WI0100099_Complete File - Historical_20220311

NCQENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee freeman
Governor Director Secretar
y
August 24, 2010 `'T 07 2M
Stephen Bagley, Director of Facilities Management
University of North Carolina at Asheville
1 University Heights
Asheville. NC 28804
Re: Issuance of Injection Well Permit
Permit No.WI0100099
Issued to UNC Asheville
Buncombe County
Dear Mr. Bagley:
In accordance with your application received May 17, 2010, I am forwarding Permit No. WI0100099 for the operation of
a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be located at the Pisgah House, 200 W
T Weaver Blvd., Asheville,Buncombe County,NC,28804. This permit shall be effective from the date of issuance until
July 31, 2015,and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. Please submit copies of the Well Construction
Completion form (GW-1)Part I,paragraph 7.
Please submit the data within 30 calendar days of receipt of this letter to the following address:
Aquifer Protection Section(APS)
Underground Injection Control(UIC) Staff
1636 Mail Service Center
Raleigh,NC 27699-1636
Additionally,your UIC system is subject to inspection by the APS and at the time of the inspection must display a
permanently affixed identification plate in accordance with requirements of 2C .0213(g). Please insure this is completed
in accordance with permit condition Part 1,paragraph 6 of this permit issued August 24, 2010.
In order to continue uninterrupted legal use of this well for the stated purpose,you should submit an application to renew
the permit three months prior to its expiration date. As indicated in the permit,this permit is not transferable to any
person without prior notice to, and approval by,the Director of the Division of Water Quality. If you have any questions
regarding your permit or the Underground Injection Control Program please call John McCray at(919) 715-6168.
Best Regards,
John R. McC�ray'
Environmental Specialist

cc: �L�dS�dzsti Da�sifion- hev�lle As�rona"i3f ice.
Central Office File—W10100099
Buncombe County Environmental Health Dept.
Larry Wells—Appalachian Well Drilling
Attachment(s)

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH,NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
UNC Asheville
FOR THE CONSTRUCTION AND OPERATION OF 8 TYPE 5QM INJECTION WELLS, defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at Pisgah House 200 W T Weaver Blvd,
Asheville, Buncombe County, NC 28804. and will be constructed and operated in accordance with the
application dated June 24, 2009, and in conformity with the specifications and supporting data submitted, all of
which are filed with the Department of Environment and Natural Resources and are considered a part of this
permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall:be in compliance
with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules., and
Regulations pertaining to well construction and use.
This permit shall be effective,unless revoked, from the date of its issuance until July 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 3l day of�_, 2010.
J UJ8
�Coleen H. Sullins, Director
V Division of Water Quality
By Authority of the Environmental Management Commission.

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
6. Each geothermal injection well system shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1)must be submitted for each injection well to:
Aquifer Protection Section—UIC Staff
1636 Mail Service Center
Raleigh,NC 27699-1636
and
Aquifer Protection Section—Asheville Regional Office
2090 US Hwy 70
Swannanoa,NC 28778
[phone]
GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on-site and available for inspection.
8. Well construction records must also be submitted for the existing water supply wells on-site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .021 I(d)(1)(1)).
PART II—WELL CONSTRUCTION SPECIAL CONDITIONS
1.At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Asheville Regional,Office Aquifer Protection Section Staff, telephone
number(828) 296-4500.
WIOI00099 2

2. Boreholes shall not connect separate aquifers which have differences in water quality (e.g., shallow
surficial aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in
the permit application.
PART III—OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV—PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or'abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V—OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
WI0100099 3

PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property,premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII—MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number(828)-296-4500, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VHI—PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit,request an extension.
PART IX—CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well
Construction Standards.
WI0100099 4

2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout,which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC.Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh,NC 27699-1636
WI0100099 5

I
I
�. 012Gi0
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee Freeman
Governor Director Secretary
June 7,2010
Stephen Bagley
UNC Asheville
One University Heights -
Asheville,NC 28804 .
Subject: Acknowledgement of Application No.WI0100099
Pisgah House
Injection Mixed Fluid GSHP Well System(5QM)
Buncome
Dear Mr.Bagley:
The Aquifer Protection Section of the Division of Water Quality(Division)acknowledges receipt of your permit application and
supporting materials on May 17,2010.This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.To ensure the
maximum efficiency in processing permit applications,the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office,copied below, must provide recommendations prior to final action by the
Division.Please also note at this time,processing permit applications can take as long as 60-90 days after receipt of a complete
application.
If you have any questions,please contact John McCray at 919-715-6168,or via e-mail at [e-mail]. If the reviewer is
unavailable,you may leave a message,and they will respond promptly.Also note that the Division has reorganized.To review our
new organizational chart,go to http://h2o enr.state.nc.us/documents/dwq_orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
cud,,, �.
for Debra J.Watts
Supervisor
cc: Asheville Regional Office,Aquifer Protection Section
Appalachian Well Drilling(Lang Wells)258 North Turkey Creek Road,Leicester,NC 28748
Permit Application File WI0100099
AQUIFER PROTECTION SECTION
1636 Mail Service Center,Raleigh,North Carolina 27699-1636
Locatbn:2726 Capital Boulevard,Raleigh,North Carolina 27604 ne
Phone:[phone] FAX 1:919-715a88;FAX 2:919-715-60461 Customer Service:1.877-623-6746 T�DorthCarolina
Internet:m^xw.ncwatemualiN.om
An EmM Opoomniiy�A"ame Action Employe• �� �����

i
Central Files: APS_ SWP_
06/07/10
Permit Number WI0100099 Permit Tracking Slip
Program Category Status Project Type
Ground Water In review New Project
Permit Type Version Permit.Classification
Injection Mixed Fluid GSHP Well System (5QM) Individual
Primary Reviewer Permit Contact Affiliation
john.mccray Larry Wells
Contact Driller Well
Coastal SW Rule 258 N Turkey Creek Rd
Leicester NC 28748
Permitted Flow
Facility
Facility Name Major/Minor Region
Pisgah House Minor Asheville
Location Address County
200 WT Weaver Blvd Buncombe
Leicester NC 28748 Facility Contact Affiliation
Owner
Owner Name Owner Type
UNC Asheville Government-State
Owner Affiliation
Stephen Bagley
One University Hts
Asheville NC 28804
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
05117/10
Regulated Activities
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

(Mice of Design and Construction
CPC#1110
one Univerelty Heights
Asheville, NC 28004
P:F:828.25"121
e28.251-e455
TRANSMITTAL
To: UIC Program From: Alan King
Aquifer Protection Section
Fax Pages:
Phone: Date 12 May 2010
Re: UNC Asheville -Pisgah House CC:
Re-purpose geothermal wellfleld
from water to glycol
WEARE SENDING YOU: ❑x Attached
❑Under separate cover
THE FOLLOWING: ❑ Drawings ❑See below
❑Specifications ❑Other.—
THESE ARE TRANSMITTED: ❑As requested ❑For review and comment
❑ For your use ❑ Please call when received
❑ For approval ❑To be returned by:_
❑With comments
y - '?^'�' .�...�..^ t s � k-� '.xnr `ATy'&�"�r+" 1' •Y'4 M?^ R..h L .. .. �i
1 2 05/12/10 2 Original copies—GW/UI457 HP
REMARKS:
Application requests that eAsting geothermal well-field be allowed to use glycol. Currently,the well-field is using
water. The geothermal piping will continue to be closed loop.
Thank you.
Alen
[phone]
eking®unca.edu
mow`/
RECEIVED I DENR I DWQ Alan L.King,PE
AQUIFFR'PRf1TFCTInN SF.C?ION Facilities Mechanical Engineer
MAY 17 2010

i
4 1 • /
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL.RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A.7 and 5QM Wells
In Accordance with the provisions of NCAC Title 15A:02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOR,NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 20
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) _ Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) x Type 5QM wells contain a subsurface system of continuous piping,that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(3) _ Type 5QW wells contain a subsurface system of continuous piping,that is .
isolated from the environment and only circulates potable water.If you selected
this well type,then complete form GW-57 CL,Notification Oflntent To
Construct A Closed-Loop Geothermal-Water Only Injection Well System.
B. PERMIT APPLICANT
Name: UNC Asheville
Address: One University Heights
City: Asheville State: NC Zip Code: 28804 County: Buncombe
Telephone: [phone]
C. PROPERTY OWNER(if different from applicant)
Name: Same
Address:
City: Sate:_ Zip Code: County:
Telephone:
D. STATUS OF APPLICANT
Private: Federal:_ Commercial: AQURFREPVED/DENR/DWQ
— R�TFCTIt1N RFCTION
State: X Municipal:_ Native American Lands:_ MAY
17
2010
Revised 5105 GW/UIC-57 HP Page I of 4

