7aaeter Weight Material
From 0 -To IP Ft. br 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 FL
8. SCREEN: Depth
From To
From To
From To
Diameter - Slot SIm .Material
FL In. In.
Ft. In. b.
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 'ID
/O
11. REMARKS:
Formation Description
rf; r-r, !oam
pa
0
•
I DOItEREBYCEYIFYTNATTNIA WELLWAS OONSIRUCTED N ACCORDAIICE WRN
16A NCAC2C, WELL CONSIRUC1ION STANDARDS•ANDTNATACOPYOMIS .
RECORD HIS BEEN PROJIDEDTOTHE WELLOWNER
23 Dry
SI .URE OF CERTIFlED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subrnttthe original to the Division of Water Quality within 30.days. Attn: information Mgt.,
1617 Mall SQTvIce Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 668. .
Form OW-te
Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 21 38
1. WELL CONTRACTOR:
James W. Camn
Wel Contmgor.(IndMdual) Name
Camp's Well & P_unD Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX
429
Ellenboro NC 28040
City orTam ' State Zlp code
( 8281. 453-7322
Area cods Phone number 2. WELL INFORMATION:
SITE WELL ID #pt applicable)
STATE WELL FERMIUM/Mathis)
DWQ or OTHER PERMIT Sof applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 5-- - C 6
TIME COMPLETED 1 AM O PM 171
a. WELL jCITY: f
1—it 4- eCK.%w(ma (Sires( N.�,1j/ Number% Community, Subdivision, Lot No., Parcel; )
TOPOGRAPHIC / LAND SETTING:
081r OVakey IPFlSat DRidge ❑Other
to asppropdstabex)
LATITUDE ,,,SS„? ,30.q A N
LONGITUDE e I ' S1. 3.5,a •L-
)atitudellongitude source: dGPS oTopographic map
docatbn of wel must be shown on a USGS topo map and
attached to this tam ifnot using GPS)
for, cout eY ✓
MAY be in deppem.
minutes, woods or
m a decimal format
4. WELL OWNER
OWNER'S NAME n`7
STREET
arheY Yn fn
or Town State
�C6,4- flay
2g13
Zip Cade
Areaccde Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES IDNO X
c. WATER LEVEL ESN Top d Casing: . FT.
(Use •v 8 Above Top d Casing)
d. TOP OF CASINO IS 1 . FT. Above Land Surface*
'Top d easing terminated at/a belay lead serrate mqy require
e valance in accordance with 15A NCAC 2C .0118. ,
e. YIELD (ppm): I 0 METHOD OF TEST ki Y
1c10
1. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To
Fran To
From To
6. CASING: abet �g
•From 0 To on Ft D�# o SDR21 PVC
From To
From To
From To
From To Ft.
From To Ft.
ThicMess/
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
Frorn__To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Sim .Material
From To Ft. in. In.
From To Ft. In. In.
From To Ft. in in.
9. SANDIGRAVEL PACK:
' Depth Sim Material
Fray,_,_;Tq Ft.
From To Ft.
Froms__To Ft.
10. DRILLING LQG
From T . Formation Despnptbn
.0' go ;r"r 5a_)ld
5tb . Icto CrvkSoItY4a_
11. REMARKS:
ea Ye
c
csm
1DDIEREBY.YAN&TTISS WELL WAS EST ANDARDs �TEDNACCORDANCE
•
WITH
BOACRECORD HAS BEEN PRONDEDTOME WELL OWNER
/ism.Q\ L.) CAmp 6-013-044
SIGN` URE OF CERTIFIED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Matt Service Center- Raleigh, NC 27699-1517 '_Phone No. (9191733-7015 ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL 4VEI.L CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION d 2138
1. WELL CONTRACTOR:
James W. Cann)
W ea Contractar.(IndWWual) Name
Camp's Well & PumD Co. Inc.
Well Contractor Company.Name
STREET ADDRESS P 0 BOX
Ellenboro NC
City or Tam State
828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID dN aopncable)
429
28040
ZIP ode
STATE WELLPERMITnNIPPaable)
DWQ or OTHER PERMIT Elf applicable)
WELL USE (Check Applicable Box): Residential Wader Supply
DATE DRILLED /
TIME COMPLETED I P M AM O PM Id'
CITY: 0 3 COUNTSd3. WELL LOCTIDN:
°olden
a.`le Kafafes - Lot'/6
(Street Name, Numbers, unity. Subdivision, La No., Parcel; A. Code)
TOPOGRAPHIC / LANDS G:
°Slope Maley DFI ET Idge OOther
o neck eppnoPdat?b?'r)
LATITUDE s5° 3o.7ZSN
LONGITUDE, L° `{4• 14z ")
Latitude/longitude source: OOPS OTopogtphic map
Pocatbn of we/ must be shown on a attached this form 7not usk,g GPS)GS topo map end
OWNER'S NAME 7 oW e } am ) TD r4. WELLOWNER +
STREET ADDRESS (c3 ( in I'f*ri u r I
charier? state
C AZ al,
My orTavn
IMay be in depa,aSautes, seconds or
in a decimal format
Ateaa code Phone number
6. WELL DETAILS: ' n
a. TOTAL DEPTH: 1.0
b. DOES WELL REPLACE EXISTING WELL? YES NOX
C. WATER LEVEL Beim Top ct CesIn X ryFT,
Woe '+'11 Above Top cI C
d. TOP OF CASING IS 1 FT. Above Land Surface•
'Tap of casing temdrmtad at/or belie land surface me regttlre
variancenaccordance w9h15ANCAC2C.0118.
a. YIELD (gpm):_4METHODOFTEST Q) r
t. DISINFECTION: Typo chlorine Amount A ct1Ps
g. WATER ZONES (depth):
From_ To From To
From To From To
From To From To
6. CASING:
DD]alneter
Fro0m Depth
Ft b#
From To Ft.
From To FL
Thlccgwbss/
SDR21 Material
7. GROUT: Depth Material Method
Frail 0 _To 20 Ft Sackrete Hand
From To Ft
From To Ft.
e. SCREEN: Depth Diameter Slot Size Material
Fran To Ftt_In. In.
From To Ft. In. In.
From To Ft. in. In.
9. SANDIGRAVEL PACK:
Depth Size Materiel
From To_ Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From .To
.0 •
76. An<
11. REMARKS:
Fomtation Desatp
br
J7to�J 1 r9 raUc(
(f1S0/,Jared Keck
fV
rV —
1—
I DO WITH
taANCAC 0. WELLCONSTRt1GROt1 STANDARDS. AO1RAATA 7ipCURVY TRAVOIS WELL WAS CONSTRUCTED N ACcORDANC6E•
: RECORD RAS BEEN PROMO:ITOTHE WEISOWNER.
n C.A
1/Y1f�tab6
SIC TORE OF CERTIFIED W ELL"CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1611 Malievi originale Center- Division of Water Quality Raleigh, NC 27699-1617 Phoneme No. (9 91733AAttn: ext 68.aon MgE,
Form GW-la
Ree.7/05

RESIDENTIAL WELL CONSTRUCTION:RECORD
North Carolina Department of Environment andNauaal Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8 '
1. WELL CONTRACTOR:
James W. Camp
W ea Cantraclar.(IndMdUS) Name
Camp's Well & PUMP Co. _Inc _
Well Contractor Company Name
STREET ADDRESS P O Bo*. 429
Ellenboro NC 28040
City or Tam State Zip Code
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 11uufapplicable)
STATE WELL PERMIT#(B+PPhMINe)
DWQ or OTHER PERMIT #(H apP9eahle)
WELL USE iCheck Applicable Sox): Residential Water Supply 0
DATE DRILLED
TIME COMPLETED •e-? o AMID PM Eil/
9. WELL LOCATION: y1 -�'
CITY: Lae_ LAY COUNTY rk�1 YIe4j
v
S-f ai- Bit (5 Mtn (k V)
a
I
(Street Name Numbed. 0«anu* Subdhisbn, W No., Parcel:)7P Code) _
'(TO ['GRAPHIC/ LAND SETTING:
lope ['Valley ['Flat ['Ridge ❑OOw
(ch.ck appoodalaPP20
LATITUDE , 5f a /(o N
LONGITUDE 1. ac e'1•.'(d LA)
May be In deices,
minutes, secondsa
in a decimal format
Latitude/longitude source: In6PS ['Topographic map
(bastion ofwelmust be shown en a USGS topo map end
attached to this hat Inot ushg GPS)
4. WELL OWNER /
OWNER'S NAME ✓ t
A'
STREET ADDRESS
itP,rtdeYsrr sal
City or Town
Aces code Phone number
5.WE LDETAILS: -t �� /
a. TOTAL DEPTH: L( yyy,,,
b. DOES WELL REPLACE EXISTING WELL? YES p NO p
WATER LEVEL Moe Top creasing: kQ 0 FT, 1
(pure .H Above Top of Casing)
d. TOP OF CASING le 1 FT. Above land Surface
At g; J'S M to
N M.th( St .
e N C- fP7f°2_-507
Zip Cede
'Top el casing terminated eVor belay land surface row require
a variance In accordance w$ h 15A NCAC 2C .0118.
e. YIELD (gpM�ODOFTEST Ai
mL• Y4
f. DISINFECTION: Type chlorine Amount I ! Eup.S
g. WATER ZONES (depth):
From To From To
From To From ToT_
From To From To
6. CASING: Depth `� �a�e�er Thldmess/
•From 0 It FL Dom_ SDRWeigh21 PVC
From To Ft
From To •Ft
7. GROUT: Depth Material Method
Fron(0 _To 20 Ft Sackrete Hand
From To Ft.
From To Ft
8. SCREEN: Depth Diameter - Slat Size .Material
Fran To Ft. In. In.
From To Ft In. M.
From To Ft In. In.
9. SANDIGRAVEL PACK:
Depth Size Material
Fran ' To Ft
From To Ft
From To Ft
19, DRILLING LOG
From .To.
0. 4-O
Formation D scription
grape/ c/ay
o .
p LHc (/%NSA I;dAte el YCG
T o
11. REMARICS:
L
r—
r'
1
I DO HEREBY CERTFY THAT THBS WELL WAS OONSIRUCIED N ACCORDANCE WUH
15A MCC 20, WELL CONST-D.AND MTACOPY OFM•
RECORD HAS BEEN EOONS�DD
Crt
SIGNATURE OOFF CERTIFIED WEU. CONTRACTOR DATE
James W. Camp
'PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit 11 17 Mall Service Center —he original to Division of Water Raleigh, NC 27 99.6017 Phoone No. (9 9� 735 7Attn: ext 68.aon Mgt,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor. (Individual) Name
Camp's Well & Pump Co. Inc -
Well Contractor Company Name
STREET ADDRESS P O BOX 429
Ellenboro NC 28040
City orTown • State
( 828 } 453-7322
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID apt applicable)
Zip Code
STATE WELL PERMIT# U apPuclible)
DWQ or OTHER PERMIT #Qf applicable)
WELLUSE1Check Applicable Boa): Residential Water Supply°
DATE DRILLED (G- -O%
TIME COMPLETED AMO PM V
3. WELL LOCATION:
CITY: M 0 ST i s COUNTY Atte
Alin k)
(Se, Numbers.
/Vt").— bt l/G
wunity, SubdMsion, Lot No., Parc&;i•Ip Code)
TOPOGRAPHIC / LAND S NG:
O Siege OValey °Flat Ridge ❑Other
(check appropriate WO
LATITUDE . 2.° M'O `b b N
LONGITUDE D I ' 5-d • 16 S iJ
Latitude/longitude source: tbdi's °Topographic map
(bcatbn of we/ must be shown on a USGS tops map and
attached to this form ►nof using GPS)
4. WELL OWNER
OWNER'S NAME f YA.h
STREE�j1 ADDRESS 5 o/ UO X b b Yn U4 k Ct
G Iee144 bolo 1vC- 14- 04'
City or Tam State Zip Cede •
Area axle- Phone number
5. WELLDETAILS: �1
a. TOTAL DEPTH: 1- /o C
b. DOES WELL REPLACE EXISTING WELL? YES p NOJ
C. WATER LEVEL Raw Top of Casing: Fr,
(Use+' If Above Tap of Casing)
d. TOP OF CASING IS 1 . Fr. Above Land Surface'
'Top of casing taminated tea below land surface may require
a valence In accordance volt 15A NCAC 2C .0118.
e. YIELD (gpm): I D METHOD OF TEST Al Y
May be. in degrees,
miana, seaads or
in a decimal format
f. DISINFECTION: Type chl or ine Amount r.e
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From - To
6. CASING;
Depth
Fran 0 •To th2
Thickness/
Ft DiameterWeight SDR21 PVC
From To Ft
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
Froth To Ft.
Fran . To FL
8. SCREEN: Depth Diameter - Slot Sim .Material
From To Ft. In. N.
From To Ft. In. N.
From To Ft In. in.
9. SAND/GRAVEL PACK:
, Depth Sim Material
From To Ft.
From To Ft.
From Tq Ft
10. DRILLING LOG
From T .
0• G-o
Formation Description
4n .)f l_'nnDI;f-L'>Led rock
11. REMARKS:
D
r
Cr"
I DO FEREBYCERraYTHATIHS WELL WAS CONSIRUCIEO NACCORWJ1OE WItM
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT ACOPY wins •
: RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
( JKLM t n23-64
SI TORE OF CERTIFIED WELLp CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: Information Mgt.,
1617 Mali Service Center — Raleigh, NC 27699-1617 ' Phone No. (9191733-7016 ext 668.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION' RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Camo
Wen Contractor. (Individual) Narne
Camp's Well & PumD Co. rite -
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
CityorTomo ' State Zip bale
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Stir applicable)
STATE WELL PERMT#(1lappnabb)
DWQ or OTHER PERMIT #(H applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 0/-a-DC° /
TIME COMPLETED 3 .3C AM❑ PM gi
TI•N:
/ o it; courm' k'wtner orri
rr'cu'nnr .
(Stre t Name, NumWf, Community, SubdMNebn, I.ot No., ParceLZl Code) .
TOPOGRAPHIC / LAND SETTING
❑Slope Malley OFlet ORidge ❑Other
(d,eck rpprolalmoirti
LATITUDE _
LONGITUDE a° © 6, IA)
Latitude/longitude source: PS aTopographic map
wed � ust be shown lam not/s GPS) GS—f7opo mapl end
a.OWELL
NERR$ NAME 1 k'e rear '`Rvi )days
STREET ADDRESS D O X 6 Y 1
UKe Lure C, 2v47L L
City or Town State Zip Code
May be in degas,
mimues, secoadsor
in a deeimsi format
(�}
Area cads- Phone number
6, WELL DETAILS: a. TOTAL DEPTH: / �C "J
b. DOES WELL REPLACE EXISTING WELL'? YES 0 NO p7
c. WATER LEVEL Belot? Top d Casing '7 h' FT,
(Use '+'.I Above Top d Casino)
d. TOP OF CASING IS 1 FT. Above Land Surface'
.Top d casino terminated affix betas lend surface mini require
afloe ln accordancewit 15A NCAC 2C .0118.
e. YIELD (gpm) ram_ METHOD OF TEST it l ✓'
f. DISINFECTION: Type Chlorine Amount A cup S.
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From To
6. CASING: Thickness/t terial
SDRWigh21 . P
From 0
From To Ft
From To Ft.
Depth ''rr De/Deter
To cr0 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
Fraro To
B. SANDIGRAVEL PACK:
Depth Size
From Tq Ft.
From To Ft.
From To Ft.T
Diameter Slot Size
Ft In. N.
Ft, In. in.
Ft in. In.
10. DRILLING LOG
From To.
0• 4O
1(-n .
11. REMARKS:
Material
Material
_ I Formation Description
nay) VaJPI
COVISOIrAated riTc_k
0
c
100A HEREBY
BC,WELL CON31R SWE WAS
COB t�NATA WtlR
RECOR
D
HAA/S BEEN PROVIDEDTDTHEE� WEE,I�,LOO�WNER.
S�(INAN NRE OF CERTIFIEDDWELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submitthe Mall Service Center the Raleigh, NC 27699-1-1617 Phone within
91733-YAttn: ext 68.aon Mgt.,
Farm GW-la
Rer.7/05

RESIDENTIAL WELL CONSTRUCTION'RECORD
North Carolina Department of Environment andNatursl Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2138.
1. WELL CONTRACTOR:
James W. Caron
Well Cantractor.(IndMduaq Name
Camp's Well & „1TmP Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City orTomo State Zip Code
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID atir aPPecaNe)
STATE WEU. FERMIUM, Venable)
DWQ or OTHER PERMIT B(B applicable)
WELL USE (Check Applicable Box): Rdsidental Water Supply ❑
DATE DRILLED A —D!o
TIME COMPLETED 4:00 AM FWD/
3. WELL LACA ON: /< r
CITY: l7i J l .>O // n cou�rT7�-Y� PN P r'l r
ti
(Suast Nam Nimbus. JjN✓✓JMl //GO .SabdiWbn, Lot No., Pnceft2lp Cade/
TOPOGRAPHIC / LAND SETTING:
p Slope OValey °Fiat ORidge OOther
(arak.pPrwd.tabm0 /q
IATTTUDE ..„8_5-Q �•zit(' ev
LONGRUDE1. 2° I / • 35o k%
Latitude/longitude source: 0'6PS oTopographic map
(Iaxtbn ofwel must be shown on a USGS topo map end
.deched to this tom snot using GPS)
May to In degree;
minutes, .aonds or
ins decimal format
4. WELL OWNER'S
ER Ulm
6 yj 1 - �(
iJ I {1 V /7SSOG .
OWNER'S NAME r�)m nm�
STREET ADDRES r 0 }� 6 X
lj partut rAyA .SG 2g30S
CI*or Town J State Ttp Cede
Area Area �e Phone number
s.WELL DETAILS: y—DS
a. TOTAL DEPTH: ii yyy
b. DOES WEU. REPLACE EXISTING WEU.? YES p No UI,
c. WATER LEVEL Below Top dCasing: nFT,
Np W. ff Above Top of Casing
d TOP OF CASING IS 1 . FT. Above Lend Surface
. 'Top dcasing tenanted atlabelow land surface may require
a variance In accordance with 15A NCAC 2C .0118.
a. YIELD (pp m): 4 METHOD OF TEST R i f
L DISINFECTION: Typo Ch I orifte Amount ,& cby) 5
g. WATER ZONES (depth):
From To From To
From To From To
Front To From To
6. CASING:
�a�,eter Thickness/
erial
From 0 Depth
X.& Ft Db# Weight
PVC
Fraq__To Ft
From To .FL
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To FL
From To FL
8. SCREEN: Depth
Fran To
From To
From To
Diameter . Slat Size
In.
Ft in. In.
Ft In. In.
.Menial
8. SAND/GRAVEL PACK:
Depth Size Material
Fran To Ft
From To Ft.
From To Ft
10. DRILLING LOG
From To . Formation Description
. 0 • RA clay
•
R.:z .C6C C'nr15,1idaterl rocK •
11. REMARKS:
L
hl
I DO HEREBY CEMFYTNATTH6 WELL WAS CONSTRUCTED NACCr a^aw'F WBN
16A 'CAC 20, WELL CONSIRUG110N STANDARDS, AN01HATACOPY OFTIBB
RECORD HAS BEEN PROVIDEAT01HE WELL OWNER.
SI TU C � IED-W ONTRACTOR
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
--a3
DATE
lh�1 the oneInformationMgt.,
1617 Mall Center NC 276991617 • PhoNo. (99)7337015 ext 568. .
Farm 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
Wd Cmtractor.(IndMdual) Name
Camp's Well &_Psamp Co. Inr_
W ell 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 #(ir applicable)
STATE WELL PERMIT#Nappncable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Arp�pUea�ble Box): Residential Water Supply❑
DATE DRILLED > — ;` — D
TIME COMPLETED ((3 O AM t'PM ❑
3. WELL L°�ON: } �-I r
crrY: F Yf 51 [) couriTv lL ri.
If(Ki t Ga u"ry.suoF °4 .,Rao Rd.
(Street
TOPOGRAPHIC / SETTING:
OSlope Matey tIFIal ❑Ridge El Other
(drank OPprroPflaeb9/0 ,,//yy A
LATITUDE SS c• .��
3.'1/31J
LONGITUDEI i ° it.)
Latitude/longitude source: PS oTopographic map
(beatbn of we►must be shown on a (MGS topo map and
aHnched to Ma form I not using GPS)
May be N degrees,
minor, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
tee Le tf-
STREET ADDRESS / 5 P10.t SA Kd-
rest Cif' State floL1
ChyerTani e Zip Cede
Area cede Phan number
5. WELL DETAILS:
a. TOTAL DEPTH: 19 I `'
b. DOES WELL REPLACE EXISTING WELL? YES p NO G1
o WATER LEVEL Bebe Top of Casing: j C ///ill
(Use '+•.SAbove Top of Casing)
d. TOP OF CASING IS 1 • FT. Above Land Surface
. 'Top of casing tanlhmted etlor belay lad surteee m!y require
a varianee In accordance web 15A NCAC 2C .0118.
e. YIELD (ppm): y—METHOD OF TEST Gil (
t. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: �. Thkllmess/
Fran 0 DDepthq� Ft Db :r Weigho ater
t
PVC
Ft
.Ft.
From To
From To
7. GROUT: Depth Material Method
Frug 0 _To 20 Ft Sackrete Hand
From To Ft.
Fruit__ To Ft
8. SCREEN: Depth Diameter . Slot Size Material
Fran To Ft. In In.
From To Ft. In. __ In.
From__To Ft_ In. __ in.
8. SANDIGRAVEL PACK: Sim MaterialDepth
Fiom,__.,_-.To Ft.
From To Ft.
Ran To Ft„__,_
10. DRIWNG LOG
From To.
. 0 ' 90
n Description
SANQy /ocem/ i ra✓e!
elm)90 c,r50i,rime rocK
11. REMARKS:
C
0
L
c
N G.
CI,
I DO HEREBY DESIST WINS WELL WAS CONSTRUCTED N ACCORDANCE WIN
teA NDAC20. WELL CONSTRUCTION STANDARDS. AND MAT ACOPY OE 11S •
RECORD HAS BEEN FRONDED TOME WELL OWNERAfIA.
46
RE'OF CERTIFIED W � CONTRACTOR / —� TE
James W. Camp •
i'RINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submft fty
Mali arvtce(nal to Center— Division of Water Raleigh, NC 27 99.6117 a( Phone No. 9 91733 7Attn: ext 68.8on Mgt.,
Form GW-la
Rev. 7105

• VRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
1. WELL CONTRACTOR:
James W. Camp
Wel Contrada.(IndMdual) Name
Camp 's Well & Pump Co. Tnc
Wel Contractor Company Name
STREET ADDRESS P O Bo
Ellenboro NC
City or Town State Zip e
(828). 453-7322
Area code- Phone number
2. WELLINFORMATION:
SITE WELL ID S9r applicable)
STATE WELL PE RMR#(9apPBeabla)
DWQ a OTHER PERMIT #N applicable)
WELL USE (Check Applicable Box): Residential Water Supply CI
429
DATE DRILLED /J -D 6
gTIME COMPLETED ' 3 c
28040
AMO PMEV
CITY: Et
3. WELL LOCATION:r���r'2N /0 (-nT--`C`OUNTY R NY 1Pflu)
Kerit f rai 1
(Street Name, N unity, sion, Ld No., Parat,2lp Code) .
TOPOG IC /LAND SETTING:
❑Slope May OFlat DRidge ❑ Oler
Klima 'Mors** )
LATITUDE g e2 3 CI
14.
LONGITUDE r y 7. ' io (J
Latitude/longitude source: fQ6PS oTopographic trap
(Wan of we/must be shown on a USGS topo map and
attached to this torn Knot ush0 GPS)
4. WELL OWNER
OWNER'S NAME T SoY� Fri Le
STREETADDRESS er; ta�'e Ti ai
IMay be. In dears.
mbmro, seconds or
In a decimal format
lien Y0 C a8040
City orTown fate Zip Cede
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 1 0
b. DOES WELL REPLACE EXISTING WELL? YES El NOX
e. WATER LEVEL BeowTopove Top pof Casing)
4S FT,
d TOP OF CASING IS 1 . FT. Above Lend Surface'
'Top d aab0 laminated aka below land surface may requite
wriana ceIn accordance with 15A NCAC 2C .0118.
e. YIELD (gpm$ ...aa— METHOD OF TEST CO It
f. DISINFECTION: Type Ch lOrine Amount i�a. Ct,
g. WATER ZONES (depth):
From To Fran To
From To From To
From To From To
6. CASING:
From 0 DToo Ft TIles
From To Ft.
From To .Ft.
7. GROUT: Depth Malarial
Frain• 0 _To 20 Ft Sackrete
From To Ft
Fran To Ft
Thickness/
terial
Weight
PVC
8. SCREEN: Depth
Fran To
From To
Front__ To
9. SANWGRAVEL PACK: Sim MaterialDepth
Ffom To Ft.
From To Ft.
Method
Hand
Diameter Slot Sim
Ft. in h.
FL in. in.
Ft. In. In.
.Material
From Tor` Ft.
10. DRIWNG LOG
Rom T .
.0' 5C
11. REMARKS:
Form n Description
aw loam
pnH50Irel a±erM ro LJC-
I00 HEREBYCERTIFY THAT TMS WELL WAS oG$smUCTEDNAccommNCE WRN
15A NCAC20. WELLCONSfRUC110N STANDARDS. AND THATACOPY OF1115
RECORD HAS BEEN PROVIDEDTOTHE WELLOWNER.
N/n R p 1 A) CAA. /Yin
SIG f �3 �l0
EOFCERTIFIED'WELLCO?TRACTOR DATE
Fames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the ity
1617 Mall Service Center- Raleigh, NC 27 99-1617 e Division of Water al Phone No. (9 9) 733 7Attn: ext 568.8 . Mgt.,
Form GW1a
Rev. T/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION p 2138
1. WELL CONTRACTOR:
James W. Camo
Well Contractor.(IndMdual) Name
Camp's Well & Pun%p Co. Inc.
Well Contractor Company Name
STREET ADDRESS P 0 BOX
Ellenboro NC
Cityor Tom ' State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL !Digit applicable)
STATE WELL PERMIT#OY uppllcable)
DWG or OTHER PERMIT Cif applicable)
WELL USE (Cheek Applicable Sac): Residential Water Supply ❑
DATE DRILLED S a,G /: —/
TIMECOMPLETED 4S AMO PMbd
429
28040
Zip ode
J. WELL LOCATION: (�^^
CITY: ',�,�_ COUNTY gu(h,y� er7brJ
Summit Mtn. — Lt 10 a-
(StraetName, Numbers, Community. SubdMalon, Lot No.. ParesI 2Ip Code)
�TO/PA� _GRAPHIC/ LAND SETTING:
�Y�"�e OValey OFlet ORldge Other
(ohs& sppropd200,09
LATITUDE .,1._ L; 711 141 N
LONGITUDEI L °. g • S 3a W
Latitude/longitude source: PS OTopographnc map
(location of wel must be shown on a USGS lopo map and
attached toff* form I not ushig GPS)
4. WELL OWNER (�-,
OWNER'S NAME %KYIIQ 51Ocker
STREETADDRgSS 1 p /a i5 l � ,
/.ecutrcr -4- t State Zip Code
City or Tam
May be in depeea,
minutes, semodsor
Ina decimal format
Area Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: �85---
b. DOES WELL REPLACE EXISTING WELL? YES p N0,K
c. WATER LEVEL Balm Top of Casing: I / 5 FT•
(Use '+• f Aboe Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Tap of casing ttarntraded aU,x below land surface may requle
avalance In accordanceweti 15A NCAC 2C .0118.
e. YIELD (gem): METHOD OF TEST A I r
t DISINFECTION: Type chlorine Amount . e-1-565
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: mar Thlcknessl
From 0 Depth D
a 0 Ft. 6a SDWeRh21 PVt C
From To Ft.
From To .Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From__ To FL
Fran To Ft
8. SCREEN: Depth Diameter Slot Size .Material
Fran To Ft. In. In.
Flom To Ft. in. __ In.
From To Ft. In. In.
B. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
Rom To Ft.
From To_ FIT_
10. DRILLING LOG
From
.0.
28 SAS
11. REMARKS:
Fermation Description
4tvtd.grAil et crab
CDnsolidAttd rcc
c_
C"
IDoNEREBY CERIFYTHATTH6 WELL WAS OONStRUCIEDNA000ROANCE WRN
EAHOAG2C.WELL CONSIRUCTIDN STANDARDS. AND WATACOPY WRVS .
RECORD HAS BEEN PRWIDEDTOTHE WELL OWNER.
) o�
TE OF CERTIMEDWL
DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mali Service Center - Raleigh, NC 27 99. 6117 Quality original to the Division of Water Phon
e No. (9 91733 9Attn: ext 68.8on Mgt.,
Form GW1a
Rev. 7105

' RESIDENTIAL WELL CONSTRUUCTIONRECORD
North Carolina Department of Environment and Natural Resoum,s- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8 '
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (IndMdual) Name
Camp's Well & Pump Co. Tnr•.
Well Contractor Company Name
STREET ADDRESS P O Bok 429
Ellenboro NC 28040
City oTam ' State Zip Code
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(It applicable)
STATE WELL PERMIT#(6 applicable)
DWQ or OTHER PERMR #(If applicable)
WELL USE (Cheek Applicable Box): Residemld Water Supply ❑
DATE DRILLED %' S D 6 /
TIMECOMPLETED /a: `J AM In PMtit
3. WELL LOCgION: I
CITY: boG I, C�1 M COUNI`T',Y',-
(SA . t1 herterA
VE I O l V molly. SebdMisLot ! No.. Parrcelalp Code) .
TOPOGRAPHIC / LAND SETTING:
[slope Malley One [Ridge ❑Other
(memneprtada�eb?=)
LATITUDE 51 4 N
LONGITUDE," 16 10 h q g IA)
Latitude/longitude source: othS oTopographic man
poatbn of wel must be shown on a USGS topo map and
attached to this dorm l not ushg GPS)
4.WELL OWNER r� /1
OWNER'S NAME Del Gie'Co l,Dy65tYLLC lorr
STREET ADDRESS P D 13 O X .3G
}wsti 1\1C_ 29o(A
Cty or Tam State Zip Code
Area aide Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: �I O
b. DOES WELL REPLACE EXISTING WELL?
YES p N0
c. WATER LEVEL Below Top of1
Casing: �Y 0 FTLl
`
Wow # Above Tap d Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Tap d casing terminated eta belay land swtsce my require
avariance tt accadancewith 15A NCAC 2C.0118.
e. YIELD (gpm): METHOD OF TEST
Maybe to depew,
minute', Reath«
in a decimal format
t, DISINPEcnoN:rypechlorine Amount /Cup
g. WATER ZONES (depth):
From To
From To
From
From
From
To
To
From To To
6. CASING: / ThWelelgllmese/
al
'From 0 Depth
Ft Diameter
SD)Rht 21 PVC
From_____ To Ft
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To FL
From To FL
8. SCREEN: Depth
Fran To
From To
From To
Diameter . Slot Slze
Ft. In. In.
Ft in. In.
FL In. In.
Material
9. SANDIGRAVEL PACK:
• Depth Slze Material
From Tq Ft
From To Ft.
Fran Te Ft
10. DRILLING LOG
From To.
0• 63
/., to
11. REMARKS:
Formation Deseription
�aV 5And
con Soliddi-ea YoC'
r
VD t
Cr,
IDOHEREBY CERIFYTHAT THIS WELL WAS OONSTRUCIEDN ACCORDANCE WTM
ESA NWC20. WW1 CONSTRUCTION STANDARDS. AND MIA COPY OF. 1HIS
RECORD HAS BEEN PRONIDEDTOTHE WELL OWNER
/vs A W C Aivo. p
SI RE OF CERTIFIED WELL tORTRACTOR 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. (9191733-7015 ext 568.
Faro GW1a
Rev_ 7/05

RESIDENTIAL WELL CONSTRUCTION RWORD
North Carolina Department of Env'vonmwd andNatural Resoatws- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 6 21 3 8
1. WELL CONTRACTOR:
James W
Well Contactor (Individual) Name
• l o r....... Cn TX1 _
Camp S
Well Contractor Company Nrune
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City a Twin State Zip mkt
(____ 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID SW applicable)
STATE WELL PERMVTflapplicable)
DWQ or OTHER PERMIT SOT applicable)
WELL USE(Cheek Applicable Etter): Residential Water Supply
DATE DRILLED
TIME COMPLETED 0 AM 0 PM
7. WELL LOCATION:
COUNTY h E c ✓
SubdMsbn, Eat No., Parcel: Code)
Nnria, Numbers, Qalltrla
tTir GRAPHIC I LAND SETTING:
,,pe OVatey 13Flat ORidge ❑Otter
_ OM* manpdarabc0
LATITUDE 3. �/r- -2--'
LONGMIDE_1 L: 4 '
Latitude/longitude source: PS OTopographic reap
(location of we/ must be shown on a USGS typo map and
attached to this foml /not uskrg GPS)
4. WELL OWNER
OWNER'S NAME
ADDRESS
5�IC
City or Town
May be in depees,
minutes, secondsa
in • decimal format
Area code Phoneunmber
5. WELL DETAILS:
a. TOTAL DEPTH: W y
b. DOES WELL REPLACE EXISTING WELL`??AYES (7 NCO p,
el WATER LEVEL Bolos Top d Casing: )
(Use+•.I Abram Top c4 Casing)
d. TOP OF CASING IS 1 - FT. Above land Surtao *
'TIN d casing terminated allot below land sufficemay require
a vice In accordance with 15A NCAC 2C ,011 &
d— METHOD OF TE$T A )Y
e. YIELD wpm;
n
f. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From _ To
6. CASING:
Thickness/
Depth Dyer Weight
From 0 To_ILA_ Ft 6a SDK. 21
From To Ft
Fran To Ft _—
7. GROUT: Depth Material
From 0 To 20 Ft Sackrete
Fro To Ft
From To Ft
& SCREEN: Depth Diameter Slot Sim
From To Ft. In. in.
From To Ft In. __ In.
Fran To FL_ In. In.
9. SAND)GRAVEL PACK: Depth Size Material
From To Ft.
Fran To Ft FromTo______ Ft -
PVC
Method
Hand
.Material
10. DRILLING LOG
From .To
0• lob
G
11, REMARKS:
Formation Description
Sant Ora✓r( clay
Can SoI;46tew) rccK
a
r—
hV
6
too HEREBY CERLFYIH8T1W6WELL. ao 1 N W
taA NCAC2C, WELL CONSTRUCTION
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
SI TURE OF CERTIRED WELL NTRACTOR DATE
James W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit
in 30.days.
1617 Mali Service Center- Raleigh, NC 27 99-6e Division of Water Quality
17 al Phone No. (9 91733-7Attn: ext 68.Oon Mgt.,
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION' RECORD
North Carolina Department of Envhomment end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Camo
Weft Contractar.(IndhAdual) Name
Camp's Well & PLimD Co. Tnc
Well Contractor Company Name
STREET ADDRESS P. 0 BoX 429
Ellenboro NC 28040
City or Tam • State Zip bode
(828)- 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID applicable)
STATE WELL PERMIT#NaPPOeable)
DWQ or OTHER PERMIT #(it applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED G - /2,- D 6
TIME COMPLETED / 1 15 AM VPM
3. WELLLOC4TION: . n I
CITY: „fr3
o Sul C- CO/UNT'{Y�KiL ll eYY
W'±e4 ^cl j14
(sash! Nemh, Numbers,(Canm Ni/
ly, SubdMsien,Lot No., Pareel';.7Jp Code)
T�P GRAPHIC/ LAND SETTING:
Vstcpe OValey 0Fiat ❑Rldge CI Other
Om& sPpropdatebo%) ,, %
LATITUDE _1,,, AS, �� g tN I
LONGITUDE , L c41 kA)
Latitude/longitude source: PS OTopographic map
(bcatbn ofwelmust be shown on a USGS topo map and
attached to this form fnot using GPS)
4. WELL OWNER /'1
OWNER'S NAME D I Greco ayi St•
STREET ADDRESS P 0 gox 30
cbs-ic 'N ;Sorg
May be in degrees,
minutia, seconds or
in a decimal format
City or Tam State Zip Cede
Area code- Phone number
5. WELL DETAILS: oZ3D
a. TOTAL DEPTH: `,
b. DOES WELL REPLACE EXISTING WELL? YES p NO,
c. WATER LEVEL Beow of Casing cg FT,
(Use '4" tt Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
. 'Tap dossing terminated atlor bebw land surface my require
a variance In accordance with 15A NCAC 20.0118.
e. YIELD(gpm): % METHOD OF TEST L1 1 V
t DISINFECTION: Type chl on De Amount M Ay
g. WATER ZONES (depth):
From To Front To
From To From To
From To From To
6. CASING: Thickness/
• Depth D meter Weight Material
From 0 To %S Ft. 0a SDR21 PVC
From To Ft _
Fran To Ft
7. GROUT: Depth Material Method
Fran 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size .Material
From_ To Ft. In. h.
From To Ft. In. In.
Fran_To Ft In. In.
9. SANI/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
From To Ft.
10. DRILLING LOG
From TA_
o�
Fo ation Description
r1 Seth 1:'_ /01
75"ilSDlidate d re ea(
11. REMARKS:
N
lD r _'
n
LU'uil
I WHERREBYCERTFYTHAT Ti6S WELL WAS CONSTRUCTED N ACCORDANCE
1EA WAG 20. WELCONSTRUCTION STANDARDS, AND THAT ACOPT SW DS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG UREA CERTIFIED WELL CO RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30.days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699.1617 ' Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

North Carolina Department of Environment and Natural Resources -Division of Water 6
Duali Groundwater Section 2
ty- t� t, 3 4
1636 Mail Service Center - Ralelgh,N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /9048Nd Q^' "`''
WELL CONTRACTOR CERTIFICATION # : .3O 4
STATE WELL CONSTRUCTION PERMIT # :
' WELL USE (Check Applicable Box): Residential r/"'•r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring n
Recovery n Heat Pump Water Injection In Othern If Other. List Use:
"VELL LOCATION how sketch of the location below)
leerest town 075D F� dto4.( County
'FFxtt 1•V41/' i p0Af'sr a/S
A Orb CihFOiJ rdA/
cc:,.. Name and Numbers Community, or Subdivision and Lot No) DRILLING LOG
(•hPINEQ
A^.dress
/Yohh,'c SM%Th
DEPTH
=rom To Formation Description
;.3 I Ale-4 j'os1! fld
'4-
(Streetor Route No.) c/ C
6 S%r C2O0
City or Town _ State - Zip Code
GATE DRILLED G —6 - ° V
TTAi DEPTH 2/.2
I,TTINGS COLLECTED YES n NOF
DOES WELL REPLACE EXISTING WELL? YES NOM
STATICWATER LEVEL Below Top ofCasin' V.r' FT
(Use "+" if above Top of Casing)
TOP OF CASING IS a FT Above Land Surface'
• -co rasing terminated at/or below land surface requires a variance in actor- - -
' --r -Niel- ' 5A NCAC 2C 0118
�E LD (GPM`: X'r- METHOD OF TEST 801,14. ‘"
• • WATER ZONES (depth)
HLORINATION. Type i%%N Amount X
BASING Walt Thickness
Depth Diameter or Weight/Ft Material
To iL0 Ft L X • 6 , /FJs+.444":"Vc'
To Gt
To Gt
4 , ROUT
SCREEN
Depth Material Method
To Ft
To Ft
Depth Diameter Slot.Size Material
- m To Ft in in
�m _ To Ft in in
-.nrn To Fr in in
SAND/GRAVEL PACK:
Depth Size Material
To Ft
=FMARKS
To Ft
If additional space is needed use back of fcrm
LOCATION SKETCH
(Showdirection and distance from at least two State
Roads. or other map reference points)
0
r
>n
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.
J
FOR OFFICE USE ONLY
Quad No.
Serial No
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

$ ya6, 1 11111/41A;;1.91.1 ;l)
North Carolina - Department Fttad y
WELLcoNT1tACrot oton O)IIAL)NAMii i �J '�•.. �-"_ �
WELL CONTRACfot COMPANYNAMR , /� 1SbMF
STATI WELL CONSTRUCTION PERf:Rr# OCIA.ZD WQ
d
41,1,26
1. WELL USE (Check Applicable Box): Residential Mtmicip.UPublie D Industrial 0 Agnmltmal 0
Monitoring 0 Recovery 0 neat Pump Water Injection CI Other 0 If Other, List Use
WELL
2. e/Land setting
Nearest Town pi ///.1 U�}-//T Comity e x ? 4trJJ 2) QRidge CJSlope ° VallMat
(cluck bin)
Latitude/longitude of well location
(Street Name, Nambm, Commmity, Subdivision, Lot No, Zip Code)
?. OWNER: _5're-el {' 1 /�/4v II c k
Address Afo /d. ,'
I i-ete5atite/IC° .
city or Iowa 9 r{,S —s
me Op Code
i v - 27 a
Area code- Phone teamster4. DATE DRILLED . V0) 7
5. TOTAL DEPTH: 9 r
5. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cr
7. STATIC WATER LEVEL Below Top ofCasing:2 ?yes- FT.
(depaealmhaarlaeeaode)
Latitude/longitude soorce:DGPSCITopographic map
( boz)
DEM DRILLING LOG
From To Formation Description
(Um "+" if Above Top of Casing)
3. TOP OF CASING IS FT. Above Land Surface*
'Top of rasing termiaated tar below bead outset rtgSns a
variance la aemrdute ,with ISA NCAC 2C .0118.
9. YIELD (gpm): / 0! METHOD OF TEST r
10. WATER ZONES (depth): l r
11. DISINFECTION: Types �C
12. CASING:
FromTDothCC
From To
From To
13. GROUT: Depth
From %L9 To ��
From To
14. SCREEN: Depth
From To
From To
I5. SAND/GRAVEL PACK
Depth
From To
LCATIONSKE[CH O
cp
Amount / / . Show direction and distance in miles from at Leas
Wall Thicimess two State Roads or County Roads. Include the mad)
Ft Dirr
or Weight/Ft Mac numbers and common road names. _
///G tE
Ft tipt_ — rfl
Ft i W a�
Material Method o Ofr
Ft �'vv+^t—� o
Ft
Diameter Slot Size
Ft in.
Ft in. in.
Size Material
Ft
From To Ft
16. REMARKS:
0 Owl,
-11
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2C, WELL
ARD$, AND THAT A COPY QF THIS RECORD HnS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTION STAND
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Stetion. 1.5.36 Nail Service Center - Raleigh, NC
-rcoa-1634'hone Ye. •919) -,! _22I, within 30 days. G.J REV TV: DO 1

4orth Carolina — A.partunent 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 ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMA' #:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FOREST CITY County: RUTH
2AVENLANE
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER. HERMOND TAYLOR
Address RAVEN LANE
"Street or Route No.)
FOREST CITY NC 28043
City or Town State Zip Code
3. DATE DRILLED 06/08/06
5. TOTAL DEPTH 45
5. CUTTING COLLELFED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
3. STATIC WATER LEVEL Below Top of Caging: 25 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 actor -
lance with 15A NCAC 2C.0118
10. YIELD (gpm): 20 METHOD OF TEST: S 1'EEL 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 45 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 25 To 45 Ft 78M GRAVEL
From To Ft
17. REMARKS:
DRILLING LOG DEPTH
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 FOREST CITY. LEFT AT KFC ON BETHENY CHURCH
RD. LEFT ON DOGGETTE RD. RIGHT ON MORNING STAR
LAKE RD. LEFT ON BRIDGES FARM RD. RIGHT ON RAVEN
LANE. SINGLE WIDE AT DEAD END.
r._
r
U
0
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
Submit original to Division o
8 ffe-24P % _(9- l`<
ON59'RUCT1NG THE WELL DATE
Groundwater 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]
YELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS " � `x'
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMTr #:
. WELL USE (Check Applicable Box): Residential ❑ Municipal 0 Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
dearest Town: RUTHERFORDTON County: RUTH
INION RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER SAMUEL ADAMS
kddress UNION RD.
Street or Route No.)
RUTHERFORDTON NC 28139
:ity or Town State Zip Code
DATE DRILLED 06/16/06
TOTAL DEPTH 505
CUTTING COLLECIEll ❑ YES ® NO
'. DOES WELL REPLACE EXISTING WFJ ? ❑ YES ® NO
i. STATIC WATER LEVEL Below Top of Casing:40 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-
ance with 15ANCAC 2C.0118
0. YIELD (gpm): 3 METHOD OF TEST: ARD
.1. WATER ZONES (depth):
If additional space is needed use back of form
2. CHLORINATION: Type: CHLORYTE Amount: 13.5
3. CASING: LOCATION SKETCH
Wall Thickness (Show direction and distance from at least two State
Depth Diameter or Weight/Ft Material Roads or other reference points)
From 0 To 150 Ft 6-1/4" SDR21 PVC HWY. #108 W. FROM RUTHERFORDTON. LEFT ON UNION
From To Ft. RD. 4/10 MILE ON LEF 1 PAST WEST POINT BAPTIST
From To FL CHURCH.
4. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From To Ft. o
5. SCREEN:
Depth Diameter Slot Size Material 0
-e-17
From To FL in. in. = c r-
From To Ft. in. in. l =1
From To FL in. in. cv rn _.
6. SAND?GRAVEL PACK: ;Ts cc
r-.J o -"-
Depth Size Material o L,_
From To Ft. t-
From To Ft -
7. REMARKS: -<
DO CERTIFY THAT THIS WELL WAS CONSTRUCTIN 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 ON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-I 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]
TELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
WELL USE (Check Applicable Borg ® Residential 0 Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION: (Show sketch of the location below)
`earest Town: FOREST CITY County: RUTH
&CK MCKINNEY RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER HAROLD HINES
Actress JACK MCKINNEY RD.
Street or Route No.)
OREST CITY NC 28043
'ity or Town State Zip Carle
. DATE DRILLED 06/02/06
. TOTAL DEPTH 705
. CUTTING COLLECTED ❑ YES ® NO
. DOES WELL REPLACE EXISTING WELL? ❑ YES NO
. STATIC WA ILK LEVEL Below Top of Casing: 100 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 aceor-
ance with 15A NCAC 2C.0I18
0. YIELD (gpm): 2 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 50 Ft. 6-1/4" SDlt21 PVC
From _ To FL
From To Ft.
4. GROUT:
Depth Material Method
From 0 To 20 Ft. QUILKRETE POURED
From To FL
5. SCREEN:
Depth Diameter Slot Sin.
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:
Material
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. #221 S. FROM RUTHERFORDTON. RT. ON JACK
MCKINNEY RD. DRIVE ON LEFT ACROSS FROM W.V.
THOMPSON RD.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFd.1
: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 PERSbN CONSTRUCTING THE
ginal to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-I 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]
VELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
.. WELL USE (Check Applicable Box): ® Residential U f Municipal
U Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
:. WELL LOCATION: (Show sketch of the location below)
leanest Town: RUTHERFORDTON County: RUTH
)BSERVATION DR
Road Name and Numbers, Community, or Subdivision and Lot No.) From To
OWNER PAUL WHITWELL
lddress OBSERVATION DR
Street or Route No.)
IUTHERFORDTON NC 28139
ity or Town State Zip Code
1. DATE DRILLED 06/30/06
i. TOTAL DEPTH 285
i. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WFJ ? ❑ YES ® NO
3. STATIC WA lbk 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.011S
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 6.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 35 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:
DRILLING LOG DEPTH
Fonnation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distant from at least two State
Roads, or other reference points)
HWY. #108 W. FROM RUTHERFORDTON. RT. INTO WILLOW
LAKES. RT. ON BAYBERRY DR LEFT ON OBSERVATION
DR HOUSE AT DEAD END.
c'N
0
0
C•
[ 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.
IGNATURE O ON ONSTRU G THE ECI DATE
original to Division of Water Quality, Groundwater 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]
YELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
. 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:
WELL LOCATION: (Show sketch of the location below)
dearest Town: BOSTIC County: RUTH
YELLS MILL RD. DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
OWNER MIKE AMACHER
lddress WELLS MILL RD.
Street or Route No.)
IOSTIC NC 28018
:ity or Town State Zip Code
E. DATE DRILLED 06/29/06
TOTAL DEPTH 245
i. CUTTING COLLECTED 0 YES ® NO
/. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
I. STATIC WAIhR 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 acoor-
lance with 15A NCAC 2C.0118
T. YIELD (gpm): 10 METHOD OF TEST: ARD
l 1. WATER ZONES (depth):
l2. CHLORINATION: Type: CHLORYTE Amount 6
D. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 95 Ft.6-1/4" SDR21 PVC
From To Ft.
From To Ft.
l4. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From _ To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in_ is
.6. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
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)
BUS. 74 E. FROM FOREST CITY. LEFT ON BOSTIC/SUNSHINE
RD. GO THRU BOSTIC. RIGHT ON WELLS MILL RD.
APPROX. 1/2 MILE NEW RED GATE ON LEFT.
DO CERTIFY THAT THIS WELL WAS CONSTRUL 1 ED 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.
SIG ATURE OP ' •N CONSTRUCTING THE `• .1 DATE
bruit original to Division of Water Quality, Groundwater 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 Carta — Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
L. WELL USE (Check ApplicableBoz): ® Residential ❑ 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)
Dearest Town: RUTHERFORDTON County: RUTTY
OVE RD. DRILLING LOG DEPTH
Road Name and Numbers, Conmmnity, or Subdivision and Lot No.) From To Formation Description
3. OWNER NOEL JOHNSON
kddress COVE RD.
Street or Route No.)
2UTHERFORDTON
:ity or Town State Zip Code
1. DATE DRILLED 06116/06
5. TOTAL DEPTH 50
5. CUTTING COLLECT tD 0 YES NO
7. DOES WELL REPLACE EXISTING WFJJ ? 0 YES ® NO
3. 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 tcmimafed aVor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 2 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To 65
From To_
From To
14. GROUT:
Depth
From 0 To 20
From To
15. SCREEN:
NC 28139
Type: CHLORYTE Amount: 13.5
Wall Thickness
Diameter or Weight/Ft. Material
Ft. 6-1/4" SDR21 PVC
Ft
Ft.
Material Method
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:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM RUTHERFORDTON. RT. ON COVE
RD. NEW DRIVE ACROSS FROM SHINGLE HOLLOW FIRE
DEPT.
-
r
c'
c.)
Crn
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.
_a, / I /f 7 w0E i O- 76/o1 6
N CON TRU l t WELL DATE
ubmit original to Division of Water Quality, Groundwater 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]
YELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
.. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial 0 Agricultural ❑ Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
'. WEI J LOCATION: (Show sketch of the location below)
Dearest Town: BOSTIC County: RUTH
3LACK RIDGE DR LOT #79 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
S. OWNER BOB BURCH
%duress BLACK RIDGE DR LOT #79
Street or Route No.)
3OSTIC NC 28018
:ity or Town State Zip Code
1. DATE DRILLED 06/13/06
i. TOTAL DEPTH 905
i. CUTTING COLLECIEI) 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
3. STATIC WA int LEVEL Below Top of Casing: 0 FT.
Use "+" if Above Top of Cuing)
). TOP OF CASING IS I-1/2 FT. Above Land Surface*
'Top of casing terminated ator below land surface requires a variance in accor-
lance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WA1bit ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 25.5
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. QUIICRETE 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)
BUS. 74 E. FROM FOREST CITY. LEFT ON BOSTIC/SUNSHINE
HWY. LEFT ON TONEY RD. LEFT ON WATERS RD. RT. INTO
YELLOW TOP MIN. LEFT ON BLACK RIDGE RD. 1/4 MILE
ON RIGHT. LOT #79.
0
1 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.
SIGNATURE • ' 'w sN CONSTRUC 1 G -1 p 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
336 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): 0 Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
If Other, List Use: IRRIGATION
❑ Recovery ❑ Heat Pump Water Injection ® Other
. WELL LOCATION: (Show sketch of the location below)
learest Town: FOREST CITY County: RUTH
51 KELLY RD. DRILLING LOG DEPTH
toad Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
. OWNER MONTY SAVOY
.ddress 551 KELLY RD.
-Street or Route No.)
OREST CITY NC 28043
Sty or Town State Zip Code
. DATE DRILLED 06/13/06
. TOTAL DEPTH 205
CUTTING COLLECIhD ❑ YES [Si NO
DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
STATIC WATER LEVEL Below Top of Casing: 40 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 acwr-
ance with 15A NCAC 2C.0118
0. YIELD (gpm): 40 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 85 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
4. GROUT:
Depth Material Method
From 0 To 20 FtQUIKRETE 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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
FROM FOREST CITY GO DOWN HWY. #221A APPROX. 5
MILES. RIGHT ON KELLY RD. 1 MILE ON LEFT/ #551 ON
MIALBOX.
0
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.
ria'iLca-) 6— ? -l✓ G
SIGNA 't OF ' IN CONSTRUC G THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Borth Carolina —Department of Environment and Natural Resources — Division of Water Quality — Groundwater Sertion
636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
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:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: BOSTIC County: RUTH
?'ELLOW TOP MTN. -LOT #115 DRILLING LOG DEPTH
Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER TONY HARRELL
Address YELLOW TOP MTN. -LOT #115
Street or Route No.)
3OSTIC NC 28018
City or Town State Zip Code
3. DATE DRILLED 06/08/06
5. TOTAL DEPTH 505
5. CUTTING COLLECIE'D 0 YES ® NO
7. DOES WFI J REPLACE EXISTING WELL? 0 YES ® NO
3. STATIC WATER LEVEL Below Top of Casing: 160 FT.
Use "+" if Above Top of Casing)
TOP OF CASING IS 1-1/2 IT Above Land Surface*
"Tap of casing terminated at/or below land surface requires a variance in accor-
iance with 15A NCAC 2C.01 I8
10. YIELD (gpm): 2 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Depth
From 0 To 45
From To
Type: CHLORYTE Amount: 13.5
Wall Thickness
Diameter or Weight/Ft Material
Ft. 6-1/4" SDR21 PVC
Ft.
Ft.
From To
14. GROUT:
Depth
From 0 To 20
From _ To
15. SCREEN:
Depth
From To
From _ To
From To
Ft.
16. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material Method
Ft. OUIKRETE POURED
Ft.
Diameter Slot Size Material
Ft in. in.
Ft in. in.
in. in.
Material
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)
BUS. 74 E. FROM FOREST CITY. LEFT ON BOSTIC/SUNSHINE
HWY. LEFT ON TONEY RD. IN SUNSHINE. LEFT ON
WATERS RD. RIGHT ON ARBRA RD. INTO YELLOW TOP.
LEP 1 ON BIG ROCK RD. ALMOST TO END OF ROAD ON
LEFT LOT #115.
I DO CERTIFY THAT THIS WFJJ WAS CONSTRUCTED IN ACCORDANCE WITH ISA 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.
days
SIGNA O PERSON CON UCTING WELL DATE
Submit ginal Q ty, Y
original to Divisi of Water Quality, Groundwater Section within 30
GW-1 REV. 12/99