E. FACILITY(SITE)DATA
(Fill out ONLY if the Status of Owner is Federal,State,Municipal or Commercial).
Name of Business or Facility: Pisgah House, UNC Asheville
Address: 200 W.T. Weaver Blvd.
City: Asheville Zip Code: 28804 County: Buncombe
Telephone: [phone] Contact Person: Alan King
F. HEAT PUMP CONTRACTOR DATA
Name: Appalachian Well Drilling
Address: 258 North Turkey Creek Road
City: Leicester Zip Code: 28748 County: Buncombe
Telephone: [phone] Contact Person: Larry Wells
G. INJECTION PROCEDURE (Briefly describe how the injection well(s)will be used.)
Recirculating 20% solution of propylene glycol &
potable water in closed loop geothermal system.
H. WELL USE Will the injection well(s)also be used as the supply well(s)for the following?
(1) The injection operation? YES NO X
(2) Personal consumption? YES NO X
I. CONSTRUCTION DATA(check one)
X EXISTING WELL being proposed for use as an injection well.Provide the data in
(1)through(7)below to the best of your knowledge. Attach a copy of Form GW-
I (Well Construction Record)if available. .
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through(7) below as PROPOSED construction specifications. Submit
Form GW-I after construction.
(1) Well Drilling Contractor's Name: Robert "Larry" Wells
NC Contractor Certification number: 2603
(2) Date to be constructed: In use Number of borings: 8
Approximate depth of each boring(feet):
(3) Well casing: Is the well(s)cased? No
(a) YES If yes,then provide the casing information below.
Type: Galvanized steel_Black steel_Plastic_Other(specify)
Casing depth: From to ft.(reference to land surface)
Casing extends above ground inches
(b) NO
Revised 5/05 GW/UIC-57 UP Page 2 of 4

(4) Grout(material surrounding well casing and/or piping): PeagravelTop 20'
(a) Grout type: Cement_ Bentonite_ Other(specify) 20% bentonite solids
(b) Grouted surface and grout depth(reference to land surface):
around closed loop piping; from to (feet).
around well casing; from to_(feet).
(5) Screens(for Type 5A7 wells)
(a) Depth: From to feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200)require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent(fluid being injected into the well)lines is required. Will there be a faucet on:
(a) the influent line? yes X no (b) the effluent line? yes X no_
(7) SOURCE WELL CONSTRUCTION INFORMATION(if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K(1) of this application form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EMIER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) Injection rate: Average(daily)_gallons per minute(gpm).
(2) Injection Volume: Average(daily) gallons per day(gpd).
(3) Injection Pressure: Average(daily) pounds/square inch(psi).
(4) Injection Temperature: Average(January) °F,Average(July)_°F.
K. INJECTION FLUID DATA
(1) Fluid source(for Type 5A7 wells) If underground,from what depth,formation and type of
rock/sediment unit will the fluid be drawn(e.g.,granite,limestone,sand,etc.).
Depth: Formation: Rock/sediment unit:
(2) Chemical Analysis of Source Fluid(for Type 5QM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
Dow Propylene G1Vco1 Dowfrost HD
L. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two maps.
Revised 5105 GW/UIC-57 HP Page 3 of 4

(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s)and any existing well(s)or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Dischargepermits
(3) Sewage Treatment and Disposal Permits
O. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the
information is true, accurate and complete. I am aware that there.are significant penalties, including
the possibility of fines and imprisonment, for submitting false information. I agree to construct,
operate,maintain,repair, and if applicable,abandon the injection well and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
5,c�-
(Signatdfe of Well Ownerlg u orized Agent) Mr 7#T-
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
P. CONSENT OF PROPERTY OWNER(Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to the Well
Construction Standards(Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center RECEIVED I DENR I DWQ
Raleigh,NC 27699-1636 AQUIFPPTRnTF(TIf1N RFCTION
MAY 17 2010
Telephone [phone]
Revised 5105 GW/UIC-57 HP Page 4 of 4

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�4'" WELL CONTRACTOR CERTIFICATION#
1.tIIIELL CONTR g. WATER ZONES(depth):
tprNy s rop Bottom Top Bottom
Well Contractor ondividual)Name Top—Bottom— Top Bottom_
1'op__Bottom Top Bottom
elln ntrector Company Name �---^�r—
Thlcknessf
Street dress V. CASING: Depth Diameter Weight Material
q�
^ 10 QR1 `3 Top Bottom Ft.-- --
CM orT '\ �t Slale`'t' tle Zip Co . lisp Bottom Ft. ----
t�J-iL'3.LJ 'op Bottom Ft. - --
Area code Phorianumber t `i- : GROUT: Depth Material Method
2.WELL INFORMATION: Top _BottomWELL CONSTRUCTION PERMIT# hl F C)l tla_A _ i Top Bottom
OTHER ASSOCIATED PERMIT#(IfapgkaM) _ Top Bottom Ft
SITE WELL tD#(N appllceble)
9. SCREEN: Depth Diameter Not She Material
3.WELL USE(Check Applicable Box):: Residential Water Supply❑ Top Bottom Ft—In. _ in.
DATE DRILLED mot[ '„11"l a� : Top Bottom FtIn. In.
TIME COMPLETED AM❑ PM❑ Top Bottom_._ _Ft In. _ in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK-
CITri� V) , ��! COUNTY ; 11 , Depth Sbte Material
pC Top Bottom R.
r— ` n Lei J Top Botiotn FL
(aaeet Name,Numbers,C rnun ,Subdivision,Lot No..Parcel,Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley []Flat ❑Ridge ❑Other 11, DRILLING LOG
LATITUDE - p Top Bottom Formation Descrlption
A.C-_.-�JIeOA) DW OR 3x.70DDtxXXIO(DD /
LONGITUDE ZEG4V--Tj ,/394- a DMS OR 7)(.=CxxXX)x DD
Latttudenongitude source: []3PS []Topographic map .
(location Of well must be shown On a USGS topo map andattached to CX)o ,� (tom/t(,rG
this form Snot using GPS) /
s.WELLOWNER Ul�iver�i}Y PF North CiYtII:I.itY� � Uot� (Ana-n -F
Owner Name L IMEJ(P It- WrA LOCKSAddress
It
/
—sttae, ll� z 111 rC�t� 44G
City or Town State Zip Code
Area code Phone number /
6.WELL DETAILS: II r **�� 12. REMARKS:
a. TOTAL DEPTH: 4DO
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use`+•N Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
tl. TOP CASING 1S FT.Above Land Surface' � n r
'Topp
of casing terminated aVor bebw lend surface may
ey require j�Lfi/�
a variance in ttccordettce wflh 15A NCAC 2C.011 B. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST _
t. DISINFECTION:Twe Amount _ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev.2/09

y AA1Fp
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resnurces-Division of Water Quality
•4""" WELL CONTRACTOR CERTIFICATION# L4 I v 1
g. WATER ZONES(depth):
11'l f S 71iYYlll S rop Bottom Top Bottom
(/Wall Contractor ondiivvidual)Name Top__Bottom Tp Bodom _
lop-- Bottom Top Bottom
dell pntrac�for Company Name -
1 ThIcknessf
l t = P. CASING: Depth Diameter Weight Material
t� _
C;ty To,�n '`6'F''J t\��1 `Jc" le lop Botlm Ft
1 Stele Zip Code- ",op Bottom Ft.
�a - � a� I -
Areacode Phonenumber F. GROUT: Depth Materiel Method2.WELL.INFORMATION: lop_ Bottom Ft. Qf i7laV' j:Q-+
WELL CONSTRUCTION PERMIT# �)J F(7)10089 1 op Bottom Ft
OTHER ASSOCIATED PERMIT#(Bapp'Nabla) lop—Bottom—Ft—
SITE WELL ID#(if applimble)_ '
9. SCREEN: Depth Diameter Sloth met&"
3.WELL USE(Check Applicable Box), Reaidentlal Water Supply p Top Bottom Ft_in. In.
DATE DRILLED - (✓ -oZ C/d : Top Bottom Ft. ! in.
TIME COMPLETED Apt[) PM Ej l'op Bottom Ft_in. � in.
4.ALL LOCATION: 10.SAND/GRAV EL PACK
CITY-'-,, /' COUNTY Depth Size tNabthl
�' C� _'�+^�-����C Top---Bottom Ff.
1\Ij_y(Y U Top—Bottom—FL
1 Beet Name,Numbers,Communes,Subdiwsbn,Lot No-Parcel,Zip Cade) TOP Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appmpdate box)
[]Slope ❑Valley CIFlat ❑Ridge pother 11.DRILLING LOG
LATITUDEA$cjo . Q56N ^ Top Bottom Formation Description
C.__ DMS OR 3X.XxxXXXXxx DD : /
LONGITUDEM2t q •l'ULU wDMSOR7X.=ixxxxxxDD _,1 1, OD('? (y}-
Ladtude/lOngitude source: E)3pS ❑ropogmphic map
(location Of well must be Shown on a USGS topo map anda#achod to
this form if not us&V GPS)
s.VWLLOMER Univerbi+V QP N,Yr h CIA.T000C,
Owner Name - -
��� 17hi i:(atl opo
Street Address t --
1
Uy )tile
City or Town State zip Code /
Area code .Phone number
rx WELL DE MILS: = 12. REMARKS;
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ ND❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing; F(, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use•+^#Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING is Fr.Above Land Surface°
Surface-
'Top of casing terminated atior below land surface,may require
a variance in accordance with 15A NCAC 2C.g118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):. METHOD OF TEST
I. DISINFECTION:Type Amount : PRiNT£D NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

a RESIDENTIAL WELL.CONSTRUCTION RECORD -�5
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#^0113
7. LL CONTRACTOR: g. WATER ZONES(depth):
'rop Bottom Top Bottom__.
^Well Contractor(Individual)Name Top _Bottom Top Bottom _
t ) k f A A/V\}(g�f Y ? A nV1 U I Ya Top Bottom Top Bottom
Jf,pntre poor Company Name �— Thleknassl
9. CASING: Depth Diameter Weight Maferfal
��,
—ISt�reeetAw1dress
A.
x : f 43 T p Bottom FL
Cit or To r � Slate Zip Coda Top_Bottom FL
Area code Phone number 8. GROUT: Depth Materiel Method
m `�'(''`�'/`)
C /
2,WELL INFORMATION: Top- _Botto Ft. + `{" l:�k.4 �j
WELL CONSTRUCTION PERMIT#._N\l F l)i IVY : Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applOW) Top BDttmn F1.
SITE W ELL ID#(If applicable) 9. SCREEN: Depth Diameter Slot she Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom—�Ft In. _ In.
DATE DRILLED �'or : Top Bottom FL_In. in.
TIME COMPLETED AM[I PM[ITop Bottom fL in. in.
10.SAND/GRAVEL PACK:4.WELLr'L�OCCATION; De _at" Maeattal
GITY be\l i 1 �f COUNTY_,_ l x y1Cr; , Top Bottom Ft
Top Bottom Ft
{street Name,Numbers,Comarunfo,SubdNWon,Lot No.,Portal.Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING' (check appropriate box)
[]Slope DValley []Flat ❑RIdge ❑Other : 11.DRILLING LOG
LATITUDE ,. —t��(.• �(5V/V^DMS OR 3x.mao(xxw DD Top / Bottom Formation Description
LONGITUDE .?-A- lgjm,' "DMSOR7XJOOW()XXXDD
Latitude/longitudesource: [BPS [jropographicmap /
00000n of well must be shown on a USGS topo reap andatrached to
this form if not using GPS) l
S.WELLOWNER Univer-l+4 pP tvor+-h G�Irotirt:. A�%t�?�ltc�;.C, �i0(� �YYt wit ,
4 iLtIrIIIPt(�� (I 1 imS
Owner Name
30:� nr I j&D S ao
Street Address /
city orTovm State Zip Code ) -
Area code.Phone number
12. REMARKS:
6.WELL DETAILS: I (
a. TOTAL DEPTH: q
It. DOES WELL REPLACE EXISTING WELL? YES NO
j 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Lend Syde *
"Top of casing terminated avor below land sud ,m aeaa require
A variance in accordance with 15A NCAC 2C.0118. S16MTURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):--- —METHOD OF TEST
L DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
4010� Rev.2/09
x.a NXIMP, !"IN

.r'n"RNEo- 1
RESIDENTIALWELL CONSTRUCTION RECORD
North Carolina IkpartmentofEnvironment and Natural Resources-Division of Water Quality
�. WELL CONTRACTOR CERTIFICATION# <9 113
1.rWELL CONTRIACTOR: g. WATER ZONES(depth):
(�C�p)L-��S : Top Bottom Top Bottom
W11 ell Contractor(Indiviidual)Name g f [ Top Bottom Top m Botto .
(1
l A k u t'A 1 �.{� Ail 21� )fyi^ : 'rop Bottom Top Bottom
Ij yllea Cpntractor Company Name
ivy IkJ II Thickness/
x � 4 ?. CASNG: Depth Diameter Weight Material
LStre Ft
1eI tltlress
1 �}h { yyS N� Ot���-j Top Bottom FL
Cit�-orT -1 � ZIP Code Top—BBottttom Ft.
Area rode Phone number A. GROUT: Depth
o Material
M1.e(t h
2.WELL INFORMATION: Top^� Bottm,tM FLA .atel -f
WELL CONaRUCTxN PERMIT# Top-Bottom Ft.
OTHER ASSOCIATED PERMIT#(If applicable) lop Bottom FL.
SITE WELL ID#(itapdimhle) : 9. SCREEN: Depth Diameter -Sion she Material
3.WELL USE(Cheek Applicable Aipplicable Box): Residential Water Supply❑ Top Bottom FL_in. _ in.
DATE DRILLED of-12 : Top Bottom FL_)n. T In.
TIME COMPLETED AM PM❑ Top Bottom K—In. ^ in.
4.WELL OCATiON: n 10,SAND/GRAVEL PACK:
cCOUN.IY_� 11 Yl ^� Depth She Materlel
op_Bottorn­FL__
Top Bottom Ft --
(Street Name,Numbers,Comm ,Subdivision,Lett W.Parcel,Zip Code) Tep Bottom FL
TOPOGRAPHIC!LAND SETTING: (check appropriate box)
❑SiOpe QValley DFlat ❑Rkige Ei Other 11.DRILLING LOG
r� Top Bottom Formation Description
LATITUDE �G35.3(a 'q5VAi,^DMS oR 3X.xx)(xxxxxx DD
LONGITUDE 36a�)-04, /13i,%DMs DR7x.xxxxxxxxx CD rcu-)l e- to
Latitudellongitudesource: Epps L7fepogmphicmap
(location Of wa#must be shown on a USGS topo map andedached to
this form if not using GPS) '
S.WELLOWNFjz 9PNu-4NCa�Ybt(rGhA�#
1 I► fp 4 �Q tom— !
Owner Name
1
Street Address _
Cityor Town Stab Zip Code )
(—_) it
Area code Phone number
12. REMARKS:
G.WELL DETAILS: I
a. TOTAL DEPTH: 4 0L
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+^if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
P�QVIDED TO THE WELL OWNER.
d. TOP F CASING IS FT. Land Surface
*TOPof casingtennlneted etlor below land surfacemayrequire /ll Q
h4v�-
a variance in accordence wah 15A NCAC 2C.011S. 7 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpan): _METHOD OF TEST
C DISNFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev.2R119

RUIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
m° « WELL CONTRACTOR CERTIFICATION# 1 I v A
1.WELL CONTR
g. WATER ZONES(depth);
GS"yo-i J Top Bottom Top Bottom_
Well Contractor(Individual)Name �^ Top Bottom Top Bottom_
I-op__Bottom Top Bottom
_--
ell ntrector Company Name
Thicknesst
Y. CASING Depth Diameter Weight Material
Sheetidress
n Top Bottom Ft._
City or 2�14� Top Bottom Ft. --
Slate Zip Code'
'op Bottom Area code code Phone number I d : P... GROUT: Depth Material Method
2.WELL INFORMATION.. ` lop,_ _Bottom_�} L Ft- -J)� t} + Usk( 1Cj
WELL CONSTRUCTION PERMIT# Y\i��"(a l� lop Bottom Ft
OTHER ASSOCIATED pERMIT#(ff applies*) Top Bottom Ft
SITE WELL ID#R applinets)
S. SCREEN: Depth Dimmemr Mot sin Mot*"
3.WELL USE(Check Applicable sox); Residettliel WaterSuPP1y q Top Bottom Ft,_in. T In.
DATEDRILLED Top Bottom Ft_hi. In,
TIME COMPLETED AM[] PM Top Bottom Ft_In. _ in.
4.WELL LOCATION- to.SAND/GRAVEL PACK:
CITYY COUNTY ,� � Depth SW Materiel
/ lop Bottom Ft.
----�-ue � (.F = rop Bottom Ft
tarreet Name,Ntxntrers,Comma ,Subdivlabn,Lot No.
Parcel.21P Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING; (check appropriate box) -
❑Slope [Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
"DMS OR
LATITUDE ^3U-iStA/, $X.XXXXXXXXX Dp Top Bottom Formation DeaCdptlon
LONGCfUDEISW2-2* ,L5,0 ^DMS OR TX.XXXXXXX(X DO _�„! 0 QQ L\k`Ce..fll �F- jy i-
Latihrdegongttudesource: BPS (]Topographic map _ /
(location of well must be shown on a USGS topo map andadached to L�. _/ _ (�Y PV t (e
this form if not using GPS) j
S.wELLOWNER univert-5ity Qf N06hCtArvkf-t^.. f4
Owner Name /
Sheet Address -- )
1aY'. )k IP- S\) a�fSS�
Qry or Ttavn Slate zip Code -
(_____) /
Area code .Phone number
S.WELL DETAILS: 1 rr 12. REMARKS:
a. TOTAL DEPTH: LK
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH ISA NCAC 2C,W ELL CONSTRUCTION
(use^+^ff Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 1S FT.Above Land Surface*
'Top of casing terminated aNar below land surface,may require
s variance in accordance with 15A NCAC 2C.0119 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpml: _METHOD OF TEST
f. DISINFECTION:Type Am unt PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