From: Scott Gantt 7044347212 To: Stephenie Wilson Date: 7/10/2006 Time: 6:D6 44 PM
Page 7 of 7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Gro1nlwwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Otter, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE
DEER RUN LOT 11, OFF GRASSEY KNOB RD
County RUTHERFORD
(Street Name. Numbers, Community. Subdivision Lot No,. Zip Code)
3. OWNER RIDGELINE DEVELOPMENT CORP.
ADDRESS 112 COCOPLUM CIRCLE
(Street or Route No.)
ROYAL PALM BEACH
City or Town
561-798-2729
FL
State
Area Code - Phone Number
4 DATE DRILLED 6/27/06
5. TOTAL DEPTH 180
6. DOES WELL REPLACE EXISTING WELL"
7. STATIC WAllat LEVEL Below Top of Casing:
33411
Zip Code
YES ❑ NO l7
40 FT.
(Use "t- If Above Top of Casing)
8. TOP OF CASING IS 2 IT. Above Land Surface`
'Top of easing terminated at/or below land surface regimes a variance in
accordance with 15A NCAC 2C.0118
9. YIELD torn). 15 METHOD OF TEST
l0. WATER ZONES (depth): 175
u. DISINFECTION: TYPE HYPOCHLORITE
12. CASING:
From 0
13. GROUT:
ARDM
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.24.556 / 82.10.095
(decrees/minutes/seconds)
Latitude'ongitude source: ❑ GPS ❑ Topographic map
DEPTH
From To
DRILLING LOG
Formation Description
0 45 Clay
45 I80 Consolidated Rock
Amount
7 Oz
Wall Thickness
Depth Diameter or Weight/Fr Material
To 51 Ft- 6 1 /4 " SDR 21 PVC
Depth
From 0 To 20 Ft.
t4. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in.
Ft,
Size
Slot Size
in.
Material
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
O
•
4T,
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.
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, N C
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
19. i % 2 U u Ci
4

From: Scott Gantt 7044347212 To: Stephenie Wilson Date: 7/10/2006 Time: 6:06:44 PM
Page 6 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)
1. WELL USE (Check Applicable Box): Residential Q
Recovery ❑ Heat Pump Water Injection ❑
2. WELL LOCATION:
Nearest town: RUTHERFORDTON County
(if applicable)
Municipal ❑ Industrial ❑ Agricultural
Other ❑ If Other, List Use'.
RUTHERFORD
FROG HOLLOW RD, OFF CASH RD, OFF MOUNTAIN CREEK RD
(Street Name, Numbers. Community, Subdivision, Lot No_ Zip Code)
3. OWNER RICKY JACKSON
ADDRESS 301 CASH RD
(Street or Route No.)
RUTHERFORDTON
City or Town
828-286-1016
Area Code - Phone Number
4. DATE DRILLED 6/15/06
NC
State
5. TOTAL DEPTH 300
6. DOES WELL REPLACE EXISTING WELL?
28139
Zip Code
YES ❑ NO ID
7. STATIC WATER LEVEL Below Top of Casing:
Rise `+' If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of easing terminated atlor below land surface roans a variance in
accordance with I5A NCAC 2C.0118
9. YIELD (gpm): 6
lo. WA 1ER ZONES (depth):
11. DISINFECTION: TYPE
12. CASING:
Depth
From 0 To
13. GROUT:
Depth
From 0 To
l4. SCREEN
METHOD OF TEST
255
ARDM
55 FT.
Monitoring
Topographic/Land setting
❑ Ridee ❑ Slope ❑ Valley X❑ Flat
Latitude/Longitude of well location
35 25.450181.59.602_
(degrees/minutesiseconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
DEPTH
From To
0 90 Clay
DRILLING LOG
Formation Description
90 300 Consolidated Rock
•
HYPOCHLORITE .Amount 13
Diameter
97 FL 61/4"
20 Ft
Oz
LOCATION SKETCH
Wall Thickness Show direction and distance in miles from at least
or Weight/FL Material ._ two State Roads or County Roads. Include the road
SDR 21 PVC numbers and common road names.
Material Method
GRAVEL MIX GRAVITY
Depth Diameter Slot Size Material
From NA To FL in in.
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft,
16. REMARKS:
--
t`
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
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
A, j, s1
20,53

From: Scott Gantt 7044347212 To: Stephenie Wilson Date: 7/10/2006 Time: 6:06:44 PM
Page 5 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 if ASSOCIATED WQ PERMIT #
(if applicable) - (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE
LOT 30, SECT. 5 RIVERBEND SUB
County RITHERFORD
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley 0 Flat
Latitude/Longitude of well location
(Street Name, Numbers, Corrmunity, Subdivision, Lot No,. Zip Code) 35.25.534 / 82.09.669
3. OWNER
ADDRESS
ROB EBERHARDT
282 TRAVERLERS REST LANE
(Sneer or Route No.)
RUTHERFORDTON
City or Town
828-625-8335
NC
State
Area Code - Phone Number
4 DATE DRILL Fr) 6/13/06
5. TOTAL DEPTH 200
6. DOES WELL REPLACE EXISTING WELL'
7. STATIC WATER LEVEL Below Top of Casing:
28139 From
Zip Code 0
YES NO Ei
75 FT.
(Usc "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
"Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 15 METHOD OF TEST ARDM
lo. WATER ZONES (depth): 190
U. DISINFECTION: TYPE HYPOCHLORITE Amount 7
(degrees/minutes/seconds)
Latitude'ongitude source: 0 GPS ❑ Topographic map
DEPTH DRILLING LOG
To Formation Description
100 Clay
I00 200 Consolidated Rock
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 114 Et 6 1 /4 " SDR 21 PVC
13. GROUT:
Depth
From 0 To 20 Ft
14. SCREEN
From
Depth
NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
FL
Ft,
Oz
Diameter
Material Method
GRAVEL MIX GRAVITY
Slot Size Material
in. in
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
c
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
711/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
f iJlt.
t UV,
GW-1 REV. 07/2001

From: Scott Gantt 7044347212 To: Stephenie Wilson
Date: 7/10/2006 Time: 6:06:44 PM
Page 2 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)
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: LAKE LURE
GROUND HOG ST. RIVERBEND SUB
County RUCHERFORD
(Street Name, Numbers. Community, Subdivision, Lot No,. Zip Code)
3. OWNER RIDGELINE DEVELOPMENT CORP.
ADDRESS 112 COCOPLUM CIRCLE
(Street or Route No.)
ROYAL PALM BEACH
City or Town
561-798-2729
FL
State
Area Code - Phone Number
4. DATE DRILLED 5/23/06
5. TOTAL DEPTH 400
6. DOES WELL REPLACE EXISTING WELL.
7. STATIC WATER LEVEL Below Top of Casing
33411
Zip Code
YES ❑ NO ❑
180 FT.
(Use "t- If Above Top of Casino]
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of c an8 tcnnmated at/or below land surface requires a vaitanee in
accordance with 1 SA NCAC 2C.0118
9. YIELD (gpm): 2 METHOD OF TEST
10. WA t LR ZONES (depth): 260
ARDM
(if applicable)
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley © Flat
Latitude/Longitude of well location
35.26.059 / 82.09.973
(degrees/minutes/seconds)
Latitude/longitude source: ❑ CPS ❑ Topographic map
DEPTH
From To
0 55
DRILLING LOG
Formation Description
Clay
55 400 Consolidated Rock
r1. DISINFECTION: TYPE HYPOCHLORITE Amount 11
12 CASING
From 0
U. GROUT:
Depth Diameter
To 65 FT 6 1/4 "
Depth
From 0 To
Ft SCREEN
Depth
From NA To
20 FL
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Wall Thickness
or WeiphuFL Material
SDR21 PVC
Oz
Diameter
FL
Ft,
Material Method
GRAVEL MIX GRAVITY
Slot Size Material
in. in.
Size
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
r
fv
o�
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.
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.
L liu1
G1V-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
Wed Contractor. (Individual) Name
Camp's Well & PUMA ro. Tor
Well Contractor Company Name
STREET ADDRESS
P 0 Bog
429
Ellenboro NC 28040
City or Town State ZIP Cade
(828). 453-7322
Area code- Phone rumba
2. WELL INFORMATION:
SITE WELL ID Mir applicable)
STATE WELL FERMIUM applicable)
DWQ or OTHER PERMIT #(t applicable)
WELL USE (Cheek Applicable Box): Residential Water Supply 0
DATE DRILLED D
TIME COMPLETED 2, /h AM PM 6d
CITY: -RAThrr yi COU ithfS. WELL LOCATION: r
Y, 1
rd
(/eitr U"nfer CY, - i f
(Sent Name, Numbers, Community. Subdlvsion, Lot No., Parul. Zp Code)
TOPOGRAPHIC /LAND SETTING:
oSlope WVadey °.Flat ❑-1Ridge CI Other
(theca apwoada4v.'L „
LATITUDE S 2—. T I A N
LONGITUDE S I. 58. 4� w)
Latitude/longitude source: OOPS OTopogtaphic map
(bcaIon of wet must be shown on USGS topo map and
attached to fhb loon- lnot using GPS)
OWNER'S NAME /,,1l Ve 6) ((I
E (3 i.(I I err
Y
STREET ADDRESS 0Kt)
May be In degrees,
mlmuta, seconds or
in a decimal brad
4. WELLOWNER
l-A-Ke L L(rre N) c_ -g74
wn State city or Tom
e
(—J-
Area code- Phone number
5. WELL DETAILS: 3 o�
a. TOTAL DEPTH: ���///
b. DOES WELL REPLACE EXISTING WELL.? ff A�YES CINO pt
C. WATER LEVEL Below Top d Casing: 4 V FT,
(Use'+'. I Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface'
'Top of cuing terminated etla below land surface may [,quire
a valance In acc`ordance wth 15A NCAC 2C .0118.
e. YIELD (gpm): -J METHOD OF TEST air
L DISINFECTION: Type Chlorine Amount
g. WATER ZONES ( ):
From To i0(�
From To
From To
1,5 cap
From To
From To_�_
From To
6. CASING: Lynda
'Frao �h /11) Ft 6#'
From To Ft
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
Thickness/
SDR21 PVC
From__ To Ft.
From_ To FL
6. SCREEN: Depth
From To
From To
From To
Diameter - Slot Size
Ft. In. In.
Ft In. In.
Ft. In. In.
Material
8. SANDIGRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From To.
0' .I(o
sA)Frotzalion Description
•
(IG -,c5 AiAma-tA
-n
co
11. REMAR
R
s: MAR 2 7 2006
Asheville Re ion
•
_ 1• > • c«r • e
IDOIEItEBYGERM Walla WELL WAS •• : '17- • ` ra.Z?-."EWRH
16A NCAC 2C. WELL CONSTRUCTOR STANDARDS. ANDTHATA COPY OF. THIS
RECORD HAS BEEN PppROVIDEDDTOOTTHE WELL
LLOOW✓NNEER.
SIG NATiU C RTIFIED-WELL'CONTRAETOR DATEolo
James W. camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Submit Mail the
Center - Raleigh, NC 2 699 1617 Quality original to the Division of Water PhonehNo. (9 9) 733-7Attn: ext 68.Non Mgt.,
Form GW-la
Rev. 7/05

C5 0 fl
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
8
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & P_umA Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tam State Zip bode
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicabb)
STATE WELL PERMIT#Napplicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE {Check Applicable Box): Residential Water SuppNV
DATE DRILLED I - 1 \:
TIME COMPLETED V.3 a AMO PM IY
3. WELL
LOCATION: 9 J
- L_t,l I - COUNTY ht. rf
CITY:
J-itlkr e l ke s -_ c f 1'1
(Strew! Name, Numbers. Community. SubdMslon, Lot No., Parcel2lp Code)
TOPOGRAPHIC / LAND SETTING:
QSlope Valley DFlat v4ldge ❑Other
(Meth appeowim box)
LATITUDE ,L 1 r
LONGITUDE12- eq tt
I
Latitude/longitude source: OOPS DTopographic map
(location ofwe►must be shown on a USGS topo map and
attached to this form I not using GPS)
May be m degrees,
minutes, seconds or
in a decimal format
4.WELL OWNER 1
OWNER'S NAME I .�CA ) Ye i .
STREET ADDRESS /9 Lt 114 C. ✓'-dL11 E
Town f 7 570
City fete Zip Code
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 17 NO
r
c. WATER LEVEL Below Top of Casing: tD 0 FT,
(Use'+' IlAbove Top of Casing)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
'Tap of casing tennblated avor below land surface my esquire
a vadance In accordance with 15A NCAC 2C .0115.
e. YIELD (gpm): METHOD OF TEST i,1-
f, DISINFECTION: Type chfor ine Amount .Q, ''tom caps
g. WATER ZONES (�deptth1):
From To (000 From To
From To From To
From To From To
6. CASING:
Depth 7Y Ft 6# ar
From 0 To
From To FL
From To FL
ThicWress/
Weight Material
SDR21 PVC
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To FL
Rom To FL
S. SCREEN:
From
From_
From
Depth Diameter Slot Sire .Material
To Ft in. in.
To Ft. In. In.
To Ft in. In.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From To
0• 33
Formation Dgscdptlon
C%ay, ennui
-; i 17o Pcl150bet e4 rec)C
1 DO HEREBY CERTFYTHA
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. MD THAT ACOPY OFTHI$
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
22,2L12
U E O
s F CERTIFIE6WE�iLLS ONTRACTOR DATE
VVVJames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DO
Submit the original to the 1617 Mali Service Center -Raleigh, NC 276994617 vision of (Quality
Phone No. (9 9) 733 7 6 eat 68.gon Mgt,
Form GW-la
Rev. 7105

1. WELL CONTRACTOR:
James W
Well Contractor (Individual) Name
Cain p'sWell Connecta Company Name
STREET ADDRESS P 0 BOX 429
EllenborO NC 28040
City or Town State Zip ode
(828t 453-7322
Area cods Phase number
2. WELL INFORMATION:
SITE WELL ID Cy applicable)
STATE WELL PERMITS(, applicable)
DWG or OTHER PERMIT S(if applicable)
WELL USE (Check Applicable Boa): Residential Water Supply rift
DATE DRILLED J_.---
TIMEECOMPLETED--- AMA PM
i
3. WELL ATION: -%
CITY: TA ke - I CCOUNTY aT err • G
/ - tEy ().] -Le 3--
(Street Name, Numbe!a, Community. Subdinsion. LCL No, Pwcel Code)
TOPOGRAPHIC I LAND SETTING:
0Slope OVaIey What ORldge ❑Other
(Gm* appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑ GPS OTopographic map
(beagon of well must be shown on a USGS topo mep and
attached fo this form if not ushg GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
r
City aTown state Zip Cede
Area �code - Phone number
May be In degas,
minutes, month or
in ■ decimal format
6. WELL DETAILS:
a. TOTAL DEPTH: yyyy��
b. DOES WELL REPLACE EXISTING WELL? AYES p NO A
11
c. WATER (UBTop of Casing:
Below Usese'*'.6 Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance In accordance with 15A NCAC 2C .0118. ,
ree. YIELD (9PFn):� METHOD OF TEST Q.I
RECEIVED
MAR 2 7 2006
S_ I ► ENTIAL WELL CONSTRUCTION RECORD
eVliie FkasMlunt of Environment and Natural Resources- Division of Water Quality
Aquifer Protection 2138
WELL CONTRACTOR CERTIFICATION #
T. DISINFECTION: Type ch 1 or ine Amount
g. WATER ZONES Weoptlt):
From To 1-00
9 1}"1
K fr1 it 0
From To
From To
6. CASING:
From 0
Fran__
From To
7. GROUT: Depth
From 0 To 20
From To
From . To
DTo1h6 FL gars
To Ft
Ft.
I ca
From To
From To.T_
Ran To
Thickness/
WeiaM Material
SDR21 PVC
Material Method
Ft Sackrete Hand
Ft
FL
a. SCREEN: Depth Diameter Slot Size .Mobilise
From To Ft In. N.
From To Ft In. __ In.
From To Ft. In. --- In.
9. SAND/GRAVEL PACK: Size MaterialDepth
From To Ft. ___—_---
From To Ft.
_. Fran_,__To_____
T2_ Ft 10. DRILLING LOG From To Fo n DeDescription`.
$ ...A M.
—n
co
N
u
11. REMARKS:
100 HEREBY CERTFYTMATTFBB war. WAS CONSTRUCTED N ACCORDANCE •
WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND *MAT ACOPY OF WS
• RECORD HAS BEEN PROVIDER TO 1HE WELL OWNER qq
1C]�
SIG T - � " C "TIRED WEL OCTOR DATE
James W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within ,30.days. Attn: Infonnatlon Mgt.,
1617 Mall Service Center — Raleigh, NO 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
1

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION g 2138
1. WELL CONTRACTOR:
James W. Ca
Well Contractor.(IndWklual) Name
Camp's Well & Pumo Co. Inc
Well Contractor Company Name
STREET ADDRESS P O Bok 429
Ellenboro NC 28040
City or Tarn State - Zip Code
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL Ina applicable)
STATE WELL PERMITil(aapplleable)
DWQ or OTHER PERMIT g(1f applicable)
WELL USE (Check Appueahle Box):Residential Water SWply
DATE DRILLED 2.- 3-Oh
TIME COMPLETED 4 ; I LI AMID PM
V
3. WELL LOCATIpN:
crrv: L Ic�KF La re coupiTY t Lea' Td
J
Lt-yiktie LaLek
(Street Name, Nanbso. CmwAX SubdiNslon;Lal No., Parcelaip Code)
TpPOGRAPHIC I LAND SETTING:
ltape Malley UFO CI Ridge ❑Other
(uwre appmpdatebm0
LATITUDE 6.-
LONGITUDE .J L 01.
Laftudelongitudesource: DGPS OTopograpbicmap
(Iocagon ol we/ must be shown on a USGS topo map and
attached to this form
tnot using GPS)
4. WELL OWNER /I
OWNER'S NAME (-(F ate n f&15
STREETADDRESS DS V a e
tI/vtood r-L
City a T State Zlp Code
May be In derma,
minute, sands or
in a decimal bleat
)
Area code Phone number
5. WELL DETAILS: ��
a. TOTAL DEPTH: `,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO {g
c. WATER LEVEL Below Top of Casing: Ft \
(Ustre if Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top ui casing terminated aUor below land surface may require
a variance in accordance wt h 15A NCAC 2C .0118.
e. YIELD (gpm): _ METHOD OF TEST a I
/
u
t. DISINFECTION: Type oh orine Amount uric
9.
WATER ZONES (depth):
From To
From To
From To
S. CASING:
netar 1
From 0 DTooI�D FL b# ten,
From To Ft _
From To Ft
7. GROUT: Depth Material
Fran To 20 Ft Sackrete
From To Ft.
From To FL
8. SCREEN: Depth Diameter - Slot Size .Material
From To Ft. In In.
From To FL In. In,
From_ To Ft In. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
Fran To FL
From To
From To
From To
Thkdmeasl
PVC
Method
Hand
10. DRILLING LOG
From ,.
0'
11. REMARKS:
C FoonRation Descriptbn
tv
O
MAR 27 2006
I DO IEREBY CERTIFY SAT THIS
15A NCAC20, WELL CONSTR --
RECORD HAS BEEN PROVIDED,
SIG
jSOFC
LIRE ERTIFIED WELLCONT
CTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Mall Servicoriginal to the Division of Water Quality
e Center — Raleigh, NC 27699-1617 h nehNo (9 9(733 70 Attn: ext 68.�on Mgt.,1617 Ma
3a days. informa
Form GW-1a
Rev. 7I05

`k G ,? S/ e Cp
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 0 Other ❑ If Other, List Use
2. WFI.i LOCATION:
Nearest Town: LAKE LURE
467 SANDERLING CT.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: BILL WALKER
Address 467 SANDERLING CT.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
(828) — 773-5383
Area Code Phone number
4. DATE DRILLED 02/06/06
5. TOTAL DEPTH: 345
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): 30 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 9
12. 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
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 _ FL _
From To FL
16. REMARKS:
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. #64/74A W. FROM RFTN, RIGHT INTO
RIVERBEND ON RAINBOW CIRCLE. FOLLOW
RAINBOW CIRCLE APPROX. 1 1/2 MILES THEN
RIGHT ON SANDERLING CT. APPROX.1/4 MILE
ON LEFT.
RECEIVED
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
w
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTIRUCTION STANDARDS, AND THAT A COPY OTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON C 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