�v<Sr�Ea
r4 .
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironmrnt and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# LA I Y } - A
1.WELL C NTRACr)' g. WATER ZONES(depth):
-fop Bottom 1�wIdakelll l(contractor((r�X alv lid uie�i)N}e/m�e Y d Top Bolbm
op Bottom Tap� in (Y4 Bottom
u or Company Name _ " p p Bottom
lI ThIclo"aw
Y. CASING; Depth Diameter Weight MMeriel
Sheet Adelman
t� I FS-1 2 Top Bottom Ft.
City or T�� I\� O Q U 1�.� [ -lop Bottom Ft.
State Zip Code tcp Bottom Ft.
Areacode Phonenumber F, GROUT; Depth Materiel Meth
od
2.WELL INFORMATION: n Top_, -Bottom FL
WELL CONSTRUCTION PERMITS Y`, F��)' I��_�_ �Rg lop Bottom Ft. J
OTHER ASSOCIATED pERMIT"fappr=W) Top Bottom FL _
SITE WELL ID#fd appilrahla) .
9. SCREEN: Depth Diameter Swats Material
3-WELL USE(Chec�klAp�pficebie Sox): Residential Water Supply❑ Top Bottom Ft,_In. _ In.
DATE DRILLED�t -of ' a C'j : Top Bottom Ft—In. In.
TIME COMPLETED. AM El PM Top Bottom Ft_in. _ in.
4,WELL LOCATION: 10.SANDIGRAVEL PACK:
Crry Depth Site Materiel
1 {�� 1� COUNTY �'�C Top Bottom FL
-- , A cry i 1 L.S 5 lop Bottom Ft.
tamaet Name,Numtxirs,C0ft1oWW,Supdirisbn,Lee No.,Parcel,Zip Code) T Bosom Ft
TOPOGRAPHIC(LAND SETTING: (check appropriate box)
❑Slope ❑ValleY ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
LATITUDE i38L35^3k•�7"171V` ^OMS OR 3X.==XXXX DO
Top Bottom FormationDescdptlort
LONGITUDE E;T '3�. /040 f
OMS OR 7X.XIfXXXXXXX DD _1 �./, (9 00L
Latdudellongflude source: (BPS (Jfopographic map
(location of well must be show on a USGS topo map andaltachad In _/ boa t ti Y"PJ[l
this form Knot using GPS)
5.WELL OWNER Univerc5it4 QF Nort h CA:MliMA
tl (PjQ r/F A"1tf1S f
Owner Name /
Street Address I /
City or Town State Zip Code
/
Area code Phone number /
S.WELL DETAILS: 400
12. REMARKS:
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(USa"+^d Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS Ff.Above Land Surface'
'Top of casing terminated atlor below land surtace,mey require
a variance in accordance with 15A NCAC 2C.011 S. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
I. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
�., Rev.2109

D /
' ¢¢ RESIDENTUL WELL CONSTRUCTION RECORD
, l North Carolina Department of Environment and Natural Resouraec-Division of Water Ouality
WELL CONTRACTOR CERTIFICATION# L4 I 1 - A
1-WELL CONTRAC20R: g. WATER ZONES(depth);
}f%` Ul I I Pf71tYY�l Top Bottom Top Bottom_
(�Iwag Contraaor(mtlivk)ual)Name Top Bottom Top Bottom --�
l A yf� 7) ��,)� A°�� A `�� I I ) 7'op---Bottom Top Bnttom '—.
dell ntract Company Name _ -_--
"'1 I Thickness)
LI T. CASING: Depth Diameter Weight Material
Streettdress
,CityorT 15 "I\)(I a� 1`t ;op Bow R
SIa6e zip Cotla
''op__,Bottom Ft. _ -
Area code Phone number R. GROUT: Depth Material Method
2.WELL INFORMATION: lop_t--Bottom-qMFI.-L L.j
WELL CONSTRUCTION PERMIT# lop,.___Bottom Ft 8
OTHER ASSOCIATED PERMIT#(gappioaNe). Top Bottom FL
SITE WELL ID#(dappl1.ble) .
-- 9. SCREEN: Depth 01aamer SlotSbe Material
3.WELL USE(Check Applicable Box): Residential Water Supply EI Top Bottom Ft—In. _ In.
DATE DRILLED /- C/ = Top Bottom Ft _ln. in.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft_ln. _ in.
4.ALL LOCATION; 10.SANDIGRAVEL PACK:
CITYY' COUNTY bi, Depth SEe Material
(�r � C lop Bottom Ft.
m t ` 1 l.i S Top Bottom Ft—_
tartest Nae,Numbers,Common ,SutxHNsbn,Lot No.,Parcel,ZIP-"")
Top Bottom Ft.
TOPOGRAPHIC I LAND SETTING: (clack appropriate box)
❑Slope ❑Va9ey []Fiat ❑Ridge pother : 11.DRILLING LOG
LATITUDE 367,f% 3^ r.1qu, /, Top / Bottom Formation Description
DM OR 3X.X)MXXXXX DD :
LONGITUDE WFd-34 /kfF-' ^DMS OR 7x.xxxxxxxxx DD ._1_/ O y �'Q„7i F. 4- lY+-
Latgudepongitutle source: BPS Qropographb map /
!location of well must be shown on a USGS topo map anda#achad to { r ! -40Q c a°
this torn ifnot using GPS) -
s.wELLOWNER l iri"�vertsit4 oP fvor+h CtAIotir'6 ASw� i ec% Q00 (Im rc -P
Owner Name /
Street Adtlress !
City or Town State Zip Corte /
Area code .Phone number
6,WELL DETAILS; 12. REMARKS:
a TOTALDEPTH: 4
b• DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(1­1130"*"X Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASIN4IS Fr.Above Land Surface"
'Top of ceeng termnated actor below lard surface may require
A variance in accordance with t5A NCAC 2C.0718. [ SKiNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm)._ METHOD OF TEST
f. DIMNFEC71ON:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form OW-in
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORI3
North Carolina Department of Environment and Natural Resources-Division of Water Quality
Pam" WELL CONTRACTOR CERTIFICATION#_L4 I 1 - A
1.lalELc CONTRACZOI R: g. WATER ZONES(depth):
f)�� 1 l C F)1111 rob Bottom TOI Bouorn___
Well Contractor(btlividual)Name p t �1�� (�/ : Top Bottom Top Bottom Din I ) t 1 Tap Bottom Top Bottom
yYell HrItractor Company Nam-a ' —
LISI. 11�e ;x -_.il ThIcknees/
Sheat fjdtlress T. CASING: Depth Diameter Weight Material
,
►- S ^ 10 r�R ( S l'ap Bottom FL
City or T i\ rJt `t Z fie. 1'op—Bottom Ft
P "pop Bottom Ft.
Area code Phone number I. GROUT: Depth ' 1 Material Methtxf
2.WELL INFORMATION: l`A, Y—J
WELL CONSTRUCTION PERMIT# lop acdcoI FL
OTHER ASSOCIATED PERMIT#Qf appiMable) Top t3ottom F1.
SITE WELL,ID#(d appllceMe) .
9. SCREEN: Depth Diameter Slot Size 11112" l
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ftln, in.
DATE DRILLED Top Bottom Ft_in. in.
TIME COMPLETED AIAL] PM Top Bottom ft.—In. in.
4.ALL LLOCtA�TI I 10.SAND/GRAVEL PACK-
Cl 1{ I �y `COUNTY—� j1t Top Bottom Ft,Depth SFse Materiel
J rob Bottom Ft
Iorreet Neme,Numbers,Commun ,Subdivision,Lot No.,Parcel,Zip Code)
Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (Gieck appropriate box) '
❑Sbpe DValley ❑Flat ❑Ridge ❑Other : 11.DRILLING LOG
LATITUDE Top Bottom Formation Description
_`t.' ^DMS OR 3x.xxxxxxxxx Do /
LONGfruDE�^37 , /yS�- o DMS OR 7X,XXXXXXXXX DOi-
Latitude/longitudesource: pGPS [Iropogmphicmap /
(locetion of well must be shown on a USGS topo map sndattachad to /_r�oa ('reP j I. Ce-
this form if not using GPS) I
S.WELL OWNER 1,11�iver�i+t� QF Not'+h C!rulir-YA nra
U r(I bErls /
Owner Name /
ph1 { Hat I 01PD 4�0 �
Street Address - I
. ly� j�
Qty or Town State Zip Code /
C---> I
Area code phone number
s.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:
L DOES WELL REPLACE EXISTING WELLS YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCA02C,WELL.CONSTRUCTION
(Use'+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface-
d. 1- �
'Top of casing terminated at/or below land surfam,may require � V I /J✓ 1. 41t tj j eA-e .>
a variance in accordance with I SA NCAC 2C.0118- SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2M