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 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: MOORESBORO
219CANE BREAK CREEK
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MARGO PORTMAN
Address 219 CANE BREAK CREEK
(Street or Route No.)
MOORESBORO NC 28114
City or Town State Zip Code
8(28) — 245-1480
Area Code Phone number
4. DATE DRILLED 02/23/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
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): 15 METHOD OF TEST ARD
10. WATER ZONES (depth): _
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 70 Ft 64/4" SDR21 PVC
FromTo_Ft_ _
From To Ft_ _
13. GROUT: Depth Material
From 0 To 20 Ft QUHKRETE
From _To_Ft_ _
14.SCREEN: Depth Diameter Slot
From To Ft. is _
From _ To _ Ft in.
15. SAND/GRAVEL PACK:
Depth Size
From _ To Ft
From To ^ Ft
16. REMARKS:
Method
POURED
Size Material
in.
Material
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS 0 Topographic map
(check box)
DEPTH DRILLING LOG
From To 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. #221S. FROM RUTHERFORDTON. LEFT
ON HINES RD. LEFT ON LAKE HILL FARM RD.
RIGHT ON CANE BREAK CREEK RIGHT ON
DRIVE AT HOUSE #219.
RECEIVED
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
0
Cf.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE PERb`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

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WELL CONSTRUCTION RECORD van carrMCTOR: ,Q ,Am) a/7'er. �'I/ 7*
11aL C0111IAC10l 1CAd01t f .jam / a
*TAW WILL CONIMI NC110MP1IYIEt
t. WILL VINt�M A1ym7.OIIr1M.1wDlIc zr CI ININOIiCI
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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 Cant actor.(IndMdual) Name
Camp's Well & Pimp Co.
Well Contractor Company Name
STREET ADDRESS I' 0 Bo 429
Ellenboro NC
City or Town State
( 828)• 453-7322
Area code- Phone number
2. WELL INFORMATION:
SfTE WELL ID #01 applicable)
STATE WELL PERMIT#N applicable)
DWQ or OTHER PERMIT #(1f applicable)
WELL USE (Check Applicable Box): Residential Water SuppFyP
DATE DRILLED -b(' -
TIMECOMPLETED AMP PMf•'
3. WELL LOCH N: ,.J
Inn.
28040
Zip code
CITY: G
++ eY c)
1 t,��CIOUNTYP 11/4
II//
(Street Name, Numbers, commuNty. SubdMslon, La No, Parcel, Code)
TOPOGRAPHIC I LAND SEp' ING: ^
❑Slope OValey OFIat Ridge Other
lama e-p ntalidabex)
LATITUDE .,1y 30. S 7 IJ
LONGITUDE g 47 - GS 7 Wl
Latitude/longitude source: OOPS oTopographic map
(location cf wel must be shown on a USGS tope map and
attached to this fain Inot using GPS)
4.WELL OWNER j,'• f et, kg:R(1 �O
OWNER'S NAME AlSTREET
•
ADDRESS _L 0 Bo X 3
IGK°/l L S��G.3 063�
City or Town II State Zip Cade
May be in depea,
minutes, seconds or
Inc decimal trod
Area code phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NOX
c. WATER LEVEL Below Top of Casing:--yOO_FT,
(Use en Above Top of Casing)
d. TOP OF CASING IS 1 _ FT. Above Land Surface'
'Top of casing Rotated at/or below land surface my require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST (L) r
6p6f
f. DISINFECTION: Type ch l or ine Amount ",( S
g. WATER ZONES, (depth):
From To kALU From To
From To From To
From To From _ To
6. CASING: Thickness/
Depth Diameter We�M
From 0 To 5' 1Ft 6t SDRZ1
Fran To Ft __
From To .Ft __
7. GROUT: Depth Material Method
Froen 0 Te 20 FL Sackrete Hand
Fran To Ft
From To Ft.
PVC
8. SCREEN: Depth Diameter Slot Size .Material
From To Ft In. In.
From To Ft. In. In.
Fran_____, To Ft. in. in.
9. SAND)GRAVEL PACK: Sim
Depth
Material
Ran ' To Ft.
From To Ft.
Ran To Ft �
10. DRILLING LOG
From To' rmation Description
(A A(vtn 9R
REf_EIVEn
---IctA-R—t72006
Asheville -Regional Office
•fettle
11. REMARKS:
0
IDO HEREBY CERTIFY THAT THIS WELL WAS OONSTRVCIED N ACCORDANCE WITH
ISA NCAD EC. WELL ONSTRUNSTAN�DDS. AN THAT ACOPY OF. THIS
RECORD BEEN TO
a2110
URE OF CERTIFIED WELLS NTRACTOR DATE
ames W. Cam
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617Subinit ty within 30 days. Attn:
Mall Seroriinal to te Division of Water vic9e Center- Raleigh, NC 276994617 a)lPhone No.3 9) 733 7015 ext 568. Mgt.,
Pam GW-la
Rev. 7/05

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & PLUM) Co._Tnc
Well Contractor Company Name
STREET ADDRESS P o Bok
Ellenboro NC
( 828)• 453-7322
City or Tom ' State
Area code- Phone number
2. WELL INFORMATION:
429
28040
Zip Code
SITE WELL ID #Or applicable)
STATE WELL FERMIUM aPr arable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE/Check Applicable Booq: Residential Water Supply 9'f
DATE DRILLED — ,?Loe t
r
TIME COMPLETED `'� � t / AMID PM Er
3. WELL LOC ION:
CITY:�,""" j5�((-'couNTY ► IA. ft
`J Ir out11}} cth& e Ks L
(Street Name Numbers, Community. Subdidalon, Lot No., Parcel, zip coda)
TOPOGRAPHIC / LAND SETTING:
❑Slope tVaalley OFlat IDA�idge ❑Otter
tawck epproPrIeb9 r0
LATITUDE L
LONGITUDE L 47. °2?"Z iA)
Latitude/longitude source: DGPS OTopographic map
(beatbn of wet must be drown on a USGS lopo map and
attached to this form I not ushg GPS)
4.WELLOWNER L j ✓' / ' /I
OWNER'S NAME 1 a.h))1 11(SS-k` (a
STRE,��(T,ADDRESS f) 4) too) 63
ttfC-KoYV state 8� z�cede - 638
City or Twin i
Area code - Phone number
6. WELL DETAILS: j /
a. TOTAL DEPTH: �%4(7 pc
b. DOES WELL REPLACE EXISTING WELL? YES p NO pT,
c. WATER LEVEL Belot Top of Casing: -10 FT,
(Use '+'.If Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Top et casing terminated ator below land surface may require
a variance In accordance with 15A NCAC 2C .011IL r
e. YIELD (gpm): .'i`t METHOD OF TEST a )
May be. in degrees,
minutes, seconds or
in a decimal brunet
•
t. DISINFECTION:Typechlorine Amount )� C.azr)5
g. WATER ZONES ¶de h)
From To M r l From To
Fran To From To
From To From To
6. CASING:
From 0
From To Ft.
From To Ft
7. GROUT: Depth
Thickness/
Depth DI eter Wei Material
OD Ft 6� M SDR21 PVC
Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft.
a. SCREEN: Depth
From To
From To
From To
Diameter Slot Sire Material
Ft._In. In.
Ft. In. tn.
Ft. In In,
9. SAND)GRAVEL PACK:
Depth Sim Material
From To Ft
From To Ft.
From To FL
10. DRIWNG LOG
From To
o ?5
b .q4t
Formation Dpgscdption
Ciel . ,midi c1Yituel
C1.)1201ir%1ei Peck
RECEIVED
MAR 2 7 2006
AChnvitle Regional Office
Aquifer F'roteetier►
11. REMARKS:
I DO HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
16A NCAC 20, WELL CONSTRUCTION STANDARDS, AND 1HATACOPY OF. THIS
RECORD HAS BEEN PROVIDED TO THE W
CyyELL.�OWNER.
wELL cis
SIG
ITUR _ OF CERTIFIED NTRACTOR bATE
antes W. Camp
i'RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wlthin,30.days. Attn: Information Mgt,
1617 Mall Service Center — Raleigh, NC 276994617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camo
W el C.mhecta.(IndMdual) Name
Camp's Well & Pump
W e0 Contractor Company Name
STREET ADDRESS P 0 BoX
Ellenboro NC
City or Torn ' State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Nif applicable)
STATE WELL PERMIT#N appllable)
DWQ or OTHER PERMIT #(e applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED
Co.
429
Inc
28040
71p bode
z{:3o AMID PM/ ((
3. WELL LOCATION:- ,. �U furl
CITY: f JOS 11- t C- COUNTY µ 14 rr vrd
tot z — S, Mt tieaKs
(Street Name, Numbers. Community, Subdivislon, Lot Na, Parce&Tlp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVarey °Flat °Ridge ❑Other
(made eppropdalab?ld n/1
LATITUDE b.. 39. 17 q
LONGITUDE L 4L7' 167 k1
Latitude/longitude source: OOPS °Topographic map
(ocechnd wmgm/not snro aUSGSjtopo mapJand/j��
4. WELL OWNER IJ Dye eK 1- U w.
OWNER'S NAME r / A
STREET DDRESS L o x 3
cxort State C °Z D3ceae G 3Zip S!
CI or Town
May be In degrees,
minutes, monde or
in a decimal format
Aseacodee Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
210
b. DOES WELL REPLACE EXISTING WELL? YES Q NOO
c. WATER LEVEL Below Top of Casing: 4 U FT.
(Use If Above Top of Casing)
d. TOP OF CASINO IS 1 . FT. Above Land Surfaces
lop Cf casing txndnated at/a below land surface may require
a valiance In accord e.
dance wEh 15A NCAC 2C .011
e. YIELD Wpm): .%`� METHOD OF TEST A 1 ✓
f. DISINFECTION: Type chlorine Amount
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING: net
er
From 0 To Depth�J/rX FL 6*
From To Ft
From To Ft
1
To
To
To
Thbl�lladessl
WeMaterial
PVC
T. GROUT: Depth Material
Fro( 0 To 20 Ft Sackrete
From To Ft.
Front To Ft.
Method
Hand
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In In.
From To Ft. In. In.
Frorn__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' Sg
Fgrma(ion Description
Lri-, Sand-
y'ST . Rio I'nn)i date r{ Itor_K
RECEIVE
MAR 27 7006
Asnevttte-Renial C
Aquifer Protect °
11. REMARKS:
I DO HEREBY CERIWYTHATTHIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 20. WELL CONSTRUC DON STANDARDS. AND THATACOPY QF TNIS
RECORD HAS BEEN PROVDEDTOTHE WELL OWNER.
/ ' Cal 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 Mali Service Center -Raleigh, NC 27699-1617 Phone No. (919).733-7015 ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 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 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC County RUTH
BOSTIC/SUNSHINE HWY.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: CONVNIENCE CENTER
Address BOSTIC/SUNSNINE HWY.
(Street or Route Na)
BOSTIC NC 28018
City or Town State Zip Cade
8() - 429-9990
Area Code Phone number
4. DATE DRILLED 02/21/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
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): 15 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 40 FL 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 _ in. _ in.
From ToFt. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft_
From To Ft
16. REMARKS:
Topograpbic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ 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
BUS. 74 E. FROM FOREST CITY. LEFT ON
BOSTIC/SUNSHINE HWY. GO THEW SUNSHINE.
NEW CONVENIENCE CENTER. APPROX. 1 MILE
ON LEFT.
RECEIVED
MAR 27 2006
Asheville Regional Office
Aquifer Protection
ca
0
0-1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND
.THAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
R/
Ad��f+sliJ �/. /� Oi o7- rJt / —SIGNATURE OF PERSON Q/2'tNG THE ( 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

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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) JEFF MELTON ChRRTIFICATION # 3417
WELL CONTRACTOR COMPANY NAME PIITMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIAILD WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential lla Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC County RUTH
HARVEY LOGAN RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip ('Me)
3. OWNER: CURTIS MEISSNER
Address HARVEY LOGAN RD.
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
(609) - 897-9677
Area Code Phone number
4. DATE DRILLED 02/20/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 11=1/2 FT. Above Land Surfacer
'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 4.5
12. 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 _
13. GROUT: Depth Material Method
From 0 To 20 FL 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
❑ 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
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 BOSTIC GO UP BOSTIC/SUNSHIE RD.
RIGHT ON SALEM CH. RD. RIGHT ON HARVEY
LOGAN RD. 1/2 MILE ON LEFT.
RECEIVED
MAR 27 2006
Asheville Regional Office
Aquifer Protection
c.3
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFJJ
CONSTRUCTION STANDARDS, AND THAT A COPY Sjf THIS RECORD Hg4S BEEN PROVIDED TO THE WELL OWNER
4S�eE!� '7L3 er
IGNATURE OF P ON a STRUCTING WELL
r12n,Q vZ .2 • F7;
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

6
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)
F.) Alli 1^y
ti 4
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: FOREST CITY
JIM DOBBINS RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: KAREN SEWARD
Address JIM DOBBINS RD.
(Street or Route No.)
FOREST CITY NC 28143
City or Town State Zip Code
(770) - 536-1021
Area Code Phone number
4. DATE DRILLED 02/08/06
5. TOTAL DEPTH: 285
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WA 1MK 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): 40 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 6.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 100 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 FL
16. REMARKS:_
Topographic/Land setting
❑ 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
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 SHHAH GO DOWN POORS FORD RD.
RIGHT ON GRAYS CREEK CHURCH RD. LEFT
ON JIM DOBBINS RD. LEFT ON BROAD OAKS
LANE. 1sr DRIVE ON LEFT.
RECEIVED
MAR 27 2006
Asheville Regional Office
Aquifer Protection
0
c�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LPYft.
SIGNATURE OF FEICSON CONSTRUC
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 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON County RUTH
HOLLY FOREST DR.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: SCOTT HOWE
Address HOLLY FOREST DR
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
9(54) - 342-8957
Area Code Phone number
4. DATE DRILLED 02/13 06
5. TOTAL DEPTH: 465
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 11_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): 7 METHOD OF TEST ARD
10. WATER ZONES (depth): _
11. DISINFECTION: Type CHLORYTE Amount 12
12. CASING: Wall Thickness
Depth or Weight/Ft Material
To 85 SDR27.6 PVC
To
To
Depth
To 20
To
Depth
From _To_Ft_ in. _ in.
From _To_Ft_ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 0
From
From
13. GROUT:
From 0
From
I4.SCREEN:
From _To_Ft
From _To _Ft
16. REMARKS:
Diameter
Ft. 6-1/4"
Ft _
Ft
Material
Ft. QUIKRETE
Ft _
Diameter Slot Size Material
Method
POURED
Topograpbic/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 DRILLING LOG
From To 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 SHILOH GO DOWN CLEGHORN MILL
RD. LEFT ON HOLLY FOREST DR. 2/10 MILL
DRIVE ON RIGHT.
RECEIVED
MAR 27 2006
Asheville Regional Office
A * uifer Protection
0
I DO HEREBY CERTIFY THAT THIS WEI I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
l SIGNATURE e P 'wON STRUCTING AWELL `¢ DATE / 3 - 6
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 0 Indushial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON
WELLINGTON DR.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Cade)
3. OWNER: BRIAN CONNERS
Address WELLINGTON DR
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
(828) — 447-3413
Area Code Phone number
4. DATE DRILLED 02/10/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Lacing: 60 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS a FT. Above Land Surface*
*Top of rasing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 50 METHOD OF TEST ARD
10. WATER. ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 120 Ft 6-1/4" SDR21 PVC
From To Ft _
From_ To_FL_
13. GROUT: Depth Material
From 0 To 20 Ft QUJXRETE
From To Ft.
14.SCREEN: Depth Diameter Slot Size
From To Ft. _ in. _ in.
From _ To _ FL in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
Method
POURED
From To Ft
From To Ft
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
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. #108 W FROM RUTHERFORDTON. RIGHT
ON WELLINGTON DR APPROX. 1/4 MILE ON
RIGHT.
RECEIVED
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
CD
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC fED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSSjtUCTION STANDARDS, AND THAT A COPY OF S 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

5�
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WFI I 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 2 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: LAKE LURE
LAUREL LAKESOLOT #65
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: NEAL BOTIE
Address LAUREL LAKES -LOT #65
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
8(28) — 651-0081
Area Code Phone number
4. DATE DRILLED 02/14/06
5. TOTAL DEPTH: 405
6. DOES WELL REPLACE EXISTING WELL? YES ❑ 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 I5A NCAC 2C .0118.
9. YIELD (gpm): 4 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 10.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 60
From _To_
From _To
13. GROUT: Depth
From 0 To 20
From To
14.SCREEN: Depth
From To
Ft. 6-1/4" SDR.21 PVC
Ft
Ft _
Material Method
Ft. OUIKRETE POURED
Ft
Diameter Slot Size
Ft in.
From To _ Ft.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From _To_Ft
Material
in.
in.
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 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. #64/74A W, FROM RUTHERFORDTON.
RIGHT ON BH.L'S CREEK RD. LEFT ON LAUREL
LAKES PKWY. LEFT ON 1" PAVED RD. TO LEFT.
DRIVE ON LEFT AT CUL-DE-SAC
RECEIVED
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
0
0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC 1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSCTION STANDARDS, AND THAT A COPY OF S CORD HAS BEEN PROVIDED TO THE WELL OWNER
& -N �. �� a - /V- 0 (
SIGNATURE OF PERSONtONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center — Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 21 38
1. WELL CONTRACTOR:
James W. Camp
Well Contnutor.(IndhAdual) Name
Camp's Well & PsmD Co. Inc'
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town State
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID l(It applicable)
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #Qf applicable)
WELL USE (Check Applicable Boo:): Residential Water Supply
DATE DRILLED 2/1 " b /
TIME COMPLETED I o 4 5-AM E PM EI
3. WELL LOCATION:( -�- `�
CITY: RI.L'i V12Y{orc lt'H COUNTY RIAt11tYfOYJ
Zip Code
1310LcK Roc?: Falls —Lot (3
(Stre t Nana. Numbers, Community, SubdMsbn, Lot No., Pamela.* Code)
tTOPOGRAPHIC / LAND SETTING:
ope DValleY DFW ORidge ❑OOmr
(cMck rppropda4bag
LATITUDE �1D 11 IN
LONGITUDE I ate° D .362WJ
Latitude/longitude source: GPS ❑Topographic map
pocatkm of well must be shown on a USGS topo map and
attached to this farm lno( ushlg GPS)
4. WELL OWNER r
OWNER'S NAME �`1 -Yesl E
STREET ADDRESS d' 0 go X
May be in dogma,
minutes, seconds or
in • decimal format
LKe i_JAre NA;
ChyorTown State
Area code - Phone number
7r't c
Zip Code
5. WELL DETAILS: 18
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES to NOX
C. WATER LEVEL Below Top of Casing: TO FT,
(Use's•' ifAbove 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): 10 METHOD OF TEST GL I r
t. DISINFECTION: Type chlorine Amount f& de
g, WATER ZONES ( t ):
Fran To i 11 From To
Fran To
From To
From To From To
B. CASING: e�e� Thickness/
eight tetial
From 0 DTole //D Ft 6# . SDR21 P
From To FL _
From To .Ft.
7. OROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
Fran . To FL
8. SCREEN: Depth Diameter - Slot Size .Material
From To Ft. In. In.
From_ To Ft. in. N.
From To Ft. in. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To , Ft
From To Ft.
Fr an_,_T@ Ft.
10. DRILLING LOG
From To.
0• 110
IIt a_`1C
RECE
Sanonnationd / Cliff Description
Gclfolidate4 re K
"Sl
CD
Shell?e Ser1U,:...:
An rir's:- rvtec'•
11. REMARKS:
1 CD HEREBY CERTI YTHATTHIS WELL WAS CONS1RUCIED N ACCORDANCE WITH
15A NCAC 2C, WELLCONSTRUCT1N STANDARDS, AND1HATSCOPY OF INS .
RECORD HAS BEEN FROVIDEDTOTNE WELL OWNER.
TUBE OF 1RT CeELL ► �D ld
SI T REOFCERTIFIED�W€LC'CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. (9191733-71315 eat 568.
Form GW-la
Rev. 7/05

•
,RESIDENTIAL WELI.coNSTRUCTIONRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 8 21 3 8
1. WELL CONTRACTOR:
James W. Camp
Well Contracta.(IndMdual) Name
Camps Well & Pnmp Co.
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Tnc_
Ellenboro NC 28040
City or Tam ' Stele - ZIPCode
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID eor applicable)
STATE WELL PERMIT9Nappli able)
DWG or OTHER PERMIT 0()t applicable)
WELL USE (Cheek Applicable Box): Rae entlal Water Supply
DATE DRILLED — 6 .
TIME COMPLETED 21:0 0 AM ❑ PM'E�/
CATI
3. WCITY:ELL LRt47ker�rd l4%'(. COUNTY -1 /per IYQ
C l ea, tAia_ter K - Li 3V
(Sheet Name. Mahan. Gomm:Wye eton. Lot No., Parc&.21p Code)
T °GRAPHIC / LAND SETTING:
lope OVa!ey OFIat ORHge ID Other
YYYYYY (Maar sPproeriolo q 'I
LATITUDE $ l+ ` • 3"AA 1V .
LONGITUDES L SDI. ¥57 W
Latitude/longitude source: 1)6PS °Topographic map
(bcatbn otwe/must be shown on a USGS topo map and
attached to this farm II not ushg GPS) /% 1
ELL OWNER
4.00WNERSNAME 1-inLI e 5 , U e ()1.() /8i✓5
STREET ADDRESS f' D I 0 X �i 'i 0I
lgteKe Lnie 4,
City or Town State Zip Cale
May be N degrees,
minutes, seconds or
bra decimal tom*
Area code - Phone number
5. WELL DETAILS: /- D.�
a. TOTAL DEPTH: k?
b. DOES WELL REPLACE EXISTING WELL? YES p N0
Cs WATER LEVEL Below Top of Casing: tP / FT,
(Use'9 8 Above Trip of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface'
'Top of casing terminated et/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 4 METHOD OF TEST aY
f. DISINFECTION: Type Chlorine Amount
g, WATER ZONES (depth):�
From To 4Cf0 Frem To
From To From To
From To From To
6. CASING: �TNcknessl
De'Front 0 TTFo oft Ft. th D61am�e ten 1 PVC
Frorn To Ft _
From To -Ft
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
From To Ft
From . To _ Ft
S. SCREEN: Depth
Fran_To_
From To
Diameter Slot Ske .Material
FL_In. ht.
From To FL In In.
9. SAND/GRAVEL PACK:
Depth Shah Material
From Tq Ft.
Fran To Ft.
Fran —To FL
10. DRILLING LOG
From Tpp . FormaWn Description
. A' *o r'ii r7"l 0
526 ctitp ro cK
11. REMARKS:
1 WHEREBY CERTIFY MAIMS WELL WAS OONSIRUCIED N ACCORDANCE W0H
11A NCAC 20. WELL CONSTRUCTION STANDARDS. ANDTHATACOPY 9F7W$
RECORD HAS BEEN PROVIDE) WELL OWNER
r c)✓rth L,) wv CO .DI-LL
SI TURE OF CERTIFIED WELL CO RACTOR BATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 3Odays. Attn: information Mgt.,
1617 Mall Service Center - Raleigh, NC 27699-1617 ' Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Cam
Well Contractor.andNidual) Name
Camp's Well & PuMO Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Tarn State tip Code
( 828 } 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#prapplicable) '
STATE WELL PERMIT#(e applicable)
DWO or OTHER PERMIT #Pf applicable)
WELL USE {Check Applicable Box): Residential Water Supply ❑
DATE DRILLED -l. -e6
TIME COMPLETED 1-SO AM PMgy/'
3. WELL LOCATION: r, �j (�
CUY7)RtA rtW,Y/1 /e"Y/t)comity l�1� her "Nei
D /ac k Rock rRLI S — Let
(Street NNNNem% Numbers, Community, SubdMsion, Lc( No., Parcel, 21p Code)
TOPOGRAPHIC / LAND SETTING:
dope °Valley ()Flat ❑Ridge DOther
land( epprapd■LLbog n'
LATITUDE _ 2 LAS • 07 (V
LONGITUDES_ 22 D4. %:z6 k)
Latitude/longitude source: 606PS °Topographic map
(location of Wei must be shown on a USGS topo map and
attached to this form #not using GPS)
4.WELLOWNER {,• I
OWNER'S NAME Lake 5 e !✓Zi) idlea
STREET ADDRESS pi) 1 t x 5 4 9
l Ke 1-u rf Nc
May be in degrees,
minutes, seconds or
in a decimal format
City or Tam State Zip Code
Area code- Phone number
5. WELL DETAILS: %15
a. TOTAL DEPTH: OA
b. DOES WELL REPLACE EXISTING WELL?
LLYES CI NO 21
c. WATER LEVEL Below Top d Casing: 70 FT,
(Use'V If Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surfaces
'Top of casing termhlated at/or beiox lard surface m@y require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ) METHOD OF TEST it I )'
L DISINFECTION: Type Chlorine Amount I CAA
g. WATER ZONES (d� e�oit
From To I i\ From To
From To From To
From To From To
6. C•ASING: �ete� TWeight Metaled
hickness/Fran 0 �To CPO Ft. Si SDR21 PVC
From To Ft
From To Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From__ To FL
Fran_ To Ft
9. SCREEN: Depth Diameter . Slit Size .Material
From To Ft In. N.
Fran To Ft. In. In.
From To Ft In. In.
9. SAND/GRAVEL PACK:
Depth She Material
From To Ft
From To Ft
From To Ft.T
10. DRILLING LOG
From .To . Foration Description
.0' 1,o di
o vLZi f'ort5o;Mate d, Yocgt
✓ EGEAN L )
rs)
J
Ashevriflb flogio ial Offce.—
hCi.1�te 'roteL:7`•3i,
11. REMARKS:
IOC HEREBY CERTIFY THAT TtaIN B WELL WAS CONSTRUCTED NACCORDANCE W
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANDTNATACOPT Of nor$
RECORD HAS BEEN PROVIDED�TO(T.HEEJWYEU.00WNER.
SIC URE 0 CERTIFIED FIED WELL'CONTRACTOR DATE
��
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within .30.days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Deparhnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION R 2138
1. WELL CONTRACTOR:
James W. Camp
Wea Contractor (Individual) Name
Camp' s Well & Psmn Co, Tor
Well Contractor Company Nerve
STREET ADDRESS P 0 BOX 429
Ellenboro NC 2;040
City or Tam State tip Code
(828} 453-7322
Area code. Pilaw number
2. WELL INFORMATION: SITE WELL ID apt applicable)
STATE WELL PERMITtr(aappacable)
DWQ or OTHER PERMIT 8(S applicable)
WELL USE (Check Applicable Box): Residential Water Supply
7 ❑
DATE DRILLED ,- 4 - D G
TIME COMPLETED '71'30 AMp PMW'
3. WELLLOTI�O1N�: 1f� 1 ..L -F!_; CITY: K.4 teYtore/ lam% COUNTY kJ'eYlaj
$I&c RocK �aJ)6 L-f 3
(street Name, Numbers, Community. Subdivision, Let No., ParceLZip Code)
T OGRAPHIC / LAND SETTING:
lope DVaeey °Fla DRidge ❑Other
(wear atah *)
LATITUDE . £o s D lit
.L N1.'
LONGITUDE, a' O • 2f I W
Latitude/longitude source: PS °Topographic map
(bcatbn Orwell must be shown on a USGS tope map and
attached to this form footushg GPS)
4. OWNER
OWNER'S 1.--k C$/ de /u/dens
STREET ADDRESS P 09ox 5214
May be in degrees,
minute., seconds or
in a decimal Sormat
rake iItre c as79-b
City or Tam State Zip Cede
Area code- Phone number •
5. WELL DETAILS:
a. TOTAL DEPTH: ) 'OS-
b. ��//
DOES WELL REPLACEEXISTINGWELL? YES a NOX
0
c. WATER LEVEL Below Top of Casing Pt') FT,
(User' if Above Top d Casing)
d. TOP OF CASINO IS 1 . FT. Above Lard Surface'
'Top d easing temgnated at/or below land surface mey require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Ow METHOD OF TEST a )
f. DISINFECTION: Type Oh orjne Amount
g. WATER ZONES (depth):
From To 11i U From To
From To Fran To
From To From To
8. CASINO: Thickness/
From 0 DToth Ft Tarter Weight ial
SDR21 PVC
From To Ft. _
From To Ft.
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
From_ To FL
From_ To FL
8. SCREEN: Depth
From To
From_ To
Diameter . Slot Size .Material
Ft. In. In.
Ft. In In.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From ' To Ft.
From To Ft.
From To FL
10. DRILLING LOG
From To0 go
orti+etion Description
d irt) Sand
go ;2103— Cort5pI!dated rock
R F CC:
AS{,GJl1iD 9/-Y
!sc:
11. REMARKS:
in
100 HEREBY CERTIFY THATTHIS WELL WAS OONS1RUC1ED 11ACCORDANCE WRH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANDTHATACOPY OF 7HI$ .
• RECORD HAS BEEN PRCMDEDTOTH.EyW��LLLE.L+,OWNER
LI)"2l
SI TORE �ERTIFIED WELL'CONTRACTOR DATE1.1
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within30. days. Attn: Intormation Mgt.,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9 21 3 8 '
1. WELL CONTRACTOR:
James W. Camn
Well ContraAu.(IndNidual) Name
Camp' s Well & Plump Co Inc
Well Contractor Company Name
STREET ADDRESS P 0 Doi 429
Ellenboro NC 28040
City or Town State Zip Cale
(828). 453-7322
Area code- Phase number
2. WELL INFORMATION:
SITE WELL ID ads applicable)
STATE WELL PERMITfh(9 applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE {Check Applicable Bar): Residential Water Supply ❑
DATE DRILLED 1 O 6
TIME COMPLETED 2 45 Am ID PM V
3. WELL LOCATION: ^ , f ('
CITY: take i lire COUNTY a ar
)
affalo ShtAk i . — tot ad
(Street Name. Numbers. Community. SabdMslen, Lot No.. Pame;Zip Code)
T POGRAPHIC / LAND SETTING:
(lope Malley °Flat Midge ❑ODIm
(check apprapdstabox) ^,
LATITUDE L .2•57 ` I q /Y
LONGITUDES. ' D, S N�
Latitude/longitude source: PS °Topographic map
(location of we/must be shown on a USGS topo map and
attached to this tom not ushg GPS)
May be In degrees,
minutes, seconds or
in a decimal tomes
4. WELL OWNER n, ^�I' r
OWNER'S NAME ) e r/I D,,)rL,tte ( .L i i c . ' J )
STREET ADDRESS PH NOM. lithe Ke'EcIyr.Hiird
Fro 5fnraof C-"i.. 33843
City or Tdxn State Zip Code
Areas code Phone number
5. WELL DETAILS: L� !`�
a. TOTAL DEPTH: J 5-
b. DOES WELL REPLACE EXISTING WELL? YES Li NoX
a WATER LEVEL Below Top of Casing: too FT
(Use '+'-if Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Lend Surface*
'Top et casing terminated et/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ;2- METHOD OF TEST a / it
f. DISINFECTION: Type chlorine Amount „2GZl�IS
g. WATER ZONES (depth): /
From To 9 b t From To
Fran To From To
From To From
To
B. CASING: n�y, Thickness/
ess/
Frar�Droth '/o Ft 6 SDR21 PVC
From To Ft _
From To Ft
7. GROUT: Depth - Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft
From_ To FL
B. SCREEN: Depth Diameter . Slot Size .Material
Fran To Ft. In. In.
From To Ft In. In.
From_ To Ft In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Fran To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From ...To.
.0 0
Formation Desgrption
lirr� sa;i1
o't wrsoli1 iW rDcK
Achsvil'C Reniald�l
LJ
C7'7f eY r'fc ertori
11. REMARKS:
100 HEREBY CERTFYmoms WELL WAS CONSTRUCTED IRACCORDANCE WITH
16A NCAC2C, WELL CONSTNUOTION STMOMDS. AND THAT ACOPY 0F. THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
n
SI URE OFFCERTIFIED
ED C CO RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submlt 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.
Fenn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Wed Contractor.(IndMdual) Name
Camp' s Well & Pump Co. Inc
Well Contractor Company Name
STREET ADDRESS P O BOX 429
Ellenboro NC
CltyorTam State
( 828)- 453-7322
28040
Zip ode
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID sac applicable) '
STATE WELL PERMIT#(dapplable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply❑
DATE DRILLED . 3- D - 0
TIME COMPLETED I , 45 AM ❑ PM iir/
3. WELL LOCATION: DD�.}�� ,,�(
CITY: NtXe tare COUNTY &l/iev rd
ga f fa l o .110415 Rd. - !^o / ie2
(Street Name, Numbers. Community, SubdMslon, Lot No., ParceLZip Code)
TOtOGRAPHIC /LAND SETTING:
ope OVatey °Flat °Ridge ❑Other
(check rppropriatebolo
•
LATITUDE _ �G, lr/0 /✓
,,,
LONGITUDE $• Zod WLatitude/longitudeessource: elIGPS °Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER D rip?
OWNER'S NAME rieri .i Y,L�/I . V c1 /�
STREET ADDRESS 814 r1JV6✓!bl r- J<e KPH/edy ./5iYcJ
osotertof Fl— 33 g431
ity or TwwAA1t State Zip Code
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal tomcat
5. WELL DETAILS:
a. TOTAL DEPTH: j/
b. DOES WELL REPLACE EXISTING WELL? YES p N0 fA
GI WATER LEVEL Below Top d Casing: 7 FTC, J
(Use '+'.HAbove Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
'Top of easing terminated at/or below land surface may require
a variance In accordance Wlth 15A NCAC 2C .0118. ,
e. YIELD (gpm): ).-fi METHOD OF TEST a / %
305
f. DISINFECTION: Type chlorine Amount /At Car
g. WATER ZONES (Qepth):
From To el
u
From To
Fran To
6. CASING:
From 0 DTo
?ire
YI Ft Trer
Fran To Ft
From To Ft.
From To
From To
From To
Thickness/
SDR21 PVC
7. GROUT: Depth Materiel Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Sim
Fran_ To Ft. in. h.
From To Ft. In. In.
From_____ To FL In. In,
Matedal
8. SANDIGRAVEL PACK:
Depth Site Material
From TO FL
From To Ft.
From To__ FL
10. DRILLING LOG
From ]7o4
0• ,
Foiratbn Deseriptbn
Ci(T, qra✓el
74 .L405 C0115oI date el rocK
RECE V
Act itvlIki Reoioriai
AP; i+la: Farr,'k'ct
11. REMARKS:
0
100 HEREBY CERTIFY THAT THIS WELL WAS OONSmUCTED NACCORDANCE WIN
15A MAC 2C, WELLCONS1RUCTON STANDARDS, AND THATACOPY OF OAS
RECORD HAS BEEN PROVIDEDTO THE WELL OWNER
LURE 0 aittCER CERTIFIED IED'VLELL'CONTRACTOR TE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30. days. Attn: infotlnadon Mgt.,
1617 Mail Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(IndMdual) Name
Camp's Well & PsamD Co. Tnc
Well 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 #lit applicable)
STATE WELL FERMIUM? applicable)
DWG! or OTHER PERMIT #(e applicable)
WELL USE (Cheek Applicable Box): Residential Water Supply CI
DATE DRILLED 3-7-a4
TIME COMPLETED 5? OO AM 0 PM V
3. WELL LOCATION: ,
CITY: bi-f� Z. 2-1-Ore COUNTY �f.I(/`P✓/-% CYO
(S (pl Name,00t TT N to ! Al unity. Subdivisbn. I.ot N rc&3Zlp Code)
yTO�y OGRAPHIC / LAND SETTING:
W'lope OValey ()Flat ORidge ❑Other
(check approrp—databoa) / j
LATITUDE , ✓ ° .26. ��p /v
LONGITUDE
Latitude/longitude source: PS ['Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL CANNER ,
OWNER'S NAME ®I e ✓iOD inT . Ti1C •
May be in degas,
minutes, seco dsa
in a decimal reset
t. DISINFECTION: Type chlorine Amount _f,,7/LCN1S
g. WATER ZONES ():
From To ri (.) From To
From To From To
From To Ram - To
6. CASING: 7 ThWeicioknesul
From 0 Depth
Too 7v Ft Diameter SDR21 Pht VC
From To Ft.
Ram To Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
Front_ To Ft.
Fran_To Ft
8. SCREEN: Depth Diameter Skit Sim
From To Ft In. In.
From To Ft. In. In.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft
From Te Ft
10. DRILLING LOG
From '
T .
..0' O
`t0. '405
STF FE TADDRESS D 9 D✓7 N( LI k Keedy Blvd.
YDSftiyotJr re_ -3 94-3
City or Tam / State Zip Code
L_)-
Areacode - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3°5
b. DOES WELL REPLACE EXISTING WELL? YES [' NOdS
C. WATER LEVEL Below Top of Casing: / FT.
TTT
(Use'+' If Above Tap d Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface'
'Top of casing terminated at/or below land surface my require
a variance In accordance with 15A NCAC 2C .0118..
e. YIELD (polityo`(inMETHOD OF TEST GLI r
Material
Size Material
Fo ation Description
a;rf 9✓ade!
r
•
conso//datpd Yock
r7
fV
11. REMARKS:
RECE taE'D
n
al Ravi Rerll;nel Gmce
1 W HERBY C'O'z"^'•rnoww�_yi�'fADNACWWNC RE WRH
15A NCAC 20, WELL CONSmUCTION STANIiXRt18, ARD1HA1 AU)VI I TW$
RECORD HAS BEEN PRWIDEDTOTHE WELL OWNER.
2SI RE OF CER IFIED WELL CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within,30.days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Camp
Well Contractor.(IndMdual) Name
Camp's Well & Plump
ro . Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 280t2de
City or Town State
(828} 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(It applicable) '
STATE WELL PERMR#(8appliable)
DWQ or OTHER PERMIT #(lf applicable)
WELL USE {Check Applicable Box): Residential Water Supply if
DATE DRILLED — I —
TIME COMPLETED f a. '-Fs AMO PMII
S. WELL LOCATION::,� _�
CITY: jZt,f Il'ledY4lo.� )pouri1Y RKHiercrd
Cr Ica),t tier Creek -
(Street Name, Number., Community, SubdMslon.Lot No., ParmN.2lp Code)
OPOGRAPHIC / LAND SETTING:
Slope Malley anal 0Ridge ❑Other
OM& appwpdatabold _ 'r
IATTNDE �1 / t`tt
LONGITUDES_ L '? �. z G t W
Latitude/longitude source: Lii4PS oTopographic map
(location of well must be shown on a USGS topo map and
attached to fhb loan #not using GPS)
4.WELLOWNER
OWNER'S NAME \ c Jc e 5 S/(' L' f/ D
1
STREET ADDRESS 13 J.4a I a f In I, ' L i) TA
Sarasota rt.- 3 o
City or Town State Zip Cede
7.IP
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS: ,2
a. TOTAL DEPTH: 3 0 i
b. DOES WELL REPLACE EXISTING WELL? YES p NOic
c. WATER LEVEL BelowTop of Casing: 56" FT,
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top d casing temlkmted at/or below bud surface may mqulre
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): rn METHOD OF TEST a))'
T. DISINFECTION: Type Chlorine Amount Lup
g. WATER ZONES (depth):
From To _A (g 0 From To
From To From To
From To From To
8. CASING: / n�t�� Thlcknessl
Weight Material
'Fran 0 DeToth/6't Ft. D6# SDR21 PVC
From To Ft _
From To Ft
7. GROUT: Depth
From 0 To 20
Material Method
Ft Sackrete Hand
From To Ft
From To Ft
8. SCREEN: Depth Diameter . Slot Size .Material
From To Ft. In. N.
From To Ft In. In.
From To Ft. In. In.
9. SANDIGRAVEL PACK:
Depth Sim Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To.
0• ta4
f1Formation DpscdptIon
1!t1 5and
•
f01f- '30h Ct1Ns0/rdatej rrrf<
V
alievilrt Ret_iOrlc
n; 7 F r Y)r,rft0C,
11. REMARKS:
rj
LIN
1 DO HEREBY CERTIFYTNATTHB; WELL WAS CONSTRUCTED NACCORDANCE WRN
15A MAC 20. WELL CONSTRUcllDN STANDARDS, AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI
(kfmi) lit) C.t).rYx 3. l C
S RE OF CERTIFIED WELL ONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within;30. days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 213 8
1. WELL CONTRACTOR:
James W. Camiz
Well Contractor (Individual) Name
Camp' s Well & Pulttp Co, Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
Zip Clty or Tam ' State -
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mir appileable)
STATE WELL FERMIUM applicable)
DWQ or OTHER PERMIT #(a applicable)
WELL USE (Check Applicable Box): Residential Water Supply I]
DATE DRILLED 5-
TIME COMPLETED ,i:0O AM❑ PM
3. WELL LOCATION:
CITY: lake Lt.(Lt.(Yrf;
e. COUNTY 1 /'lPY
6vt) eat 6Y IAJ' — �-o t 6:1
(Street Name, Numbers, Community, SubdMsion, Lot No., Parcel Z p Code)
TOPOGRAPHIC / LAND S NG:
°Slope Malley °Fiat DIMIdge ❑Other
(ehWr appropdate bap
•
LATITUDE „t 5i 2-9. 3' 4
LONGITUDE S 2.` 15 I. 419aLI)).
May be In degrees,
minutes, seconds or
in a decimal bone
Latitude/longitude source: MOPS oTopographic map
(kcatbn of wet must be shown on a USGS fopo map and
attached to this form snot ushg GPS)
4. WELL OWNER
OWNER'S NAME Ickes)
e l,Ltl�eYS
STREET ADDRESS P O IS 0 X 549 .
take Luxe_ NI (;R /74 tv
City or Town State Zip Code
(—>
Area code - Phone number •
6. WELL DETAILS: �I
a. TOTAL DEPTH: O�� 5
b. DOES WELL REPLACE EXISTING WELL?/ YES p NO K
c. WATER LEVEL Below Top O( Casing: (G C FT,
(Use '+'.9 Above Top et Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top d casing terminated et/or below land surface may [equine
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 71 METHOD OF TEST
f. DISINFECTION: Type chlorine Amount 1/ Z rap
g, WATER ZONES (depth
From To �b V
From To
From To
B. CASING:
Fru 0 Tod ? 1 Ft. of
Fran To Ft
Fran To Ft
From To
From To
From To
Thlclmess/
Weight Material
SDR21 PVC
7. GROUT: Depth Malachi
From 0 To 20 Ft Sackrete
From To Ft.
From To Ft
Method
Hand
8. SCREEN: Depth Diameter . Slot Size
From To Ft In. In.
From To Ft. In. h.
From To FL In. In.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft
From _To Ft
From To Ft
10. DRILLING LOG
From '7
.0•
Material
Materiel
Formation Descriptlen
SA Rd 1 cAai
fphsol;dAre e roc-
RECE
Ashnt/Ora R'+r(ic;fl< _
h.z.ecuL
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED NACCORoANCE WITH
115A MAC 2C, WELL CONSTRUCTION STANDARDS. AND 'MAT A COPY qT Ttp$ •
RECORD HIS BEEN PRONIDEDTOTHE WELL OWNER
i la) CALveNg 41.111116
S TURE OF CERTIFIED WE CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within;30. days. Attn: Information Mgt,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05

ti
North Carolina • Department of Environment and Natural fir nourcos - Division of Water Ounfty - Groundwaler Snctinn
1636 Mail Service Center • Raleigh, N.C. 2763n-1638-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: l i-lell / teSere. S Ye abc.,
WELL CONTRACTOR CERTIFICATIOFI U: a/9/
STATE WELL CONSTRUCTION PERMITti:
1. WELL USE (Check Applicable fox» Resldonfia)`T I Municipal 0 Indushial fJ Agricultural [ Monitoring
El
Recovery ❑ Heat Pump Water Injection ❑ Other II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road Name Qnd Nvmbers, CAmrnunity, or Subdivision nod Ln1 No.)
3. OWNER JC)A4 / IC 6/d»'s
Address F/fait LAY
jSheet o'r tloulo Do APO
"i, CAAAl AA.) 2
City or Town Slain Zip Coda
4. DATE DRILLED •D - ILI " D w
5. TOTAL DEPTH 2D-° — y 1( li_o_—
6. CUTTINGS COLLECTED YES 1-1tI.Cit4J Ho - 1 1-1 01
7. DOES WELL REPLACE EXISTING WELL? YES LJ NO 1 _ .li.c - _3ao
8. STATIC WATER LEVEL Below Top of Casing: _ `i 5 FT.
(use'. 11 Abovo T op of Casino)
9. TOP OF CASING IS "r 1 FT. Above Land Surface'
•Top of ceslnp terminated eUor below land sus taco regWIres a verlance In accor-
dance with 15A NCAC 2C .0110 —
10. YIELD (gpm): 3____ MELHOD OF TEST A 1R
11. WATER ZONES (depth): I a O
Df1ILLIiG LOG
nom To
4346-1
3-Dr
a a' 4 ill
y o'
12. CHLORINATION: Typo 1a 41d
13. CASING:
From
From
From
Ft.
To F1.
To Ft
Depth
FI To NCS
14. GROUT:
Diameter
lo1
Amount I4
Wall Thickness
or Weight/Ft. Material
a;rt p ✓c
Depth Material
From C To a G Ft 'Bar e
From To Ft _
15. SCREEN:
Depth
From To Ft
From To FI.
From To Ft
16. SAND/GRAVEL PACK:
Depth
To
To
From
From
17. REMARKS:
Melliod
PV'-ry f'
Diameter Slot Size Malndal
In. in
In In
In In
Material
DEPTII
fnnration Dcsainlicn
Qd eA
120c.)�
Rosh
R —(bit
W
en
V
II additional space Is needed use back of form
LOCATION SI_ETCH_
(Slrovr direction and distance Tram nt Ienst Iwo Stale
Fronds, or other map reference points)
4
c
Pr.
Li/Cal.:- Rau
RECEIVED
Asheville Regional Offire
Ari'iitei PrTtectri io
1 DO HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCTED INACCORDANCE WITII 1 SA MAC 2C. War -_
—
CONSTRUCTION STANDARDS, AND 11IAL A COPY OF15 RECO( IIAS PEEN PROVIDED TO 111E WELL O'V/?IEUI.
L
ifa- 01-f* Deo
L._OR OFFICE USE ONLY
uad No:
Size
F-t
Ft
i
Serial No
SIGNATURE or PERSOII co usTRUCrirlo TIIE WELL DATE
Submit 0401a1to Division of WaterOualily. Groundwater Section will in 30 days
GW-1 ItEV. 1212)

ri om. OWL vai ni Iu. Qmpi mule rumor rasa a u.
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)
1. WELL USE (Check Applicable Box) : Residential El
Recovery ❑ Heat Pump Water Injection ❑
2. WELL LOCATION:
Nearest town: RUTHERFORDTON
116 GILMER EDWARDS RD
(if applicable)
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Other ❑ If Other, List Use:
County RUTHERFORD
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
3. OWNER HORTON HOME OF RUTHERFORDTON
ADDRESS 342 HWY 74 BYPASS
(Street or Route No.)
RUTHERFORDTON NC
city or Town Sute
828-287-3366
Area Code - Phone Number
4. DATE DRILLED 2/21006
5. TOTALDEPTH 220
6. DOES WELL REPLACE EXISTING WELL,
7. STATIC WATER LEVEL Below Top of Casing:
28139
Zip Code
YES ❑ NO 121
60 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
"Top of casing terminated at/or bdow land surface requires a variance in
accordance wilh 15A NCAC 2C.0118
9. YIELD (gpm): 6 METHOD OF TEST
10. WATER ZONES (depth): 120
ARDM
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
3524.914 / 8157.488
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
DEPTH
From To
0
DRILLING LOG
Formafion Description
70 Clay
70 220 Consolidated Rock
u. DISINFECTION: TYPE HYPOCHLORITE
12. CASING
From 0
13. GROUT:
Depth
To 80
Amount
8 oz
Wall Thickness
Diameter or Weight/Ft. Material
Ft 61/4" SDR21 PVC
Depth
From 0 To 20 FL
14. SCREEN
From
Depth
NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Diameter
FL
Ft,
Material Method
GRAVEL MIX GRAVITY
Slot Size Material
itt in.
Size
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
RECEIVED
+„ I3 i. 9nng f;;'A
GW-1 REV. 07/1001
Asheville Regional Office
Aquifer Protection

rr tun. ouon Gantt io: otepneme wnson
Date: 3/17/2006 Time: 6:48:58 PM Page 3 of 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: RUTHERFORDTON
120 LEWIS RD
County RLITHERFORD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER HORTON HOME OF RUTHERFORDTON
ADDRESS 342 HW Y 74 BYPASS
(Street or Route No.)
RUTHERFORDTON
City or Town
828-287-3366
NC
State
Area Code - Phone Number
4. DATE DRILLED 2/20/06
5. TOTAL DEPTH 300
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28139
Zip Code
YES ❑ NO 0
45 FT.
(Use "s" [(Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surfaces
•Top of casing terminated aUor below land surface requires a variance in
accordance with I5A NCAC 2C.0118
9. YIELD (gpm): 6 METHOD OF TEST ARDM
to. WATER ZONES (depth): 110
lt. DISINFECTION: TYPE HYPOCHLORITE Amount 12
12. CASING:
Depth
From 0 To 140
U. GROUT:
Diameter
FL 61/4"
Depth
From 0 To 20 FL
H. SCREEN
Depth
From NA To
l5. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.25.994 / 82.00.185
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
From
0
DEPTH
To
135
135
DRILLING LOG
Formation Description
Clay
300 Consolidated Rock
Wall Thickness
or Weight/Ft. Material
SDR21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
Ft. in.
Size
Ft,
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 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 Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
RECEIVED
Asheville Regional Office
Aquifer Protection

I VI II. I pl,CIIIC vvIIauII
pate: 3/ 17/2006 Time: 6:48:58 PM Page 2 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 ❑ Municipal P ❑ r, strUl ❑ Agricultural ❑ Monitoring 0
Recovery
0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE
LAURAL LAKES LOT 22
County RUTHERFORD
(Street Name, Numbers, Community, Subdivision Lot No,. Zip Code)
3. OWNER
ADDRESS
RIDGELINE DEVELOPMENT CORP.
112 COCOPLUM CIRCLE
(Street or Rowe No.)
ROYAL PALM BEACH FL
City or Town State
561-798-2729
Area Code - Phone Number
4. DATE DRILLED 2/16/06
5. TOTAL DEPTH 600
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
33411
Zip Code
YES ❑ NO El
140 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.0118
9. YIELD (gpm): 15 METHOD OF TEST
to. WATER ZONES (depth): 520
ARDM
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.27.759 / 82.08.650
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
From
0
DEPTH
To
55
DRILLING LOG
Formation Description
Clay
55 600 Consolidated Rock
RECEIVED
II r,-., - 1 ., �.....
Asheville Reylorldt Office
AauifCr Platection
11. DISINFECTION: TYPE HYPOCHLORITE
12. CASING:
Depth Diameter
From 0 To 60 Ft 61/4"
13. GROUT:
From 0
14. SCREEN
Depth
To 20 Ft.
DepthFrom NA To
15. SAND/GRAVEL PACK:
Depth
NA To
16. REMARKS:
Amount 22
Wall Thickness
or Weight/Ft. Material
SDR21 PVC
oz
Diameter
FL
Ft,
Material Method
GRAVEL MIX GRAVITY
Slot Size Material
in. in.
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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 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