f^ RESIDENTIAL WELT:.CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 5103
1- LL CONTRACTOR: 9- WATER ZONES(depth):
fop Bottom Top Bottom___.
^Well Contractor ondividual)Name Top _Bottom Top Botlom
�,��o nu 1 Yp Y �l1�)11 Do i���� : 'rop--Bottom Top Bottom
I�1ye11 Gpntrapor Company Name -m�ne�
_� : 7. CASING: Depth Diameter Weight Material
,�,St\re1et4pq,drags r� lop
t u : l )p�ll� 5 M ) A143 Top ottom Ft
City.or Ton —�� State Zip Code Top Bottom Ft-
_UaQ - a41
AfP,acode Phonenumber R. GROUT: Depth Material Material Method
2,WELL INFORMATION! Top_�Bottom �Yl rAJFt.Q�lT{-
WELL CONSTRUCTION PERMIT# V\J�'l f`11 _ : lop Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) _ Top Bow FL
SITE WELL ID#(rapplcahle) -- 3- SCREEN: Depth Diameter Slot Size Material
3,WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft_In. T, In.
DATE DRILLED .mil -�c : Top Bottom Ft_ln. _,_, in.
TIME COMPLETED AMC] PM p Top Bottom FL in. _ in.
4.WELL OCATION; (���, 10"SAND/ORAVFLPACK: s ize l
CITIt:_ ,, I PVi 111[�^�f� COl1NTY LLd_.1.iI� Top Bottom Ft.
awn'I JL�S : Top Bottom FL
(Street Name,Numbers,Cornnnwy,Subdwion,Lot No.,Parml,Zip Code)
Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope OValley OFhat ❑Ridge pother : 11.DRILLING LOG
LATITUDE Sit•937N " Tap Bottom Formation Description
_ DMS OR 3X.XXXXXXXXX DD /
LONGITUDE Xt6-J "34 '149/.0 "DMS OR 7X.XXXXXXXXX DD
Latitude/longitudesource: EpPS ETfopographictnap /
00cslian of well must be shown on a USGS topo map andattached to
this torn;if not using GPS)
S.WELL OWNER l,�IZtvertii�Y OF
ttlllin'sf 4 f14I(A iLYI� /
Owner Name /
6o--; p{� s Hail CPa H&U
Street Address —
City or Town Stele Zip Code )
Area coda ,phone number
12. REMARKS:
6.WELL DETAILS: 400
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: Ff, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
Y-ROViDED TO THE WELL OWNER.
d. TOP CASING IS FT. sun ,m
Land Surface
'Topp of casing terminated attar below landnd sudaceay require
a variance in accordance with 1 SA NCAC 2C.01111 c SIGN— AT 1/—RE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm}: �zl METHOD OF TEST
f- DIMNFEC71ON:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW1a
Rev.2MQ

eo.AATFa
c RESIDENTL4L WELL CONSTRUCTION RECORD
W North Carolina Department of Environment and Natural Resources•Division of Water Quality
WELL CONTRACTOR CERTIFICATION# c 113
CONTRACTOR: 3- WATER ZONES(depth):
'fop Bottom Top Bottom___,
Well Contractor Qndlvid )N
t 'amLe Top Bottom Top Bosom
A�O YA )n IJ Y I!\�) p I (�yA : Top Bottom Top Bottom
rr dell C�/pntre Ydor Company Name �- Thairnesar
?. CASING: Depth Diameter Weight Material
Streetpd dress
�� 11 r� � Top Bottum FL
ill: lY�rll1/15 ?143 Top Bawm Ft.
Ci or To n� code
T� ^ Stele zip Top Bottom Ft.
Area coca Phone number d : 8. GROUT: Depth Material ,1 Method
2.WELL INFORMATION: f� �) Top _.Bottom Ft l--� 1- CAU -'��
WELL CONSTRUCTION PERMIT# \� ��I(7l Lq"C J Top Bottom Ft. _
OTHER ASSDCIATED PERMIT#(Bappllcable) Top Bottom Ft
SITE WELL ID#Qlappitceble) : 9. SCREEN: Depth Diameter -Slot Size Material
3.WELL USE(Cheek Applicable Box):nResidential Water Supply❑ Top Bottom Ft^,in. ^ In.
DATE DRILLED .� - .�C./.'/ �' : Top Botta l Ft._in. _ in.
TIME COMPLETED AM❑ PM❑ Top Bottom FL in. _ in.
4.WELL LOCATION: 10,SANDIGRAVEL PACK:
4 \ r -„, _ _,�� Depth Size Materiel
CITY.��, }hP V) _(' COUNTY i( 1 X� ` T Bottom Fi.
cop Bottom Ft
(Street Name,Numbers,Comnutnilf,SubdMslon,Lot W.Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
[]Slope OValley OFiat ❑Ridge mother 11.DRILLING LOG
LATITUDE =�310•C'f'-&tiV.DMS OR 3x.XXXXXXXXX Dp Top Bottom Formation Description
LONGITUDE,7609201 ' IL{9 DMS OR 7X.XXXXXXXXX DD
Latitudellongitudesource: fpPS ETropNraphicmap 1
(location 0f well must be shown on a USGS top0 map andalfached to i x l
this form if not usklg11 (,GPS) '-
S,WELLOWNER �-l"V(ftb NGt`�T'1 -f�t"U1.1 t"(;c � 1b.�tic , t.(Vl� (Arn F,
Ft�,rn 4- f�nar��iLrl.� /
Owner Name
Street Address
City or Town ^ State Zip Code / -
(--) /
Area code .phone number
12. REMARKS:
G.WELL DETAILS: I ,p(q
a. TOTAL DEPTH: �t't/l l
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO O '
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 16A NCAC 2C,WELL CONSTRUCTION
(Use'+'ff Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' I-f��t
'Top of casing terminated aVor below land Above
Land Su require
A variance in accordance with 1 SA NCAC 2C.0118. SIGMA RE CER ED W ELL CONTRAffO DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2MQ

y e
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
~w<
WELL CONTRACTOR CERTIFICATION# U I I
1.WELL CONTRA g. WATER ZONES(depth):
c U
rop Bottom Top
Well Contractor(Individual)Name p 1 Top Bottom Top Bollom_ ___
Top__ Sottorn Top Bottom
ell ntrector Company Name ---
Thicknessf
Street
t"dram 1. CASING: Depth Diameter Weight Material
L C T prl 1\�cl a� !`t�S 1 p Botom Ftt.0
Sfele Zip Coda-- Bottom Ft.
Area code PMnenumber F. GROUT, Depth Material ,JI Method
2-WELL WELL
'iDp,�_Bothom�Ft--f4C�2-t_�' T `C.�)...1[I<
WELL CONSTRUCTION PERMIT# 1�Olrt _ lop Bottom Ft.
OTHER ASSOCIATED PERMITIl(l apptidsm) Tap Bottom FL
SITE WELL ID#(d applicable) '
9. SCREEN: Depth Diameter allot Size Materlat
3.WELL USE(Check AApplicable Box): Residential Water Supply 0 Top Bottom Ft_ln. _ in.
DATE DRILLED�c -��-'2C%a' Top Bottom FL—_In. in.
TIME COMPLETED AM Q PMO Top Bottom Ft_In. in.
4.WELL LOCATION: - 1e.SAND/GRAVEL PACK:
CITy`\ COUNTY a I nC; b j Depth Sirs MaMtlel
^ ��, �^DlIs Top Bottom Ft.
rreat Name,Num at 1 1 TOP Bottom Ft.
te
hers,Rommuntfy,Subdivisiwy Lot No.,Parcel,Zip Coda) Tap Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appmprlate box)
❑Slope ovaliey ❑Flat ❑Ridge ❑Other : 11.DRILLING LOG
LATITUDE C�5^r�( 1t�S-Sn,� Top Bottom Formation Description
"DMS OR 3X.XXXXXXXXX DD /
LONGITUDE 7 0JUY 11) ^pMS OR 7X.xXXXXXxxx DD
Latitude/longitude source; pGPS lc ma
(location Of we#must be shrm o on a USGGreS tt p ma a�ftached to
this form ifnot using GPSj -/—� —
S.WELL OWNER ul7I VCr i51}tt QF NOr�h CWDLil-C- AaltO�
E kt�Yatf� a bERS %
Owner Name /
�y�_-- I ps Hat1 SSG
Street Address /
City orTgwn State 21p Code /
Area code .Phone number
G WELL DETAILS: I 'I^�(j 12. REMARKS:
a. TOTAL DEPTH: `till 1
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: Fr. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use^+^W Abe Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS Ff.Above Lend Surface* PROVIDED TO THE WELL OWNER.
n^Top
of casing terminated allor below lend sur/aca,may require ( y
e variance in accordance with 15A NCAC 2C.g118. SIGNATURE O CERTfF1ED WELL CONTRACTOR DATE
e. YIELD(gpm)i: _METHOD OF TEST
f. DISINFECTION:Typo Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1A
Rev.2/09