IUIII, JFVtt. VCIIII Ili. oleo ICI Ile VVIIbUll
Gate: 3/1 /(2U06 Time: 6:48:58 PM
Page 1 of 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality -
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED
(if applicable)
1. WELL USE (Check Applicable Box) : Residential ❑
Recovery ❑ Heat Pump Water Injection 0
2. WELL LOCATION:
Nearest town: HARRIS
SULFUR SPRINGS CHURCH RD
Groundwater Section
CERTIFICATION # 2584
# [phone]
WQ PERMIT #
(if applicable)
Municipal 0 Industrial 0 Agricultural 0
Other ❑ If Other, List Use:
county RUTHERFORD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER DANNY SCOTT
ADDRESS SULFUR SPRINGS CH. RD.
(Street or Route No.)
HARRIS
City or Town
828-245-7692
NC
State
Area Code - Phone Number
4 DATE DRILLED 2/27/06
5. TOTAL DEPTH I80
6. DOES WELL REPLACE EXISTING WELL'
7. STATIC' WATER LEVEL Below Top of Casing:
Zip Code
YES ❑ NO ID
35 FT
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of easing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gym): 10 METHOD OF TEST ARDM
lo. WATER ZONES (depth): 38
Monitoring ❑
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
LatitudeiLongitude ofwell location
35.15267/ 81.54.298
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS 0 Topographic map
DEPTH
From To
0
DRILLING LOG
Formation Description
20 Clay
20 180 Consolidated Rock
u. DISINFECTION: TYPE HYPOCHLORITE Amount 7
12. CASING:
Depth
From 0 To 27
13. GROUT:
Wall Thickness
Diameter or Weight/Ft. Material
FL 6 1/4 I' SDR 21 PVC
Depth
From 0 To 20 Ft
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To Ft,
16. REMARKS:
oz
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in
Size
Slot Size
in
Material
Material
RECEIVED
Asheville Regional Office
Aquifer Protection
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
7-0
rV
CD
CD
CT+
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.
371/06
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. 072001

ct C2 v' _ ' A&F WELL DRILUNG
AND PUMP SERVICE,INC.
Nab Crate iasr-� M6 ttfl ante MAIM ll.s uj ' CMabas et WS away• GraRtlwwt Sedan 911H Business 4
to]e Mao iraea RWlak aL0. tltleF 11131- 7a ns ptq 733.2221 Bostic, NC 28013
WELL CONSTRUCTION RECORD wwscoNTRACTOR: , ��le)6// ?8 4j y s
WELL CONTRACTOR CIRTIFICATTON r. 213 S
STATE WELL CONSTRUCTION PERMITN
1. WELL UaEESaleek wsmoth Roo:SW MunIupb � lahntial0 AprkY118r.I ❑
Newsy Heat Fan WOK klloellen ❑ Ofw ❑ It Oflar, Lbt U e:
2. WELL LOCATION: (Stow eloloh4 YoeellO tan below)
(IA ��Ac�. r77�—
pUdRowInl/a+ak..s n rib- r--"oteree.wtrIN.) OM.LINQLOQ QJPTH
A OWNER r 1 !/ -- ewe To Rano Deusdpied
Ad&sfl
comers Ec jT arA ` mc1 c z 24
4. DATE O
S. TOTAL DEPTH
i. currlttoa TEED ►lo -?
7. DOES WELL REPLACE EX1S11NO WEU.T YES 0 NOET
S. STATIC WATER LEVEL Raw Too adCoast: gSnFT. _,
No •9AtmTap Oattw
S. TOP OF CASINO tS,L_. 5 FT. Move Lind Swim'
'TM M subs hnalwAsi IS estw Mad sods swim • miss Is sasr
demi dM WAIICAC39Jiti
1D. YIELD (IIPmk M'INOO TEST 11- 1 n
11. WATER LONELf eaaplb): 6
12. CHLORNATIOtt Type . R4 3 Amount /Oct'
13. CASINO: 'va '
Wazenu
Depth Mbar .WiYMI t . *yid
F
rom To FL,-
.- Tim_. Ft.
To FL
1 t. GROUT:
pth MOS
From ke . To .ram© FL SA M1 X qt5r ice rk
Preen To R.
IS. SCREEtt:
OspItt Una( S1otSILi
Faro _...To ' Ft In. .—.—
ROM To FL— IL — In.
From To ___... FL In.
10. sAND/oRAVH.PACK:
Ooprt Slut MSS
From To
From . To FL_�_�
17. REMARK&
CERTIFY THAT THIS WELL WAS CONSTRUCTION fN A ONDMNCE WITH ISA ICAO *C. WELL
MSS
J
ISAMS owMNeededwhewsbm
LOCATION SKETCH
phew aeeUanallddotr1c1Awn Meow Sues ,' A
Roods. wOhs poor .. : )
sY y s l-!</i• s /1 Cosi
i Up HERESY '
CONSTRUCTION STANDARDS. AND THAT *COPY OF THIS RiOORDl1As KEN PROMS TOME WELL OnaER
roll OFFK USE ONLY
ai ME
forum wreaor +F °
lobs * IIflobMeedWderOdIh0111/441 rSna � > ®Itl1EY.>*
Asheville Regional Office

Novel Cesar . 0 ew Yr s en/ Nature, MseuSs - dNrion
me See L-Meee*SSW N.C. stew-te,7e•Mrne 60E 7334221
WELL CONSTRUCTION RECORD
zl
A&F WELL DRILLING
war TWIG • wounsfs.t Snarl AND PUMP SERVICE, INC.
911 Hwy. Business 74
> Bostic, NC 2801 S
WELL CONTRACTOR:: f� T � r» f // / ),/4 7- �
NT1773
WELL CONTRACTOR CERTIPICATION IT: 2.1.35
STATE WELL. CONSTRUCTION PERM/11: -
1. WILL USE crtook woe l sl 0 MankW ❑ ApdcoNwal
Raceway Root Puny WE S N cion ❑ Oelree p N OBrer, LW Um:
2_ WELL LOCATION: (Slrr sl,.lelr d watt lenree WW1)
r,E//9.E49/ /c•/- r-, hc- pi" r//cal//s
mom Nsowse MRr-�--sAike 1 -NM DMJ.I&G1.00
a. OWNER i r&,9NI� %/ � Fire To
•JLeAc,�
AOS
IIeTI�e.-_.
/3c°-DC),/./-1cd.s fr-hs,ge,44 35/Y
C,rwToW aria $4M
4, DATE ORE.LEO C2r:
8. TOTAL DEPTH o
e. CUTTINGS No
7. DOES WELL RERACE Busts. G winoYEi (0 Non—
S. STATIC WATER LEVEL Ws Top of Cale: "n FT.
,/rn v9AIasTa,.....M
S. TOP OF CASING Sl/ . FT. Mew Lend Sldelsae'
'rn er sub. WSW* svaeele. lewd seAeatwelwe• ee.Ynse lean -
Inn volit SIA MAC AMN
10. YIELD Wink %/a Mi' OF TEST n- i n iT /z;k.)
11. WATER ZONES. ,aq 4 '
12. CH ORIiATgtt Type rat 4:C.:4 t Mount/ 2,4 wez
13. CAM: '5 '
WS Nano
Dg1Y1 , apneas ee F:9YIIYFt . liYlA.l
From j.� op To S�j Rt a" 4 frJ•'''-"
Fran Tee FI..-
Frown To.— ft
14. GROUT:
Depth
From %IV . ye cap FL Si nterli.
From To FL
15. SCREEIt
'USW
Lice r1.
►1r1pm Dlemelee Slot Lite M otodN
From To - Ft . In. ----- In.
From To__FL— tR _In.
From To __ FL__ in. In
18. 8ANDORAYEf-PACK:
Dope
Frain . TO..r
From To
17. REIAARKIt
CearnTHATTHISWELLWASCONSTRUCTE FirAmmonite vdmiiSA *IC C/C.Y/ELL
DE,TH
Poewlse Desea7rn
II __asosle _ we boa orIan
LOCATio, SKETCH
pew *aft u16. idle Men *1 Sew
Saw situate S
Roo* aOwprepS OW
r e/ Aic
—_1
0
on
W SMISS
FL
1 CC I1flECY
CONSTRUCTION STANDARDS./I,p7NATpCOPY OFDos M.aw,DIMSWEN MAIM TOUIEWE LGISEP
FOR OFFICE USE ONLY
Omar
1144414.
CioNATORI
So6oSwl jol M p111lMeI
WSW OWIS.Slq _ Sat 111766
a:E
Asheville Regional Office

City a Town State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
RESIDENTIAL WELLCONSTRUCTION '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 Cmtractar.(Individual) Name
Camp's Well & PumD Co. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 Bo, 429
Ellenboro NC 28040
Zip Code
SITE WELL ID #(It applicable)
STATE WELL PERMIT/Mtapplicable)
DWQ or OTHER PERMIT #08 applicable)
WELL USE (Cheek Applicable Box): Residential Water Supply
DATE DRILLED 3�
TIME COMPLETED 14" : 2b AMP PM/
1I
3. CITEI LOC6xi N5 ` COUNTY R#ijVLeY 4
(Street Name, Rumbas. Ca nmunity, Subdivision, Lot No., ParceLZip Code)
TOPOGRAPHIC / LANDS G:
p Slope OValey OFlat Inidge ❑Other
(ched: app�ro�pdatabwd0
;L, LATITUDE � - 1 . lo`J_V
LONGITUDES ) o
Latitude/longitude source: iD(GPS OTopographic map
(bcatbn of wag must be shown on a USGS topo map and
attached to this form If not using GPS)
May be in degree;
minutes, seconds or
In • claims! format
4. WELL OWNER I '�7
OWNER'S NAME % psi l7 e B.
Ri l ers
STREET ADDRESS O B o X 5 'F 9
l..xke LLArt NI c AS
City or Tam state Zip Code
(_—.)-
Area code - Phone number
5. WELL DETAILS: /ej
a. TOTAL DEPTH: `i l S
b. DOES WELL REPLACE EXISTING WELL? YES p NO p
c. WATER LEVEL Below Top of Casing •/ 5 FT,
(Use If Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top el casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST a i
1, DISINFECTION: Type chlorine Amount g Gaf15,
g. WATER ZONES (depth): 1
To From To
Fran To
From To
From
From To
From To
6. CASING: n jester
From 0 DToh-16 Ft D6$
From To Ft.
From To .Ft
Thlclmesal
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
From To
From To
Diameter . Slot Sim .Material
Ft. In. h.
Ft. In. b.
From To Ft in. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From Tq Ft.
From To Ft.
Fran__To Ft
10. DRILLING LOG
From .To.
0 96
Fgqrmation Description
rit(t Sark.d ff
IC•5—ti17 eRkso)idafeA red<
11. REMARKS:
c/ C,+
I DO HEREBY CER1WYTHATTNIS WELL WAS CONSTRUCTED NACCORDANCE WITH
15A NCAC 20, WELL CONSTRUCTION STANDARDS. AND THAT ACOPT OF THIS
RECORD HAS BEEN PROVIDED TOTHE
I(WELL
L�OR.
OWWNEE
SI�G�'' R OFCERTIEDWELL''CONTRACTOR �rDAEOb
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within .30.days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 ' Phone No. [phone] ext
Form GW-1a
Rev. 7/05

• RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2138
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Name
Camp's Well & PIMA Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 Bok 429
Ellenboro NC 28040
City or Town State
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #9f applicable)
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(N applicable)
WELL USE(Check Applicable Bout): Residential Water Supply
DATE DRILLED
TIME COMPLETED ' I 0
3. WELL LOCAT
ION:
CITY: l.-alYe. Lure_ COUNTY
Zip Code
AMO
PMC
rd
j� r�
l�s C. .— L7r0Df(511Je 1.10t38
(Street ame, Numbers, Community, SubdMsion, Lot No., Parcel.Zip Code)
TOPOGRAPHIC / LAND SETT G:
❑Slope ['Valley ['Flat Idge ❑Other
(oherk appropriate box)
LATITUDE _3_ ' 5-S7
LONGITUDE g .Le 011 �• 3` I0
Latitude/longitude source: DeS OTopographic map
(bcatbnoched Mwet
fmust
be n/ shownot Gp S GS topo map and
4. WELL OWNER �'J(/ — pp�`//
OWNER'S NAME / i0 ve INe Y77771a,�/f I;��jj
STREET ADDRESS q 17 I ate s J7 K .R3L
/4upye5t/il/e NC- 2$1/i
City or Town State Zip Code
Area code Phone number
May be in degrees,
minutes, seconds or
in a decimal foment
5. WELL DETAILS:D /
a. TOTAL DEPTH: h
b. DOES WELL REPLACE EXISTING WELL? YES p NO la
•
c. WATER LEVEL Below Top of Casing: 5?o FT,
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING le 1 FT. Above Land Surface*
:Top of casing terminated at/or below land surface may require
a variance in accordance ce with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST a 1 Y
f. DISINFECTION: Typech 1 orl ne Amount I i tn,16
g. WATER ZONES (depth): ! `�
From To From To
From To From To
From To From . To
6. CASING: l ThibWeIglmh�essl
Material
Fran 0 DTohSS Ft. plater SDR21 PVC
From To Ft 6'#' _
From To .Ft
7. GROUT: Depth Material Method
From 0 To 20 Ft Sackrete Hand
From To Ft.
Fran To Ft.
8. SCREEN: Depth Diameter . Slit Size
Front_ To Ft In. N.
From To Ft. In. N.
From To Ft. In. In.
Material
9. SANDIGRAVEL PACK:
Depth Size Material
Fran" Tp Ft.
From To Ft.
From To Ft_
10. DRILLING LOG
From To
0IC
Fo'ation escdption
artPay
r
'5 . 4-05 Conso/ da -ed ✓acK
11. REMARKS:
c•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 20, WELL CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS .
RECORD WAS BEEN PROVDEDTOTHE WELL OWNER.
SI TURE OF CERTIFIED WELL CCUACTOR DATE
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within ;30.days. Attn: Information Mgt.,
1617 Mall Serviee Center— Raleigh, NC 27699-1617 ' Phone No. [phone] eat 568.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 3 8
1. WELL CONTRACTOR:
James W. Camp
Well Contractor (Individual) Nano
Camp's Well & Pumn Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 BOX 429
Ellenboro NC 28040
City or Town ' State Zip bode
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Or applicable)
STATE WELL PERMIT/Rif rentable)
DWQ or OTHER PERMIT #(ff applicable)
WELL USE (Check Applicable Bag: Residential Water SupplyV
DATE DRILLED 3' - I - 06 �� /
TIME COMPLETED rat 3o AMO PM Ili'
3. WELL LOCATIDI-U1��� ,Ify(��{(-_' Jj
b{.I /l_✓ i(1(O COUNTYRL(--te Tore
//jj Iru,,
(S1%e!\f�ime Num n.0an ty.SubdMWsio_n. Lot No.. ParceL7Jp Code)
AT,,O�P,_O_ GRAPHIC / LAND SETTING:
4t10Pe Malley OFlat ORidge ❑Other
(eMak appropriate
LATITUDE S Z' ,erg
LONGITUDES ±1 .5 S . to
Latitude/longitude source: jdPS OTopographic map
(bca/bn of well must be shown on a USGS topo map and
attached to lids form I not using GPS)
May be in degree,
minutes, seconds or
in ■ decimal lama
4. WELL OWNER -} n/
OWNER'S NAME Ot�PY1 /' CPYmQ2
STREET ADDRESS I Q0 µ cal U ptiry alit) O
F rest. City Nc- agc4o
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: . ��
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? TES TES ND
c. WATER LEVEL BeiowTcp d Casing: 6 0 FT,
(Use '+'.ff Above Top of Casing)
d. TOP OF CASING IS 1 . FT. Above Land Surface*
*Top d casing terminated et/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD(gam): 0 METHOD OFTE$T Gil
1. DISINFECTION: Type chlorine Amount iA cts
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From - To
6. CASING: Thickness/
Depth Dammeter Weight Material
From 0 To 76 Ft. Diameter
SDR21 ' PVC
From To Ft _
Fran To .FL
7. GROUT: Depth Material Method
From 0 To 20 FL Sackrete Hand
From To FL
From To FL
8. SCREEN: Depth Diameter - Slot Size .Material
From To FL in. In.
Fran To Ft. In. In.
From To FL In. In.
9. SANDIGRAVEL PACK:
Depth Slze Material
From To Ft.
From To Ft.
From To FL
10. DRILLING LOG
From
1i-!o
CIFormation Descp'p5on
aY I Sand
0-c)4S0 i,da
er
RECh1V
la\Poc b `,.
A
11. REMARKS:
•_r
100 HEREBY CER1FY THATTHIS WELL WAS CONSTRUCIED N ACCORDANCE WITH
ISA NCAC 20, WELL CONSTRUCTION STANDARDS. AND THATACOPY OF THIS
RECORD HAS BEEN PROVIDEDTO THE WELL OWNER.
4 1.A �, CLLIC 1F AT -a‘
SI RE OCERTIFIEDWELCCO RACTOR BATE
ames W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within.30. days. Attn: Information Mgt,
1617 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 # 21 38
1. WELL CONTRACTOR:
James W. Canto
Well Contractor Name
Camp'S Well & Pump Co. Tnc
Well Contractor CompanyName
P 0 Box 429
STREET ADDRESS
Ellenboro NC 28040
City or Taan State tip Cede
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #9t applicable)
STATE WELL PERMIT/NI applicable)
DWQ or OTHER PERMIT #(fl applicable) /
WELL USE (Check Applicable Boon: Residental Water Supply fir
DATE DRILLED % -4 —. .
TIME COMPLETED 4: to AMC PM ij/
3. WELL LOCATION:
n ,y( (� I
CITY:
11 +1OonS I f COUNTY ka (fie Y,.4 rd
1-0 l 'f �i.(-WlmI (
(Sinai Neme, Numbers.. mangy. Sub , Let No., Parcd:IDp Code)
TOPOGRAPHIC / LAND SNG:
CI Slope OValIey °.Flat Vidge ❑Otter
(cnwr apgepdatebQ)
LATITUDE _ ' `U 021 • °2oj /V
LONGITUDE ) `_ 4?' glow
�
Latitude/longitude source: �cPS °Topographic map
(location of welmust be shown on a USGS topo map and
attached to this tam snot using GPS)
4. WELL OWNER �/j % -�-
OWNER'S NAME / r 1. L' waq no' Kt/acloY5
STREET ADDRESS I3L`F Ida X v is it Dr.
�AYrbk ag 75g.da
City or Town State Zip
Area -code Phone number
6. WELL DETAILS:
a TOTAL DEPTH: 4 f) 5
b. DOES WELL REPLACE EXISTING WELL? YES p NOX
WATER LEVEL Below Top d Casing: t CO FT,
(Use's' if Above Top of Casing)
d. TOP OF CASING 1S 1 . FT. Above Land Surface'
:Top of casing terminated ator beim land surface nray require
a variance In accordance with 15A NCAC 2C .011 B.
e. YIELD (gpm): METHOD OF TEST rZ 1 r
IMay be. in degas,
minutes, seconds or
in a decimal format
t, DISINFECTION: Type chlorine Amount I7a cy
g. WATER ZONES (depth)
From 0 To 4549 Ram To
From To From Tom__,_
From To From - To
6. CASING: '1
From 0 Too q
From To
From To
FL E•;C
Ft
Ft.
Thickness/
SDR21 PVC
7. GROUT: Depth Material
From 0 To 20 Ft Sackrete
From To FL
From . To Ft
9. SCREEN: Depth
From To
From To
From To
Method
Hand
Diameter Slot Sim .Material
Ft. In. h.
Ft. In In.
Ft In. In.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Free+ To R.
10. DRILLING LOG
From To
0' 11 Li
Sim
Material
Formation De¢odptbn
clay 5artd
44 .&QS Consolidated rect.
11. REMARKS:
I DO HEREBY CERTIFYlitareOS WELL WAS CONSTTUCTED lliAT1 ACCORDANCE W�
GA HCAC 20, WELL CONS1RUCRON
COPY OF THIS •
RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER.
•
SIG
r1 �v D 6
RE OF CERTIFIED WELL 'CO RACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of VVater ty witn 30 days. Attn:
1617 Mail Service Center - Raleigh, NC 27699-1617 a((Ph ne Ninformation Mgt.,o. 9 9) 733 7 5 ext 68.
Form GW-la
Rev. 7105

City or Town Stale
( 828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID (Mr appllmele)
STATE WELL PERMIT#Ofapplicable)
DWQ or OTHER PERMIT #(1 eppllcable)
WELL USE {Check Applicable Box): Residential Water Supply It
L
DATE DRILLED 'T - 3 - 6 , l /
TIME COMPLETED 30 AM CI PM (S
3. WELL LOCAA(�TION: V'I
CITY: SD 5t1 C. COUNTY bl eY br
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
James W. Camp
Wen Cuntractar.(Indhddual) Name
Camp's Well & Mama Co. Inc
Well Contractor Company Name
STREET ADDRESS P 0 Doi 429
Ellenboro NC 28040
Zip Code
(Street Name, Number,!
TOPOGRAPHIC / LAND SE_T/ING:
❑slope °ValIO
ey °Flat RIdge ❑other
(Gwdt sPprCCWdaIa box)
LATITUDE _ 1f 9-9.39'Z
LONGITUDE $ L° `fig.16,2
Latitude/longitude source: MOPS OTopographic map
attaof WIPi MS be ched dtorobroan7 sfusino on aU GStopomap and
4.
f-
unky. Subdhiskin, Lot No.. Parcel,2lp Code)
dep
May be l ees,
minutes, woods or
In a decianl totomem
WELL OWNER M I' / T1
OWNER'S NAME . ✓�� i'I eY n±ra or$
STEM ADDRESS MA fAJeII I7>-
(Y1G.YIOK N C- ar15—a
State Zip Code
City orTown
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES W NOA
c. WATER LEVEL Belau Top of Casing: / JSo FT,
(Use'+'.ff Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top cf casing tematated at/or below land surface m@y require
a variance In accordance with 15A NCAC 2C .011B.
e. YIELD (ppm): 2- METHOD OF TEST 1-/ ✓
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
2138'
f. DISINFECTION: Type chlorine Amount l 71 tar
g. WATER ZONES (depth): /
From To 54O From To
From To From To
From To From To
6. CASING:
Depth �8 D7apieter
Fran To Ft bt
From To Ft
From To Ft.
7. GROUT: Depth - Material
Fran, 0 To 20 Ft Sackrete
Front_ To FL
From . To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. In.
From To Ft. in. In.
From To Ft in. kt.
Thickness/
SDR21 PVC
Method
Hand
9. SAND/GRAVEL PACK:
Depth Sim
From To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From .To.
0 33
Material
Formation Dpscdption
rico/ 5awd
38 605- Coi260/1deted re)�J
REGE
11. REMARKS:
0
•
I DO HEREBY RDANCE WIN
15A WAG 2C, WELL CTHAT MIS ERTIFY
RUC11ON SLWAS TANDARDS. ANDDTHATA� OE Thi$ .
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
SIq .TUBE OF CERTIFIED WELL'CONTRACTOR DATE
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1Submit ll service Center -nal to Ralvision of Water eigh, NC 2 6991617 QualityPhone No (9 9) 733 i 5 ext 568.Npn Mgt.,
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County RUTHERFORD
LOT 9A SILVER TREE LANE, OFF JUSTICE RD, OFF HWY 64/74
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER MARATHON BUILDERS
ADDRESS POB 33
(Street or Route No.)
LAKE LURE
City or Town
828429-4486
NC
State
Area Code - Phone Number
4. DATE DRILLED 3/18/06
5. TOTAL DEPTH 200
28746
Zip Code
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ei
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "V" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface`
'Top of casing terminated at/or below land surface equir variance in
accordance with I5A NCAC 2G0118
9. YIELD (gpm): 20 METHOD OF TEST ARDM
lo. WATER ZONES (depth): 125 195
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.25239 / 82.10.780
(degrees/minutes/seconds)
Latitudellongitude source: ® GPS ❑ Topographic map
DEPTH
From To
DRILLING LOG
Formation Description
0 100 Clay
100
200 Consolidated Rock
ti. DISINFECTION: TYPE HYPOCHLORITE Amount 7
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 115 FL 61/4" SDR21 PVC
13. GROUT:
Depth
From 0 To 20 FL
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
oz
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in.
Size
F4
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.
A
O
T
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TIES RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center -Raleigh, NC.,
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
JUN 05 20Q6