✓p;A�q
RESIDENTIAL WELL CONSTRUCTION RECORD /
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# L4 I 1 - A
1.tatFLLC NTRAC 9. WATER ZONES(depth):
�tf)11YYl TOp Bottom
TOP Bottom
/welContractor(HMividual)Neme op Boom Top Bottom
WI
A ( � I�{V� ---
_
Top Bottom Top Bottom
dWe[l ntrecl Company Name
—]I T h eknesW
1 T. CASING: Depth Diameter Wefghe Mabrlsl
Street dress
`� �j I a�14,2 lop--Bottom Ft
C!t�+or T —�^'�- State Zip Coda Top Bottom Ft.
�( :i() ( n� fop Botom Ft.
41
Areacode Phonenumber H. GROUT. Depth ` t Material Method'
2.WELL INFORMATION: \ _ /� lop�_Bottom�; Ft
WELL CONSTRUCTION Pr tlt� H( N I cnot!"1 lop Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Tap Bottom Ft _
SITE WELL ID#tH applicable) .
9. SCREEN: Depth DItalleter slot Site Material
'.WELL USE(check AmicableBox): Residential Water Supply❑ Top Bottom Ft_In. _ in.
DATE DRILLED .y - 2C-2c/> Top Bottom Ft__in, In.
TIMECOMPLETED AMLI PMO TOp Bottom Ft_In. _ in.
' a
4.WELL LOCATION: - 10.SANDlGRAVEL PACK-
CI7Y1 COUNT'YLiLtC Depth $Ito lederfel
yQ /�Q/ TOp Bottom Ft.
P 1 TOP Bottom Ft.
(Street Neme,Numbers,COMMUlft SUMIVislon,Lot No.,Parcel,Zip Coda)
Top Bottom Ft
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
[]Slope Clvagey OFiat ❑Ridge []Other 11. DRILLING LOG
LATITUDE =3(O. Cf MAI Top J Bottom Formation Description
R _ DMs OR 3x.xxxxxxxxx DD
LONGITUDE T .Ea•Y ,!±q "DMs oR 7x.XXXXxXXXx DDLatitude/longitude source! MPS Qfopographic map J
(location Of well must be shown on a USGS topo map andattached to C>>1��1 1 �-�0 (��QV t Cz✓.
this form if not using GPS) J
S.WELLOWNER Univer6i{y of NcN+hCLA,rvl.rc-
F t1IrlYttf �( p I/p iLt15
Owner Name
�o� �hi_i_�����p� �`, BOB,_&.�ao `
Street Address I — /
rMN
Qty or Town State ZIP Code J
Area coda ,phone number
s.WELL DETAILS: 400
12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+^rf Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED OTHEWELLOWNER,,,, /
d. TOP CASING IS Above Land Surface"
'Topp of casing terminated al/or beloww land surface my require
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2189

3
.^'"M ssnrty
r �
�� R�iSjDENTIAL WELL,CONST llC RECORD
TION
North Carolina Department of Environment and Natural Resnureec-Division of Water quality
WELL CONTRACTOR cERTMcaTION#_U
g, WATER ZONES(depth)
Bottom - Top_
1.WF1.t CONTRACTOR: �oP_ __ flatten__
f I 1 t Gib lt1 Y 1 S Bottom_
rrW,,err1,,l/C/o��ntr�br ndividuel Name t Top-----
1�3.1� p Ate) t, rl p g A 1 Bottom_- Top- Bottom---
V� 1. /��j� �Op--�---
--�"'- Thick
en ntractor Company Name
Y. CASINO: aPth Diemater Walght tght Material
-7' t Bottom—_FL —----
Street�d`ASS � Top BottomTop­
Bottom__.Ft —
city 2 or t&An
^,t Stale zap Code Top ,Bottom Ft - -
4 R. GROUT: Depth (� Materiel Method
code da Phone number Ft -
Z.WELL INFORMATION: .-1--
��� Topes__Bottom FL --
W ELL CONSTRUCTION PERMiT# PI
OTHER ASSOCIATED PERMITN(if appllmNa) Tnp�-Bottom
SITE WELL ID reppllaflh -- S. SCREEN: Depth OlameWr mot Sbta Mnhrlal
N{ le)
Tn Bottom Ft._in. _ In.
(
a.WELL USE Cheek Appeb le Box): Residential Water Supply❑ F--
Tnp Bottom Ft In. �•
DATE DRILLED .'1 � Bounm FL_irL _ hl.
TIME COMPLETED AM 0 PM
• 10,SANDIGRAVEL PACK: Ske NOW"4.WELL OCATM Depth
Cl11^ ev{/�; )e r� COUNTyiU0CQdf t 4 Top Bottom Ft.
ToP Bottom_ Ft. -
(Street Name,Numbars.ConOmtrn ,Suhdlwabn.Lot No..Parcel,ZIP Cam) Tap Bottortt FL__
TOPOGRAPHIC/LAND SETTING: (check approPdeta box) 11,DRILLING LOG
Dftpe ❑Valley i7Flat ❑Ridge ❑Outer Top Bothm Formation D89NWM
LATITUDE 3W2_" ' SS`C`rN•DMS OR 3X.XXXXXXXXX DOVE,
LONGITUDE��" ' (,�i��"
pMS OR 7X.X700rXX m DO _�..�- Y-- —T ,{ L�
Latitudellongitude source: E13PS UrdpagraPhto map
Wittion of way must be shown an a LISGS tope MAP snare#ecaed tothis form/f not using GPS) 1Clil l
S.WELLOWNER Ufliverc5�4y t N [;Q)YU)11-Irn t)t�
F AMICAP
Owner Name "
51U Phillis��� L T 11
Street Address �� /
Cfty or TownSM Zip Code
^.
1
Area code Phone number 12. REMARKS:
6.WELL DETAILS: -
a. TOTAL DEPTH 4VO .-
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ I DP HEREaY CERTIFI'THAT THIS WELL WAS CONSTRUCTED IJ
c, WATER LEVEL Below 70 of CaslnO: ACCORDANCE WITH A A NCAC 2C,WELL CONSTRUCTION
HAS
B
P FT' : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(use_+•g Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOp OF CASINO IS FT.Above Land Surface' �n `�/r✓1^,/
'Top of casing tenMnatod at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118, : 3KiNATt1RE OF ERTTFIED WELL CONTRACTOR DATE
P. YIELD(gpm): _METHOD OF TEST
I. DISINFECTION:TWe Amount PPoNTED NAME OF PERSON CONSTRUCTING THE W ELL
Farm GIN-ta
Rev.2109

4��A . ,RESIDENTIAL WELL,CONSTRUCTION RECORD
North Carolina Department of Environment and Natural RMaree Division of Water Uualiry' ' WELL CONTRACTOR CERTIFICATION#
g. WATER ZONES(deem):
1.WELL CONTRA
t Ii t71CY LEI l S °P— — —Bottom TOP­Bottum
Well Contra4w prxtfviduei)Neme Top---- -.
(7kCILA-1 l(�tT� i' A'14 nV1I I(YTi Top----- Bottom-
ottom TOP Tbiattrosst
{ yJe11 ntrector Company Name
7, CASING: Depth Diameter Weight Material
J)f x) i
J Sir real 1 TOP Bottom FL
A1
4� Top Botom Pt
State Zip C'am Top Bottom Ft
Method
R. GROUT: Depth �y � MateAei
Area code Phone number �___Bottom_A n�Ft��"
2.WELl,INFORMATIINJ: Top
ti 1 4(7 Top--Sot om Ft__ ----
WELL CONSTRUCTION PERMIT#­ Fi
OTHER ASSOCIATED PERMIT#(if apMl alia} l
SITE WELL IDf if apoicable) -- 9. SCREEN: Depth Diameter Moist" Material
3.WELL USE(Check AppN-c7eble Boxy Residential Water Supply Q Top--Bottom Ft In.
^in. _
DATEORILLED ��o� Tnp Bottom—
Top,. Fi. in. in,
Bottom Ft_h h1.
TIME COMPLETED AM❑ PM❑
a 10,SANDIGRAVEL PACK:
4.WELL OC( I A.TIOft � { Depth Stab �
Cnw.1 1,1le I Ir Y� COUNTY ` r4 TOP Bottom Ft ----
A TOP eottom Ft. _
(Sweet Neme,Numbers,Comma ,SubdWlrbn,Lot No..Pared.Zip code) Top Bottom FI
TOPOGRAPHIC I LAND SETTING: (check approprieta bexI 11,DRILLING LOG
OSIOPe ❑Valley ❑ Oth
Flat ❑Ridge ❑ er Top Bottom FormationDesciption
LATITUDE 3� • •.�.1ai4fv "DMSOR3x.xVMiO(XxXDD
LONGrruDEX1•- -31 •G$7Uu. +DMS OR 7x.1DDtxxX00(x DD
Latitude/longkudesource: MPS Eppographic map _ ( _ (�Y'(�j1(P
(location of well must be shotm on a USGS topo map andeBeched Io —�
Mis form W rict using GPS)
S,WELL OWNER IPA-ft.
UI IIVFY Jt�y - -.
owner Name
Street Address
Jl ie\>�1 c _ —
CityorTown
Am code Phone number 12. REMARKS:
S.WELL DETAILS: ..
a. TOTAL DEPTH: 400 ---
h. DOES WELL REPLACE EIDSTING WELL? YES❑ NO❑ � i pp HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+•If Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS Fr.Above Land Surface'
"Top of casing terminated attar below fend surfaca.may require J-i T .ri�7✓�r`v i-v
a vedanCe in ectxtrtlsrtce w(th 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amoum PRINTED NAME OF PERSON CONSIRIICTIFIG THE WELL
14
Form GW-Ta
SHIMMIES Rev.2MM9

Y# �
R DEjVT IAL WELL CONSTRUCTION RTsCORD
Tiorlh Catalina Dcpattn=iofEnvironment and Nntural Resources-Nvfaion Of Water Quatily
WELL CONTRACTOR CERTIFICATION#
1.1aM1-L CONtRACIOR: g. WATER 20N (depth):
.) Bottomom TOP
��1 >yLLl 1r t71(l YNI� 1Op--— Tap-
-Doeotmm
WeaContractorQntlhritluel)Neme lop_.--__Bottom
1_ ,_, I Top_ Bot om Top Thidmesel
elI ntrector Company Name
LX)� i T. CARING: Depth Diameter Weight hhutlet
street TOP� r� —7 Bottom Ft
j1 Top Bottom Ft
orT
^7 Blase ZM Code Top Bottom FL
{ one � ' t t A. GROUT: Depth ` t+� Materiel bard.,
E -
2.WELLe FORMATION:numbe Top �m�Ft 1(C) a11J1�-
2.WELL INFORMATION:
WELT_CONSTRUCTION PERMIT# �!4171��aq : T°P-sottom FL --
OTHER ASSOCIATED PERMIT#(if appilcahie) --
T'np Bottom M-
SITEWELLID#(ifapptrabieJ —' S. SCREEN: Depth Dionsier Slot Sire Material
3.WELL USE Check A ) Supply❑ _ Ft. in. ,_ In.
( ppAceble Box: Residential Water Su Tap Bottom Ft M. ,�, yr• J
DATE DRILLED ��a��l : Tnp
Top Bottom Ft h _ lit.
TIME COMPLETED AM 11 PM❑
10,SANDIGRAVEL PACK
4.WELL ATlcft �,J�h,� Depth "am"
CITY,;,,rl / V i/Ilv�\ COUNTY I 1 Top Bottom Ft.
tDUJ _ Top Bottom Ft ---_—
(Street Name,Numeem.commune',SupgV+iebn.Lot No.,Past.ZIP ) Top__Bottom Ft._ -
TOPOGRAPHIC(LAND SETTING: (check appropriate box) 11.DRII-LING LOG
OSIOpe ❑Valley OFlat ❑Ridge ❑Other lop glom Formation Description
LATITUDE S•31F .SiaUON 'DMS OR 3X.XXXXXXXXX DD
LONGITUDE, 8L •: V kP I.k7^DMS OR 7X.XXXXXXXXX DD
Latitudeliongituds source: Q3PS []topographic rrual) it r n l k C e—
(Ocation of well artistes aflown one USGS tgoo reap andaVaChadlo /
fh/s form If not usMg GPS) R Ill V
S.WELLOWNER UniVcr�S%+4 OF (vu1-4�
F
Owner NameStreet Address
�u� ►�ht li.�_NAII C3� �� U _ r
city or Town Slate ap Code _`!
Area code Phone number 12_ REMARKS:
S.WELL DETAILS: I 1 t^�,( ..
a. TOTAL DEPTH: 400 —_
h. DOES WELL REPLACE EXISTING WELL? YES❑ NOG I DO HERl;BY CEIt I ll , tHAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 20,WELL CONSTRU"ON
c. WATER LEVEL Below Top of Casing: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use•+'I Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING tS FT.Above Land Surface' 5 1 / , ��
"Top of casing terminated atl r below land surface.mey require `� V
a variance in accordance with 15A NCAC 2C.01115. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_ METHOD OF TEST_— a
f. DISINFECTION:Type Amount —_ PRl TED NAME OF PERSON CONSTRUCTING THE WELL
�S
Fafm GW-1a
Rev.2M9

M.A y4
ENTIAL wt:u,coNSTtLucTtoN REcoRn
Tdorih Carolina Dglartlfeat of Environment and Natant Resources¢-Division of Water Qunliry
WILL CONTRACTOR CERTIFICATION
g. WATER ZONES(depth):
1.YELL CONTR Bottom Top Bottom —"
j 1 ; 1 Op__—.—
���`,1 -� 1'1 U1)�YY� S Top_ lts Bottom Top Bo "--_
Name
W eli Contractor(Indtviduai) I
jTOP._--------Bottom op Bottom
Thkknaasf
yJell nxtrector Company Name Diameter Weight dal
,_) 7. CASING: Depth
street`Add / r�G Bottom Ft
U
1JLc L_cJ�s 9143 Top Bottom_—R.
0 )Twin Stele Zp�e TOP Bottom FL
( � _ - a. GROUT: DePth Material
L ,1
Artie code Phone number 1'op j—Bottom l., '�FL Ft—
WELL
2.WELL INFORMATION: /a
CONSTRUCTION PERMIT# �'� i l l"�11'�(�I�"1 Top. _Bottom
TOP wi R.
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID#(A applicable) -- 5, SCREEN: Depth Dhowlar BIM WIN MgMtlal
TMp_.Boffom Ft,_.In. _, In.
3,WELL USE(Check Applicable Box): Residential Water Supply Q Bottom__Ft.in. ._^ in,
DATE DRILLEDA 9_ Top Bottom__Ft_kt In.
TIME COMPLETED AM❑ PM q
y 10.SAND/GRAVELPA
YYE CfC 8kla� Illaat�
4.ALL.LOCA71DIt Depth
Cf(Y\. �UI { 1< COUNTY t t�C� TP.Bratorri R.
Top Bottom Ft
(Sweet Name,Nameers,commune,auhdNebn,L t No.,Parcel.21p Cafe) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING' (check app(oprlsfe box) 19 DRILLING LOG
OSlope GValley pFIat ❑Ridge ❑Outer Top Bottom Formation Deseciption
LATITUDE _ •3U •SL'S L N ,DMS OR 3X.XXV-XX D0C DD
LONGITUDE 7A'aa' •O�i Li y- •DMS OR T XXXXXXXX ODY---
Latitude/iongttudeasxce: MPS Qtopographiefili
(location of nett must be shoran on a USGS ropo clap artdaltached to
this 10iirl If not 1/StMJ GPS) ) IN
5.WELLOWNER UIl4VFYUl�y J
Owner Name A �,,,• n
Street Adtlresa nC�l
Cityor Town staletCada ^_`�
J
Am coda Phone number 12. RBVJO S:
S.WELL DETAILS: 4Vo -
a. TOTAL DEPTH;
6. DOES WELL REPLACE EXISTING WELL? YES❑ NOG I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below To of Casing: ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(use-*'ff Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS Fr,Above Land Surface'
'Top of rasing b TWMatad at/or below land surface.may require A{•T EIOF CJEJRTIFIED WELL CONTRACTOR DATE
a varianoa in ac ordence with 15A NCAC 2C.0118. 4
e. YIELD(gpn): METHOD OF TEST
I. DISINFECTION:Type Amount PRINTI�NAME OF PERSON CONSIRUCTIOG THE WELL
Fam OW-Ta
Rev.209