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
AQUIFER PROTECTION SECTION
March 28, 2006
Mr. Scott Gantt, WCC #2584
Carolina Well Drillers, Inc.
522 Gantts Grove Church Road
Mooresboro, North Carolina 28114
JUN 05 tuU5
RE: Variance Request to Rule 15A NCAC
2C. 0107(a)(2)(M)—Well Location -.
Marathon Builders Property, Lake Lure
Rutherford County, North Carolina
Dear Mr. Gantt:
On March 28, 2006, the Asheville Regional Office received your request for a variance to Rule
15A NCAC 2C. 0107(a)(2)(M). This Rule requires a 25 ft. separation distance between a well and a
building foundation. This variance request is for the construction of a water supply well on property
owned by Marathon Builders off of Silver Tree Lane, Lake Lure, in Rutherford County, North Carolina.
In your request you indicate that the only suitable location for the well is 12 feet from the nearest
building foundation. Based upon the information you have submitted to this office a variance to the
above -cited Rule is granted. The variance will be effective for a period of six (6) months beginning
from the date of issuance. Since the well will not meet regulatory requirements, the following minimum
additional construction requirements will be necessary to mitigate any potential problems that could
affect public health and/or the well's effective operation:
1. The casing shall be PVC or galvanized and shall extend the greater of 40 feet below land
surface or at least 5 feet into consolidated bedrock;
2. The entire depth of the casing shall be grouted. A drill bit that is 1/3 greater than the outside
diameter of the casing shall be used to drill the cased portion of the well. The grout should
be installed using the pressure method. The installation of the grout using a tremmie pipe is
acceptable if the annular space is free of obstructions;
3. The well shall be located in the area identified on the map included with the variance request;
4. The well driller shall be certified by the North Carolina Well Contractor Certification
Commission as required by General Statutes 87-98.4, Title 15A NCAC 27.0101 and .0110;
5. Notification shall be given to H.E. Minnick or Landon Davidson at the letterhead address or
by telephone at [phone], at least 24 hours prior to the start of well construction; and
6. Notification shall also be given upon completion of the well.
N%�TT�hinCarolina
Naturally
North Carolina Division of Water Quality - Asheville Regional Office 2090 U.S. Highway 70 Swannanoa, N.C. 28778 Phone [phone]
FAX [phone]
Customer Service 1-877-623-6748
Internet: h2o.enr.state.nc.us
An Equal Opportunity/Affamalive Action Employer -50% Recycled/10% Post Consumer Paper

From: Scott Gantt To: Slephenie Wilson uate: aaeauuti ime: a:Ua:au ran rage a oT
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ® Municipal 0 Industrial ❑ Agricultural 0 Monitoring ❑
Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County
RUTHERFORD
LOT 9A SILVER TREE LANE, OFF JUSTICE RD, OFF HWY 64/74
(Street Name, Numbers, Community, Subdivision, LotNo,. Zip Code)
3. OWNER MARATHON BUILDERS
ADDRESS POB 33
(Street or Route No.)
LAKE LURE
city or Town
828-429-4486
Area Code - Phone Number
4. DATE DRILLED 3/18/06
NC
State
5. TOTAL DEPTH 200
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES 0 NO
60 FT.
(lee "4" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated atlor below Imd surface requires a variance in
accordance with 1SA NCAC 2C.0118
9. YIELD (gpm): 20 METHOD OF TEST
10. WATER ZONES (depth): 125 195
ARDM
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley © Flat
Latitude/Longitude of well location
3525.239 / 82.10.780
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
DEPTH
28746 From To
DRILLING LOG
Formation Description
Zip Code 0 100 Clay
100 200 Consolidated Rock
11. DISINFECTION: TYPE HYPOCHLORITE Amount 7
42. CASING:
From 0
13. GROUT:
From 0
14. SCREEN
Depth
To 115
Wall Thickness
Diameter or Weight/Ft. Material
Ft 61/4" SDR21 PVC
0z
Depth Material Method
To 115 FL GRAVEL MIX GRAVITY
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Diameter
FL M.
Ft,
Size
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
c
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

From: Scott Gantt To: Stephenie Wilson
FACSIMILE COVER PAGE
ua[e'. 42b/2uub Ilme: b :ua:SU VIVI rage 1 01
to:
Sent :
Subject :
Stephenie Wilson
4/26/2006 at 5:08:26 PM
From :
Pages :
Scott Gantt
2 (including Cover)
I mailed a well record in with a variance for distance from the house. Please replace that record with this one.
I had to change the grout depth.

orth Carolina —Depmtme t of Environment and Natural Resources —Division of Water Quality — Gmlmdwater Section
536 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 #:
327381
. WELL USE (Check Applicable Box): ® Residential ❑ Municipal 0 Industrial 0 Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If other, List use:
WET! LOCATION: (Show sketch of the location below)
earest Town: LAKE LURE County: RUTH
HAPEL POINTE RD. DRILLING LOG
load Name and Numbers, Community, or Subdivision and Lot No.) From To
. OWNER TERRY DUFFY
,ddress CHAPEL POINTE RD.
'Street or Route No.)
AKE LURE NC 28746
'ity or Town State Zip ('Me
. DATE DRILLED 05/23/06
. TOTAL DEPTH 185
. CUTTING COLLEC1tD ❑ YES ® NO
DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
. STATIC WAl'ERR LEVEL Below Top of Casing:_FT.
:se "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
fop of casing terminated at/or below land surface requires a variance in accor-
mce with 15A NCAC 2C.0118
0. YIELD (gpm): 20 METHOD OF TEST: ARD
I. WATER ZONES (depth):
2. CHLORINATION: Type: CHLORYTE Amount: 3.5
3. 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.
.4. GROUT:
Depth Material Method
From 0 To 50 Ft. NEAT CEMENT PRESSURE
3ROUIED
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.
1.7. REMARKS:
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)
HWY. #64/74A W. FROM RFTN. GO PAST MARINA & TURN
RIGHT ON BOYS CAMP RD. RIGHT ON CHAPEL POINTE RD.
FIRST ON RIGHT.
DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFT.T
ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
T ,PAtTL
SIGNATURE
PERSON 7tIE� S d ATE 6
.bmit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Envimoment and Natural Resources
Alan W. Klimek, P.E. Director ,
Division of Water Quality ,
Mr. Delbert Pittman, WCC #2159
Pittman Well Boring, LLC
460 Glover Road
Ellenboro, North Carolina 28040
AQUIFER PROTECTION SECTION
May 16, 2006
RE: Variance Request to Rule 15A NCAC
2C. 0107(a)(2)(M)—We11 Location
Neil Kay Property, Lake Lure
Rutherford County, North Carolina
Dear Mr. Pittman:
On May 16, 2006, the Asheville Regional Office received your request for a variance to Rule
15A NCAC 2C. 0107(a)(2)(M). This Rule requires a 25 ft. separation distance between a well and a
building foundation. This variance request is for the construction of a water supply well for the Neil
Kay residence located on Chapel Point Road at Lake Lure in Rutherford County, North Carolina.
In your request you indicate that the only suitable location for the well is 12 feet from the nearest
building foundation. Based upon the information you have submitted to this office a variance to the
above -cited Rule is granted. The variance will be effective for a period of six (6) months beginning
from the date of issuance. Since the well will not meet regulatory requirements, the following minimum
additional construction requirements will be necessary to mitigate any potential problems that could
affect public health and/or the well's effective operation:
1. The casing shall be PVC or galvanized and shall extend the greater of 40 feet below land
surface or at least 5 feet into consolidated bedrock;
2. The entire depth of the casing shall be grouted. A drill bit that is 1/3 greater than the outside
diameter of the casing shall be used to drill the cased portion of the well. The grout should
be installed using the pressure method. The installation of the grout using a tremmie pipe is
acceptable if the annular space is free of obstructions;
3. The well shall be located in the area identified on the map included with the variance request;
4. The well driller shall be certified by the North Carolina Well Contractor Certification
Commission as required by General Statutes 87-98.4, Title 15A NCAC 27.0101 and .0110;
5. Notification shall be given to H.E. Minnick or Landon Davidson at the letterhead address or
by telephone at [phone], at least 24 hours prior to the start of well construction; and
6. Notification shall also be given upon completion of the well.
rate ally
North Carolina Division of Water Quality — Asheville Regional Office 2090 US. Highway 70 Swannanoa, N.C. 28778 PhFone (820 ; 296-45
299-7043
Customer Service 1-877-623-6748
Internet h2o.enr.state.nc.us
An en,iai f n.wtinitulAfmwrrva A'finn Fmninvnr— 50% Rn,wd.N10%Pact Consumer Paper

05/15/2006 07:55 028-453-0665
Mt. CL Lima Davidson. La
IDW¢GW Section.
2090 L$ figbs sy?o
•
Swann's',NM* C mina WU
Subject~ .Request For aims( net
Dear Mr. Davidan:
Iwould Ince to rat a valance to the NC WSI • stems. mos
spikes a well tobe re,- feet from a sevs oefar .licnose
rate ry' f fu,a r '_n - . the well wittbatb$kd
/1. feet from t e 4t ass . lvmfls
This is dse sly place that a vidi could be chiliad. I have included a sk erakofthe
propeywiththelea6mofthe bona -9.0 te.ijnof . 1%.s a- amd
the proposed well dtv.
Ifyou bays anyquestinns, phatsc Call me at 0/60T D
Sincerely.
PITTM4N WELL-6®2ING
Owner's arse and mailing address:
NN, c I or
c3,7j h..-/is 72 id
4.o.Yc As•it J(74'
Driller's name, WC�C # and address:
72,, s,o 4Yr os. 6-7/7 / Q
(Sketch. inn( sheet name yr Dar W)
PAGE 02
4f;, dWor4,10 j
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\1163 A&F WELL DRILLING
Nee. Caa m• M in.Mr�wwifaid NESS Aww -MC, MIS Maw• lac AND PUMP SERVICE, INC.
1r7r4W�iM G'MnYr->tAM%►M.R iiMF/a7L F1w P1o7ii411121 911 Business 74
Bostic NC 28013
WELL CONSTRUCTION RECORD WaLcONTRACTOt: 828-247-1773
WW. CONTRACTOR esr,CATUON /: a.13S
MATE WRL CONSTRUCTION 1NOII TL
1.
A
WILL Ufl RIPS * P .'&L.J4J 0 WSW Afl Sw$l ❑ Montalns �
hoswary 0 - . lQ MiS romp WMwI looloo ❑ Ole CI NOON; 1*Uus
WEU. LOCATIOttallow00. olMbeiMaM&.4
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/S '7�.%.�tni/ .✓J i�i /-7 C.L /%-C
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s. OWNER (C-,iFt f, o1)4 4 Sea
Fall T.
Fwrrfr t—.-Wr
4. DATE DRAM
a. TOTAL !WPM p No�-
s. corms Flxlstsl0 osoaa
7. DOOM WsaNI JiCE NO
•. STATIC WATER LEVEL Eat Top GICsdsp T., s FT. ---
pNs•�•IMeisl►MOuu W �.--
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N
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ram To - F1 M. --
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ONO
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17. REAWIKh
001101EMYCM/1F1fTiNT/MISMU. WAR COPSTRUDISM 44A sin IS.'iCSC.VOW
CONEMOCTIONSTANDS* M MAWFLOFTNI{RIODIbrIMIT IImono Ton WILL se
-
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A&F WELL DRILLING
AND PUMP SERVICE, INC.
911 Hwy. Business 74
Bostic, NC 28018
man" C...*L • ofEnnbmm ero an! Hai n IlnowrM • Madan of wow oaf • OroundwWr Swoon
le7[ MS sato M� -sopa K.C. 27/S-1CIS ons pm) 7334221
WELL CONSTRUCTION RECORD
WELL CONTRACTOR. / /{7Fi(� .iA128-77-1773
WELL CONTRACTOR C C1tTIOH t € 1.15
STATE WELL. CONSTRUCTION PERMITS
1. WELL UllEa Alleww as* Pawns MWd ps1 0 IIIduaaid ❑ AOiI ne ❑ 0rIng
Ra:ovor M
Hod Pon Ws Lotion ❑ Oha ❑ E Ohar. Lh4 Use:
2. WELL LOCATION: (Show * 4pf of loo Ioaaon Wow) /�
liesstTerm• .e._ ii �. o , w)-r" vaunt( /"R - -s- /—�Ni
2�! 9;ai.g-5Ate— �%��% ». //C'`
IRe
ei and ISISCedar' r AS .%ender NO DREIJNG L00
3. OWNER asp/9.4Z C-, f .e,o ,, isasall.1111a. Fees Ye
Addiss.
4. DATE DRIU.E0
6. TOTAL DEPTH
s. cuTTINOS OLLEL YES[] S
7. DOE' WELL REPLACE E%ISTINO WEtl9 p N E1
s. STATIC WATER LEVEL Slow Top o1 Casing: • _
plea'v I NOS Tops! CUM
S . TOP OF CASINGIS4—,7L. FT. Mows Lend WSW
R w r/ moo 1-J... ra V*r bS. led series Men • yams a War"
• wIbIMI MAC *an n
10. YIELD Sink cJ�. 'MI moo OF TEST 1
11. WATER ZONED Asper 37
pcp7ll
Sure*' Dsfolplo
12. CHLORINATION: Typo C;//e: 4`e Acaustian (..- files-•
13. CASINO: R5
From .1✓p TO L TS-6i ""s
Rm.— To Ft. ---
Flan To FL
It. GROUT: iodal
Front To San —
th
Freon To FL .—.----
1S. SCRIM A
r)ph Dins Slot Ski MASS
Flom --- To:.__R . Ill. ----In •--'
From To__FL— M. In.
From ._.._To R. in. YL
13. SAND/GRAVEL PACK: SOSGSMFrom . To FL . '�•---
From To FL _�-
1T. REMARK&
I op HERESY CERTIFY THAT TIES WELL WAS CONSTRUM1 O NI �p pO NCSC EIOlr Ca�(D
CONSTRUCTION $YANDARDS. NCmAT ACOPY OFTIES RE00RD
wa;Nr—a111 tea WOW
t+Z2-Cr
sadtll -swoof aseelodfoe b.*Wfans
phew p.[Ionsofdemo Wm 0 leagueSly
Rondo. or ohm •lap tubes polo!
rFOR OFFICE
USE
ONLY
oees Ns
sows.
MAW
/cc
!/ c/< 40(
'-(-0 �
SrbmA*ad WDAWNS TRW OsIM)QNMIdmMrr Own wins 30 eals
tom pet 1.7I

AAF WELL DRILLING
AND PUMP SERVICE, INC.
Nwnncams . Aioi+wMw1awe/ Nalin'Asa -OMYwMWMuONUS •OiwwMerSwim 911 Hwy. Business is
1838 MMrMdw{'«wr- Sala 11r .E/88•487{ rpfemas ' Bostic, NC 28018
WELL CONSTRUCTION RECORD nuecorrnACTOR: %kt 828-247-1773
was COWIRACTOR g111wCAnoN r. 1 L3S
STATE WILL CONEIMI n ON MINIM
1. nu. me A//- u nem Padd malClY sss .10 Isles ❑ *gtbSwS 0 0 0
ftwomm a Hod Pep W.N. WSW Ober p It awc WI Usm
2. WELL LOCA (OhsMNoh a1 Mo Sooalon below)
Ns«.MTwss io 1 t. - ors ghiAe TFo c77
AI' 20444 ios- R, leer hefu/
Paw .nsesoars •- "ass
i. OWNER , /%crPi/(J
Ad"'yd twat —�� ereli ct
ant mas
4. DATE — Ve�ca
S. TOTAL DEPTH
.. CurrDOSS s3SMI �7N O M®.
7. oopwILLNEPtACE
S. STATIC WATER LEVEL 01n1.oTapalCasks 1.0
FT-
/ yipaw.iisr spelCu d
O. TOP OFCA*NIGIS y 40 FT. Abyss Lad ease
Resr*SwF $ 840411 u►kW hudS14NraMrss1.YmaMaNi
San al NA NOAO*JIM moo or TEST I n
1o. vito' -* ?
11. WATER yaw As.* 962
DREli wo _
1a TO
DSPTH
F.saa404•44414s
D
12. cMASMSATIDIt Two tQesper ism
13.CAINII ,/ •
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Wa.e a
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1T. REMANKt
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From: Scott Gantt To: Stephenie Wilson
Date: 4/4)2UUti I ime: b:3/:1ti PM rage 4 of 4
WELL CONSTRUCTION RECORD 3 2 4 6 8 4
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial 0 Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County RUTHERFORD
THREE CREEK SUBDIVISION LOT 16
(Street Name, Numbers, Community, Subdivision. Lot No,. Zip Code)
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley Flat
Latitude/Longitude of well location
35.30.656 / 82.10.814
3, OWNER MARATHON BUILDERS (degrees/mirmtes/seconds)
ADDRESS POB 33 Latitude/longitude source: ❑ GPS 0 Topographic map
(Steen or Rome No.) DEPTH DRILLING LOG
LAKE LURE NC 28746 From To Formation Description
City or Town State Zip Code 0 22 Clay
828-429-4486 22 500 Consolidated Rock
Area Code - Phone Number
4. DATE DRILLED 3/8/06
5. TOTAL DEPTH 500
6. DOES WELL REPLACE EXISTING WELL"
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO
207 FT.
RIsc "+- IfAbovc Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
^Top of casing terminated at/or below land surface nguires a variance in
accordance with 15A NCAC 2C 0118
9. YIELD (Rpm): 2 METHOD OF TEST ARDM
10. WATER ZONES (depth): 450
D. DISINFECTION: TYPE HYPOCHLORITE Amount 15
12. CASING: Wall Thickness
Depth Diameter or Weighat. Material
From 0 To 27 Ft 6 1/4 " SDR 21 PVC
13. GROUT:
Oz
Depth Material Method
From 0 To 20 Ft. GRAVEL MIX GRAVITY
14. 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:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

From: Scott Gantt To: Stephenie Wilson slate: 4/4/2uuo rime: is:acro voi
rage 3 uI't
WELL CONSTRUCTION RECORD 324663
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 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: RLTHERFORDTON
1205 BOLAND RD
County RUTHERFORD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER JOHN LYTLE
ADDRESS 5528 HWY 64/74
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
3529 640 / 82.05.932
(dewees/minutesiseconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(street or Route No.) DEPTH DRILLING LOG
LAKE LURE NC 28746 From To Formation Descnption
City or Town State Zip Code 0 90 Clay
828-286-3346 90 180 Consolidated Rock
Area Code - Phone Number
4. DATE DRILLED 3/6/06
5. TOTAL DEPTH 180
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES D NO E)
65 FT_
(Use "t" If Above Top of Casing)
8. top OF CASING IS 2 FT. Above Land Surface*
'Top of casing terminated attor below land surface requires a variance in
accordance with 15A NCAC 2C 0118
9. YIELD (Wm): 15 METHOD OF TEST ARDM
l0. WA 1 EAe ZONES (depth): 175
D. DISINFECTION: TYPE HYPOCHLORITE Amount 7
Oz
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 96 Ft. 6 1/4 " SDR 21 PVC numbers and common road names.
G. 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.
is. 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.
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

From: Scott Gantt I o: Stephanie VVilson
Date: 4)42UU6 I ime: 8:31:16 PM Page 1 of 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)NAME (print) SCOFF GANTT CERTIFICATION#2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE Of [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) Residential © Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Cnher, List Use:
324681
z. WELL LOCATION:
Nearest town: BOSTIC
DEPRIEST RD
County RLITHERFORD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
3526.514 / 81.48.997
3. OWNER HORTON HOME OF RUTHERFORDTON (dewees/mimrtes)seconds)
ADDRESS 342 HWY 74 BYPASS Latitude/longitude source: ❑ GPS ❑ Topographic map
DEPTH DRILLING LOG
(Street or Route No.)
RUTHERFORDTON
City or Town
828-287-3366
NC 28139 From To Formation Description
State Zip Code 0 85 Clay
Area code - Phone Number
4. DATE DRILLED 3713/06
5. TOTAL DEPTH 180
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO CI
55 PT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
"Top or casing terminated actor below land swfaee requires a variance in
accordance with 15A NCAC 2C.0118
9_ YIELD (gpm): 15 METHOD OF TEST ARDM
10. WATER ZONES (depth): 170
85 180 Consolidated Rock
tt. DISINFECTION: TYPE HYPOCHLORITE Amount 7
12. CASING:
From 0
13. GROUT:
Oz
LOCATION SKETCH
Wall Thickness Show direction and distance in miles from at least
Depth Diameter or WeightEL Material two State Roads or County Roads. Include the road
To 93 FL 6 1/4 " SDR 2l PVC numbers and common road names.
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 FL
16. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE1= 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4/1!06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

Dlne..n Slot Ski MMMR
PI In. In.
AU WELL DRILLING
Ne+w c.aeL. .a..a r`. rsumem.sr nobs - mum
_ .agsticaVion AN9 PUMP SEERRVICE, INC.
1 Hwy.ness 74
sea MSleas Garr.r-.44.4"M.¢lf8N-taH414n4 +732-7721 Bostic. NC 28018
WELL CONSTRUCTION RECORD wsu. CONTRACTOR: /7 /% 26 /✓/'` /1628 247-1773
wat CONTRACTOR CSIITw,CATION a 11.35 (
STATE WILL coseiaiCRON AUNT!
1.
nu. unpins re.Rookba larMon*.0 ISSN ASAddows❑
Rw-.-'i PO Hal
M.dPomp Web bl..ios❑ Ober NOSayUNU..:
2. well LOCATE)* @lbw Ma11AetIRO bake LL.4 /
tk Twnc /.,a n +C L i. r P cos X %ftt"/ —i(
IC-Wittys>.'ir'/ro .�Grr Lalif re
o
!Rob Noe b'_.. eamOars- S•.,sw • I DInLLEIoloE -
a. °W W1 494 LJC..YI .jr rw. 7 F....nor.lr
Addle. ,it/ 3 �%p�%� 64 ?ace
4. DATEORILI.IA
. TOTAL DEPTH 0
. 7DOOMcureMILL I�T
Q
T. DOOM REPLACE NO®.
S. STATIC WATER LEVEL ma o Toll .8 C.s 77 FT.
fuss ••.Nw.TtFdosse
S. TOR OF CASSIE li i FT. Above Lad Ws'
'rwrSag I—rlolesr.rw •SineenMAms.wsY..a.sse r
Mora seWANC*C$ 1. Yl n
It "SD MP*' 'IN000R TEST Ain
11. WATER7+011EL Ape* 345
•
12. ctLanNATlat s Type a Aaoolr —`'
13. CA81110: 4? L
Its se
oprt DMIt ateRL WSW
Feral .gyp T. -. .1L/rs.:- af r
Fan Te FL. -
Fs? Te R
t4. GROUT:
Fwa � th MORI
To
Fans To FL
1S. scams
PAS Fan o.
Ern To FL b.
Fraar To R. in. h
S. SANOIERArS.RACK: i
ONO Eta
From
Flea To R. -_
1T. REMARK*
WAS LCIMMOA NWCIC.
1oN fNNRFVTI Oa B.1.
CONSTRUCTIONstue S.pNDTIMTRan oIlia 11[o010lMEFl1 )1OflflU1
FOR OFFICE USE Ott
oast
isa
1
aPNTI/IMIRIP.ON
ISItobAstoisOlabidWest
Se111.118Pose kaWldtoo SOO ban
Wilit On. -.0: _ .MeHatun
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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) 6Aggll 3LI54 t' CERTIFICATION AZ%S b
WELL CONTRACTOR COMPANY NAME ,7V StIC (11 vit t) r\Let hati PHONE M e(%Z1: =1tree
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMIT!
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 12 Municipal/Public 0 Industrial ❑ Agricultural O
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
c �f•
2. WELL LOCATION: v� LL C„ Y' �� Topographic/Lat)d setting
Nearest, o ran: O( Ij FDY'r County l J Art j 6 ❑Ridge ❑Slope [)ikalley ❑FIaNu
"� (check appropriate box)
Latitude/longitude of well locatign
;$fo,9coy ,a08Z,OZZ?W
(degrees/minutes/seconds)
Latitude/longitude source:OGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To
['E Cpeek Lotl
(Street Nana. Numbers. Community. Subdivision. Lot No., Zap Code)
3. OWNER: 6/ et'a.po/(1 f�b 1 r-I)Ur+
Address K.240 t4)01-f Pe se1.,,A
(Soccl or Rome No.)
Fort ZiaEF2t
City or Town State Zq Code
(7^_t )- 4/4 - gee'?
Area cake- Phone number
4. DATE DRILLED 2-13�0Iu
Q -Z
5. TOTAL DEPTH: /(, Z, O. 40
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 63/
7. STATIC WATER LEVEL Below Top of Casing: 2)2FT. 54. i Z
From 0
From To Ft
From 'jjtr To 3a Ft
13. GROUT: Depth
3 (Use"+'ifAbove Top ofCasing)
`Top of casing terminated aUor below land surface requires a
variance in accordance with ISA NCAC ZC .aI I&
9. YIELD (gpm): 20 METHOD OF TEST Ril i P
3. TOP OF CASING IS FT. Above Land Surface*
32-5Y
10. WATER ZONES (depth)• 305pse -tea $ eat e»o»"fya5S-" JGf
Show direction and distance in miles from at least
two State Roads or County Roads. include the road
nurnbers and common road names.
Formation Description
(1;t-r
i
.5Aax-k�� E G RAOIrC,
�L b &C3 t l'-
152ert it. -- ftt-
Z°9 w 00 LOCATION SKETCH
11. DISINFECTION: Type If Ott Pt Amount 2, 02.
12. CASING: Wall Thickness
Depth
36 FL la 1( Diameter__ orL Material
To
From To FL_
From m To 311 Ft.
t
P
14. SCREEN: Depth Diamtier Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
I5. BePACKER
Depth Size Material
From To Ft.
From © To toe FL 14
16. REMARKS:
pu
14421cek
711 J
cogt cleadrigh-
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD. HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Grouttdwaters, ee lon,1636 Mail $trriceCenter-Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

AU WELL DRIWNG
Mom comas. +Mwwr 0t -Isd N- NmewiM• ---- lbrtOva •Oi i r?4d°^ AND PUMP SERVICE, INC.
911
ism .. Mot Cie - Rekta C f/ outs � n S 737I y. Business 4
Bostic,
ITC 28013
M
�•y B 247--.17fl
WELL CONSTRUCTION RECORD nu. cowman*:
wow. CONTRACTOR CIRITSlcanoN r, .11.1C
STAIR WELL CONSTRUCTION PURISM •
1. WILL USE Apllkowo so* Rookkod IUF Mud�M O - -- -Y ❑ AOdd/wtl Mates
CI
R.eo.vrf No.IFars wa..te(.el.n❑ morn IOII.r,uNu.o:
2. W19.L LOCATIOIt: (Show Os o1 so 1oeMoa allow)
thnu1T..n r rrgC /G.A. & . kJ c-Ow.o1r. 41/41-1/7" !%>
a. OWNER , f,
Okla ws -
FT.
w
AdtraN 7 rt{13 ,t� ,�
G.4�lqn 2 hi/
r �
as
4. DATE ORURO or
S. TOTAL DEPTH
t. currant VEa
7. OOP wua REPLACE WMUI1i< TYBJ.T Q_ ten
I. STATIC WATER LEVEL Was Top al Combs
FT.
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mono"c.u•oart`ea.aer eantMinllueui..-OrtYtowdrarrrOAS • l.rdsn AND PUMPSEsiness INC.wrreee.
tan .a ewe Coe. MSS a/ea►taS.r FePS Mani 911 Hwy. Business AND
m
Bostic. NC 28018
WELL CONSTRUCTION RECORD waLcoNTwtcloR: �-�� 1/ l.�s' l8�f a7-m3
WALL CONTRACTOR CERTIPICATION r, (3S
STAR HS S. CONS1R n=N FIRST!
1. WELL UIE AMatttiMAwlr R41dwIMl[" w+urd O wear sQ AShdlarrl ❑ MSS O
Reeev.ry0Ne.lPflWa.Li.a.e❑ Osw[j UO*ut tMtla :
2. WEU. LOCATES* Phew Salt d bWaco MOM
sal Twws ,P�rTAF�`i,.t/2-n4/ cost •Pu
L rT,r'c r/ems, re--v r A/l.
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a. OWNER
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sin•
4. CATEDIEU.ND G
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S. 000CuTTIW �T O Non
7. opTRi.LNEFtJ10�
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asic ti o .
it a TO
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13. CAINE: 3 0so sans
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on
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�ARNalfA•MMaRerwM7 1 � 911
Bostic, PC 28013
WELL CONSTRUCTION RECORD WILL CONTRACTOR: e4 49j ,• /, 48-247-177s
WILL COMNACTORCO1,RICATIOMJk a135
STAIN MILL CO IMDIKIN Isi1MEIlR
1. wasuss= r,J+ror to r.1la.rwQY wB" 0 ISMS, Aas sa10 tI.,aaer _
a 0000st CJJN..hopW'___1 S OswO SS UN Uosc
WELL LOCATE** Mow sholik Ipso INS DOSS
them,? Len Er ,oif .
ter q c Ara CA P , /« 6..Jro ) . -
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WELL CONSTRUCTION RECORD vnta.coirrawiOlc ereCryi
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0'

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 it (828)-453-0662
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC
761 WATERS RD.
(Street Name, Numbers, Conununity, Subdivision, Lot No., Zip Code)
3. OWNER: WILLIAM NORRIS BLACK
Address 761 WATERS RD.
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
(828) — NONE
Area Code Phone number
4. DATE DRILLED 03/07/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IZ
7. STATIC WATER LEVEL Below Top of Casing: 10 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): 5 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 90 Ft.6-V4" SDR.21 PVC
From To_Ft.
_ _
From _To_Ft.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft.OUHCRETE 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 FL
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Fiat
(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. #74 E. FROM FC. LEFT ON
BOSTIC/SUNSHINE HWY. LEFT ON TONEY RD.
LEFT ON WATERS RD. DRIVE ON RIGHT. BOX
#761.
CD
CD
c.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS UCQN STANDARD THAT A COPY OF T/HI RECORDS SCBE�EN PROVIDED TO THE WELL OWNER
",ICA2—A
SIGN TURE OF PERrSON 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) 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 131
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC
493 WATERS RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LEWIS MOORE
Address 493 WATERS RD.
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
(!1/1) — 289-7635
Area Code Phone number
4. DATE DRILLED 03/06/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO LE
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): 6 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. CASING: 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 ____ _
13. GROUT: Depth Material Method
From 0 To 20 Ft.OUHZRETE POURED
From To FL
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in.
From ToFt. _ 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: 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 FOREST CITY GO UP BOSTIC/SUNSHINE
HWY. LEFT ON TONEY RD. LEFT ON WATERS
RD. RIGHT ON DRIVE AT BOX #493.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS {tUC)'IPN STANDARDS, AND THAT A C(,)P\ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PS*SON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural 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 ® MunicipalPublic ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC
QUEBEC TRAIL -LOT #174
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: RON DEMARCO
Address QUEBEC TRAIL
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
2(_ 39) — 225-2298
Area Code Phone number
4. DATE DRILLED 03/16/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
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): 7 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
From 0 To 80 Ft.
County RUTH
CHLORYTE Amount 6
Wall Thickness
Diameter or Weight/FL Material
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 _ToFL
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 FL
16. REMARKS:
Topographic/Land setting
0 Ridge ❑ 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
BUS. 74 E. FROM FOREST CITY. LEFT ON
BOSTIC/SUNSHINE HWY, LEFT ON TONEY RD. IN
SUNSHINE. LEFT ON WATERS RD. RT. ON ARBRA
MTN. WAY INTO YELLOWTOP. LEFT ON BIG
ROCK RD. LEFT ON SARANAC DR. LEFT ON
WESTRIDGE DR. LEFT ON QUEBEC TRAIL tar
HOUSE ON RT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTj()JI STANDARDS, AND THAT A COPY OFS RECORD HAS`BBEEEN PROVIDED TO THE WELL OWNER
/T SIGNA OF PERSON /y$.4
SNG THE L DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
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)
I. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON County RUTH
1620 LEE CUD RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: RICHARD SACHSE
Address 1620 LEE CUD RD.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
(828) - 551-0227
Area Code Phone number
4. DATE DRILLED 03/21/06
5. TOTAL DEPTH: 185
6. DOES WELL REPLACE EXISTING WELL? YES ® NO ❑
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): 30 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 3.5
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 110 Ft. 6-1/4" SDR.21 PVC
From To Ft_ _
From To FL
13. GROUT: Depth Material
From 0 To 20 Ft. QUIKRETE
From To ____Ft.
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in.
From _ To _ Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
POURED
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. #221 S. FROM RFTN. RIGHT ON POORS
FORD RD. LEFT ON LEE CUD RD. APPROX. 1/2
MILE ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSI$UCTIQN STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-4?'4 .1 ->t / - (-
SIGNAtRE OF PERSON ONS UCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

15u
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERI IF1CATION # 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 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON
ELLIOTT RD. EXT.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DEAN ELLIOTT
Address ELLIOTT RD. EXT..
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State hip Code
(828) — 288-7272
Area Code Phone number
4- DATE DRILLED 03/28/06
5. TOTAL DEPTH: 365
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 30 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): 3 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 9.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 20 Ft 6-1/4" SDR21 PVC
From_ To_Ft. _
From _ To _ Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft
14.SCREEN: Depth Diameter Slot Size
From _ To _ Ft. _ in. _ in.
From _ To _ Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
From
From
Depth Size Material
To
To Ft
16. REMARKS:
Material
Topographic/Land setting
❑ Ridge ❑ Slope 0 Valley 0 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. #64/74A W. FROM RUTHERFORDTON.
RIGHT ON COVE RD,. RIGHT ON PARRIS RD,
RIGHT ON ELLIOTT RD. EXT. RIGHT ON DRIVE
AT BOX 253.
t_ A eh n " -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST$L(CTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 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 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: ELLENBORO
221 DYCUS RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: JEFFREY KELLER
Address 221 DYCUS RD.
(Street or Route No.)
ELLENBORO NC 28040
City or Town State Zip Code
8( 28) - 453-0829
Area Code Phone number
4. DATE DRILLED 03/29/06
5. TOTAL DEPTH: 205
6. DOES WELL REPLACE EXISTING WELL? YES ❑ 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): 40 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.5
12. 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.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUJKRETE 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 FL
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
HOLLIS RD. FROM ELLENBORO. LEFT ON
DYCUS RD. 1-1/2 MILES ON RT. (221 ON BOX)
<EC;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON Th JCTN STANDARDS THATs�AACCOPY OF AS RECORD/HAS BEEN PROVIDED TO THE WELL OWNER
�4 `t --xd / 1 ✓l- ‘77-..4.c1. .�':-C 9_di..
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

/Wu
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 ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:RUTHERFORDTON
104 SEASONS DR.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MIKE & DIANA BROWN
Address 104 SEASONS DR.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
(828) - 245-1335
Area Code Phone number
4. DATE DRILLED 03/17/06
5. TOTAL DEPTH: 68
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 48 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 RUTH
11. DISINFECTION: Type CHLORYTE Amount 9.2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 68 Ft. 24" CEMENT
From To Ft.
From _____To ____ Ft ____ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT 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 48 To 68 Ft 78M GRAVEL
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 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
CLEGHORN MILL RD. FROM SHILOH. LEFT
ON EPLEY RD. LEFT ON SEASONS DR 1sT HOUSE
ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CfOp1PPY/L09' THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATE
OF 2Tt_S(jN 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

U
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 ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON
237 CLARENCE HENSON RD..
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MITCHELL BUFF
Address 237 CLARENCE HENSON RD.
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
8( 28) — 245-9795
Area Code Phone number
4. DATE DRILLED 03/30/06
5. TOTAL DEPTH: 40
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 30 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): 10 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 4.6
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 40 Ft. 24" CEMENT
From _To_Ft.
_ _
From _To_Ft.
_
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft
I4.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in.
From _ To _ Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 30 To 40 Ft. 78M GRAVEL
From To Ft.
16. REMARKS:
Topographic/Land setting
❑ Ridge 0 Slope 0 Valley 0 Flat
(check appropriate box)
LatitudeAongitude 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 SHILOH GO DOWN BIG ISLAND RD.
LEFT ON HARRIS HOLLY SPRINGS RD. RIGHT
ON DUNCAN RD. LEFT ON CLARENCE HENSON
RD. APPROX. 1 MILE ON RIGHT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS CTION STANDARDS, AND THAT A COPY OF THIS RECyORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN TURE OF ERSON,CJ5NS UCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

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 N Municipal/Public ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: RUTHERFORDTON
143 BUSH LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: FLAY WATKINS
Address 143. BUSH LANE
(Street or Route No.)
RUTHERFORDTON NC 28139
City or Town State Zip Code
SL �8) — 287-4652
Area Code Phone number
4. DATE DRILLED 03/31/06
5. TOTAL DEPTH: 55
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (21
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): 15 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 6.9
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To 55 Ft. 24" CEMENT
From To Ft_ _
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 40 To 55 Ft. 78M GRAVEL
From To Ft.
16. REMARKS:
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley 0 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. #64/74A W. FROM RUTHERFORDTON.
RT. ON HAMILTON RD. RT. ON BUSH LANE. LEFT
FORK HOUSE AT DEAD END ON RIGHT.
.: •e ".. 1 L Nr.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF t . RECORD HAS BEEN PROVIDED TO THE WELL OWNER
. C ��, % L'' t I- 3 /- l 1.
SIG ATURE PE C S STRUCTING 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) 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 0 Industrial 0 Agricultural
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: BOSTIC
LUCKADOO MTN. RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: JEFF ROSENBERG
Address LUCKADOO MTN. RD.
(Street or Route No.)
BOSTIC NC 28018
City or Town State Zip Code
(828) — 248-3235
Area Code Phone number
4. DATE DRILLED 03/04/06
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES ❑ 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): 7 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 7.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 70 FL 6-1/4" SDR.21 PVC
From To Ft. _
From To Ft _
13. GROUT: Depth Material Method
From 0 To 20 Ft OUHCRETE 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 To FL_
From To FL
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
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 BOSTIC GO OUT BOSTIC/SUNSHINE
RD. LEFT ON LUCKADOO MTN. RD. GO 1 MILE
ON LEFT. OLD BOX #1013.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,
AND THAT A COPY QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
NATURE OF RSO�
N CONSTRUCTING THE WELL "' DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — 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 # f828)453-0662
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: LAKE LURE
1116 CONNER RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LUCAS CONNER
Address 1116 CONNER RD.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
gal) — 668-9121
Area Code Phone number
4. DATE DRILLED 03/09/06
5. TOTAL DEPTH: 185
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): 25 METHOD OF TEST ARD
10. WATER ZONES (depth): _
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 3.5
12. 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.
13. GROUT: Depth Material Method
From 0 To 20 FL 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 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
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. #64/74A W. FROM RFTN. RIGHT ON
COVE RD. LEFT ON BILL'S CREEK RD. RIGHT
ON CONNER RD. APPROX. 1.5 MILES ON
RIGHT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
`4 .%,
SIGNATURE PERSON CONSTRUCTING THE CVEL 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 U
North Carolina — Department of Environment And Natural Resources — Division of Water Qwlity — 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 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: LAKE LURE
ROCKY MOUNT DR
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DAVE MATTHEWS
Address ROCKY MOUNT DR.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
(828) — 388-1184
Area Code Phone number
4. DATE DRILLED 03/09/06
5. TOTAL DEPTH: 425
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO rEl
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): 3 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 11
12. 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. _
13. GROUT: Depth Material Method
From 0 To 20 Ft QUIKRETE 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 _To_Ft.
_
From To Ft
16. REMARKS:
Topographic/Land setting
0 Ridge 0 Slope 0 Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS ❑ Topographic map
(check box)
DEPTH DRILLING LOG
From To 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 RUTH. GO UP HWY. #64/74. RIGHT ON
BILL'S CREEK RD. LEFT ON BUFFALO
SHOALES RD. LEFT ON RALLEGH DR LEFT ON
ROCKY MOUNT DR. GO TO END OF ROAD.
NEW DRIVE ON LEFT.
-1
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP 'O S REECCOO HAS
BBEEEN�PROVIDED TO THE WELL OWNER
-77
i
SIGNATURE OF ' RSON CONSTRUCTING THE WEL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Senice 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 ❑ MunicipalPublic ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: ELLENBORO
HATCHER RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: MAXBURGIN
Address HATCHER RD.
(Street or Route No.)
ELLENBORO NC 28040
City or Town State Zip Code
(704) — 434-9830
Area Code Phone number
4. DATE DRILLED 03/29/06
5. TOTAL DEPTH: 165
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
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): 40 METHOD OF TEST ARD
10. WATER ZONES (depth):
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 3.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 38 Ft. 6-1/4" SDR21 PVC
From To Ft _
From _____To _____FL ____ _
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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC
CONSTRUCTION STANDARDS, AND THAT A COP,
GNATURE 0
Topographic/Land setting
0 Ridge ❑ Slope ❑ Valley 0 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
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 ELLENBORO GO UP HOLLIS RD.
LEFT ON HATCHER RD. 1 MILE ON LEFT. 1"
DRIVE ON LEFT PAST BOX #636.
,7
L%
L A 1SAC 2C, WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
VG 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

OA)
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 11 ASSOCIATED WQ PERMIT # _
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: ELLENBORO
NEWHOUSE RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DAVE GREENE
Address NEWHOUSE RD.
(Street or Route No.)
ELLENBORO NC 28040
City or Town State Zip Code
7(D4) - 597-8299
Area Code Phone number
4. DATE DRILLED 03/28/06
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): _
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 12
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 75 Ft. 6-1/4" SDR21 PVC
From _To_Ft.
_ _
From _To_Ft.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From _ To Ft.
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft.
From To _ Ft. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _____To ____ Ft ____ _
From To Ft.
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 DRILLING LOG
From To 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 ELLENBORO GO UP NEWHOUSE RD.
5 MILES. NEW DRIVE ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
«
IGNATURE OF ' RSO C S NSTRUCTING 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) 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 fl Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: LAKE LURE
METHO TRACE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: TOMMY HARTZOG
Address METHO TRACE
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
(828) - 625-2500
Area Code Phone number
4. DATE DRILLED 03/13/06
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 160 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): _
County RUTH
11. DISINFECTION: Type CHLORYTE Amount 13.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 20 Ft. 6-1/4" SDR27.6 PVC
From _ To _ Ft.
From To Ft
13. GROUT: Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From _ To Ft
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft. _ in. _ in. _
From _ To _ Ft. _ in. _ in. _
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To _ Ft.
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley 0 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
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 RUTH GO UP HWY. #64/74. RIGHT ON
BILL'S CREEK RD. LEFT ON BUFFALO CREEK
RD. RIGHT ON METHO TRACE. STAY LEFT AT
FORK. BIG WATER TANK ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COAJISTRUCTION STANDARDS, AND THAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
� /�C-�� r L ��/`/li, 're - J -/._3-6 (:
SIGNATURE OF PERSON CONSTRUGT1NG 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) 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 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: LAKE LURE
323 MATHO TRACE
(Street Name, Numbers, Community, Subdivision, Lot No
3. OWNER: TOMMY HARTZOG
Address 323 MATHO TRACE
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
(828) — 625-2500
Area Code Phone number
4. DATE DRILLED 03/15/06
5. TOTAL DEPTH: 685
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EI
7. STATIC WATER LEVEL Below Top of Casing: 200 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 ARID
10. WATER ZONES (depth): _
County RUTH
, Zip Code)
11. DISINFECTION: Type CHLORYTE Amount 18.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 70 Ft. 6-1/4" SDR27.6 PVC
From _To_Ft.
_ _
From _To_Ft.
_
13. GROUT: Depth Material Method
From 0 To 20 FL 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 FL_ _
From To FL
16. REMARKS:
Topographic/Land setting
❑ Ridge 0 Slope ❑ Valley 0 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
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and conunon names
FROM RUTH GO UP HWY. #64/74. RIGHT ON
BILL'S CREEK RD. LEFT ON BUFFALO CREEK
RD. RIGHT ON MATHO TRACE. STAY LEFT AT
FORK. DRIVE ON RIGHT. ACROSS FROM BIG
WATER TANK
• )
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONISTRUCTION STANDARDS, AND
AND THAT A C PY OF THIS RE ORD HAS
BEEN PROVIDED TO THE WELL OWNER
GNATURE PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 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: LAKE LURE
CEDAR CREEK RD.
(Street Name, Numbers, Community, Subdivision, Lot No
3. OWNER: JOHNNY LULD
Address CEDAR CREEK RD.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
(828) — 421-6008
Area Code Phone number
4. DATE DRILLED 03/15/06
5. TOTAL DEPTH: 185
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LEI
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): 40 METHOD OF TEST ARD
10. WATER ZONES (depth): _
County RUTH
, Zip Code)
11. DISINFECTION: Type CHLORYTE Amount 3.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 80 FL 6-1/4" SDR21 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
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. #64/74A W. FROM RUTHERFORDTON.
RT. ON BILL'S CREEK RD. LEFT ON CEDAR
CREEK RD. 1S7 DRIVE ON RIGHT PAST
CONNER RD.
R CEIV'ED
4•haeP rtt,� n&
(71
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON TRUCTION STANDARDS, AND THAT A COPY, F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SICiNATURE OF P RSO 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) 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 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: LAKE LURE
PHEASANT ST. (RIVERBEND)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DAWN LITLE'
Address PHEASANT ST.
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
9(04) — 673-4905
Area Code Phone number
4. DATE DRILLED 03/16/06
5. TOTAL DEPTH: 185
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
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 I5A NCAC 2C .0118.
9. YIELD (gpm): 25 METHOD OF TEST ARD
10. WATER ZONES (depth): _
11. DISINFECTION: Type CHLORYTE Amount 3.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
To 40 Ft 6-1/4" SDR.21 PVC
To Ft. _
To Ft. _
Depth Material Method
To 20 Ft OUIKRETE POURED
To Ft. _
Depth Diameter Slot Size Material
From _ To _ Ft. _ in.
From _ To _ Ft.
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To _ Ft.
From To Ft
From 0
From
From
13. GROUT:
From 0
From
14.SCREEN:
County RUTH
16. REMARKS:
in.
in.
Topographic/Land setting
0 Ridge 0 Slope 0 Valley ❑ 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
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. #64/74A W. FROM RUTHERFORDTON.
LEFT ON PHEASANT RD. ACROSS FROM MAIN
ENTRANCE TO RIVER BEND. 5TH LOT ON LEFT.
RECEIVED
^,r l .n.a! Office
Aculter Fyrota ie Ji?
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION SSTTA7NDA/R/DS, AND THAT A COPY O�.F-THIS
RECORD HAS BEEEN/PROVIDED TO THE WELL OWNER
SIGNATURE OAF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 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 0 Industrial ❑ Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: LAKE LURE
VISTA AT BILL'S MOUNTAIN
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: BETH BUTLER
Address VISTA AT BILL'S MOUNTAIN
(Street or Route No.)
LAKE LURE NC 28746
City or Town State Zip Code
8(W — 684-7777
Area Code Phone number
4. DATE DRILLED 03/23/06
5. TOTAL DEPTH: 1200
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 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):
11. DISINFECTION: Type
12. CASING:
Depth
From 0 To 35 FL
From _To_Ft.
_ _
From _To_Ft.
_ _
13. GROUT: Depth Material
From 0 To 20 FL OUIKRETE
From To Ft. _
14.SCREEN: Depth Diameter Slot Size
From _ To _ Ft. _ in. _ in.
From _ To _ Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
CHLORYTE Amount 36
Wall Thickness
Diameter or Weight/FL Material
6-1/4" SDR21 PVC
Method
POURED
From
From
To FL
To FL
Material
Topographic/Land setting
0 Ridge ❑ Slope 0 Valley 0 Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS 0 Topographic map
(check box)
DEPTH DRILLING LOG
From To 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. #64/74A W. FROM RFTN. RIGHT ON
BILL'S CREEK RD. RIGHT INTO VISTA BILL'S
MOUNTAIN ONTO GOLDEN RIDGE. GO
THROUGH GATE & HEAD UP THE HILL. LEFT
ON BILLS MOUNTAIN TRAIL NORTH. LEFT ON
HALF MOON MILL GO STRAIGHT AT CUL-DE-
SAC. HOUSE ON HILL ON LEFT.
RECEIVED
AShevjjfe RC-gjnna(()r{ice
16. REMARKS:_ A ulfl;E=Pr^itent or,
0
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
County RUTH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
cted--
t
SIGNATURE OF ERSON CONSTRUCTING WEL DATE
t

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 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest town: LAKE LURE County RUTHERFORD
LOT 11, SILVER TREE LANE, OFF JUSTICE RD, OFF HWY 64/74
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER MARATHON BUILDERS
ADDRESS POB 33
(Street or Route No.)
LAKE LURE
City or Tout
828-429-4486
NC
State
Area Code - Phone Number
4. DATE DRILLED 3/27/06
5. TOTAL DEPTH 300
6 DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28746
Zip Code
YES ❑ NO El
150 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 Fr. 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): 12 METHOD OF TEST ARDM
10. WATER ZONES (depth): 270 290
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.25.277 / 82.10.749
(degrees/minutes/seconds)
Latitudellongitude source: ® GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0
100 Clay
100
300 Consolidated Rock
It. DISINFECTION: TYPE HYPOCHLORITE Amount 7
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 110
13. GROUT:
Depth
From 0 To
14. SCREEN
Depth
From NA To
Ft 6 1/4 " SDR 21 PVC
Oa
Material Method
20 Ft. GRAVEL MIX GRAVITY
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Diameter
Ft 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.
I •
01
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. - -
GW-1 REV. 07/2001
JUN 05 2005

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. PAORhIITNE # (704) 77
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED
applicable)
WQ PE
(if applicable)
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:
Nearest town: LAKE LURE County RUTHERFORD
LOT 10 SILVER TREE LANE, OFT JUSTICE RD, OFF HWY 64/74
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER MARATHON BUILDERS
ADDRESS POB 33
(Street or Route No.)
LAKE LURE
City or Town
828429-4486
NC
State
Area Code - Phone Number
4. DATE DRILLED 3/25/06
5. TOTAL DEPTH 220
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
'Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 17 METHOD OF TEST ARDM
10. WATER ZONES (depth): 180
28746
Zip Code
YES ❑ NO Ei
160 FT.
I1. DISINFECTION: TYPE HYPOCHLORITE Amount 3
12. CASING:
Depth
From 0 To 82
13. GROUT:
Depth
From 0 To 20
14. SCREEN
Depth
From NA To
Diameter
Ft. 6 1/4 "
Wall Thickness
or Weight/FL Material
SDR21 PVC
Or
Diameter
Ft.
Material Method
GRAVEL MIX GRAVITY
Slot Size Material
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft.
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ® Flat
Latitude/Longitude of well location
35.25.270 / 82.10.772
(dGy, ecs/mtnutes/seconds)
Latitude/longitude source: ® GPS 0 Topographic map
DEPTH
From To
0 75 Clay
DRILLING LOG
Formation Description
75 220 Consolidated Rock
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.
4/1/06
SIGNATURE OF PERSON ('( )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. 4919) 733-3221, within 30 days.
GW-1 REV. 07/20011
JUN 05 2006