f�s.FnTEy ,
REsmEN L wFLL coNs RucT>oN coRR
North Carolina Department of Environment And Natural Resources-Divisihn of Water Quality
WELL CONTRACTOR CUTWICATION# U �5 '
9- WATER 20NES(depth):
t.WF1L CONTRAC Bottom T°P— ----
Top_. __._.
I f >`'�1 �'101711 � - Bottom Top
Well Contraebr Qndtvitluel)Neme TOP- .— BMtam
Top
k(� y(�l1($r11' 1n 1 aott°m Tnxkrxesl
j Company Name 'I, CASING: Depth
Diameter Weight make"
ve1 reA 1 1 T Bottom FL
St�re�et chess f��nrt t, �/� r�G °P
1 L�VVn ,� IVC.� [�10��� Top Bottom FL —
To�(j `�[ SIB 7-Ip C°da : Tcp Bottom Ft
8. GROUT: Depth Materiel Method
Area code Plane number t l f'!'1 Ft
Top Bottom `-1�A J
2,WELL INFORMATION:
TOPS.-----50m°m
WELL C:ONS{RUCTKIN PERMIT# \ I4..,
T°p...---_Bottom
OTHER ASSOCIATED PERMIT#QfsP0fflb )
Material
WELL,IDp{da*cable --- S. SCREEN: Depth
Diameter Slat SLte
Tnp_Bottom_Ft._In. In.
3,WELL USE(Check Applicable any): Reside tiel Water Supply❑ Tnp Bottom Ft._—�n. — In.
DATE DRILLED 3 �2/ Topf_-Rottom__,FL`NL In.
TIME COMPLETED AM❑ PM Q
d°.SANDIGRAVEL PACK: She
4.WELL OCATI( t Depth
�'•h� l Ft.
CITY,.".I� V 1 � P couNTv �� Top Ronom
Top Ft.
Bottom ht• ----
(Street Neme,Numhms,Commc ,SuhdlAW1 Lot No.,Parcel,ZIP., pop-
TOPOGRAPHIC I LAND SETTING: (check eppropri>de box) 11,DRILLING LOG
❑Slope ClValley OFlat oRidge ❑Omer TOP Bottom Formation Deacdption
LATITUDE '3ty '.S42ZN "DMS OR 3X.XJOOW"U DD i
LONGITUDE?i6�°1 '3� 'UR30 1, 'WS oR 7X.XXXXX)O=
Latitudellongttudesource. 03PS [AOPOW"bi ma xr J —. 1)rev
t
(location of well must be shown on a USGS topo map andattached to J
this form itnot Using GPS)
s,weu oWrtER 11niVFYin�v Qf Nur�4� CJ)Uclir�n
F'cwriCn 4Owner Name
r
Street Address J
(l ►�llr ��c ale ode
City or Town _- -
Area code Phone number : 12. REMARKS:
6.WELL DETAILS: 1�a,j� -
a. TOTAL Dlz 400 --
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO LI 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below To of Casing: ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
p FT' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'*"d Above Top of CASing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING is Fr.Above Land Surface' 1 t (�
'Top of casing accordance
with belo15A CA 2Csur.0 18, require SIGN(AAT(iUKI:url cm;II ED WELL CONTRACTOR DATE
n variance in accordance with 15A tJCAC 2C.011 B,
c. YIELD(gpm):, _METHOD OF TEST
f. DISINFECTION:Type Amount PW796 NAME OF PERSON CONSTRU-CTiNG THE WELL
1
Form GW-la
Rev.2M9

R WELL CONSTRUCTION RECORD
(,1, • North Carolina Departtnant of Environment and Natural Pesm" ea-DivLathn of Water Guwlity
WELL CONTRACTOR CERTIFICATION# 11
g. WATER ZONES(depth):
1.1NELL CONTRACZOR: Bottom T°P— BoUoht,—_----
( Top
Baitom Bottom--_
j�welt Contrar�r Q/n�d,yt�-iduel)Name p (� ` !�� To Bottom _.
)L.81 Ia� �11 p 11 Din 1 I 1 r j Top—_--Bonom p ,rotuttrossf
{ it ntree�iIwr Col1 lm1penY Neme 1 Diameter weight Metertel
)) l Y J n I l T. CASING: Depth
Toip�Bottom FL
Street�ddress Top Bottom——Ft,
j yvCity,r T tt �7/� ( Slate Zip Code : Top Bottom_ FL
i l�� t ol�f - R. GROUT: Depth rry�} � Materiel 1 Method
Area WELL
I Phone numbeINFORMATION:
Top __Bottom -�n n,,FL�1 -
2,WEil INFORMATION:
ftTDP_Bottom FL
W FLL CONSTRUCTION PERMIT# 1n I t(�( ,y
Top Boom tt -
OTHER ASSOCIATED PERMIT#(If applh")
SITE WELL ID#(If appameta — 9, SCREEN: Depth Diameter Slot Site Material
Top__-Bottom Ft. __In. _ in•
3.WELL USE(Cheok AppAceble Box? RsWdW"Water SupPty❑ Bottom Ft._,Ht. in,Top_ -
DATEDRILLED Top__ Ronom___,FL ML In.
TIME COMPLETED AM El PM
10.SANDIGRAVEL PACK:C.ALL LOCATION: - Depth SI>:e
MOWN
II
CITYr C r�<,) V 1 4 !r COUNTY Top Bottom ft.
ToP Bottom—Ft.
i ttNa ,N f�un1Dl�l �,.
(Street Name,Numbers,comm ,Subdbn.lNe Lot N. Parcel,ZIP ) - Top Bottom
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11,DRILLING LOG
[]Slope ❑Valley J]FTat ❑Ridge DCMer '(gP BoaerD FomtatfortDeenlP txt
LATITUDE 3S•Sic S73d N ,DMS OR 3x.X%IC*o0(X DD : / Q.t_GXII
LONGITUDE 7,6`5z •31 '064 � ; .DMS OR 79.XXXXXXXXX DD ._L--�.,1
Latitudellongitude source: MPS 0TOPograPhlo map
(location of well must be shown on a USGS top,map andatteched to ,
this form ffnot uskxU GPS) --
5.10uELLOWNER Ut�ivert5i�y 4F Nur+i� CLNJot(rt 1 ? ��IS�L2— I.
Owner Name
tS1D3 Phi tlipl 11 �h 14aU
Street Address ' 1
City or Town State, Zip
Area code Phone number 12. REMARKS:
6-WELL DETAILS: ��^^aa,, -
a. TOTAL DEPTH; q0D
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ i 00 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED M
c, WATER LEVEL Below Top of Casing: Ff. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'*"I Above Top of Casing) PROVIDED TO THE WELL OWNER.
d, TOP OF CASING IS FT.Above Land Surface* ,yf,{r�,,y
"Top of rasing termineted eHor below lam surface.msy require Q 'J
n variance in accordance with 15A NCAC 2C.0118- 9H3NATURE OF CERTIFIED W ELL CONTRACTOR DATE
e- YIELD(gpm): METHOD OF TEST•.__,
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUC-T1NG THE WELL
Form GW-1s
Rev.2/09

}M$TN£y
R�ENTIAL WELL CONSTRUCTION RECORD
North Carolina DopartmentofEnvironmeot and Natural Reamneea-D'v's'rn of Water Quality
WILL CONTRACTOR CFRTIIi'ICATIO"I#­W :5-1 - N
S• WATER ZONES(depth): Bottom_._--_.
I-TL CONT'RAC [ I op-- Bottom Top—
S1 i}` 1YY1I1 S Bottom Top Bottom
Well Contraemr pntlWLdual)Neme Top___—— To Bottom -.
(� �!
�� �(➢ l�(�� 1� V\� d IJIn II I 1 7 _. Top-------Bottom p Thhknesst
�)yJell Gpntreclor C.I +{any Nome I e, CAsiNDepthOtam�r Weight Mef°rl°t
I(IIJJ\\ �)x J G: m
1 Top Bottom Ft.
Street
l 1�nh n s 1 Vl. � - Top Bottom Ft.
or TToor'n�� hum Z'p Code Top Bottom Ft.
R. GROUT: Depth Materiel
Aria code Phone number � �{f��1 � 1 (m
Top�__Sonom "1'IA JJ -
2,WELL INFORMATION: —
\n 111"7(I�rnR� T"np`._Bottom Ft.
WEI_I_CON5iRUCTION PERMIT# Topes -Bottom
OTHER ASSOCIATED PERMIT#(If appitmble)___-------- Diameter Blot 312a M9Hrle1
SITE WELL ID#(if a*leable) — S. SCREEN: Depth
T°P--Bottom FL,- in. _ in.
3.WELL USE(Cheok AAppgcebI8 B0X Reaid&"Water SuPPIy❑ ^
DATE DRILLED : Tnp—__Bottom FL_,in. In
Top,,, __,Bottom Ft_,kl _, In.
TIME COMPLETED AM❑ PM❑
: ge.SANDfGRAVELPACK Stee MabtfM
4.ALL LOCATION: r-,��{�A Dept
Cff\? '_`]hP�/I �.(' r� COUNTY_V_ D 1.'t�Cr Top Sottom Ff.
1 J 11 - Top Bonom_----Ft.
(Street Name,Numbers,Commun ,Suhdlia ,Lot No.,Parini.ZIP Code) : Top Bottom R•
TOPOGRAPHIC t LAND SETTING: (cheek apptoptlate box) 19 DRILLING LOG
❑Slope evalley, oRat ❑Ridge pother Top Bottom FO�t�'Description
LATITUDE 3s" 0l .S71 i N ^DUB OR 3X.XXXXXXXXX DD : / r�� ) —•-5- ,,I Y —,
LONGITUDE 7,6X-' -34 OqO- "DMS OR 7X,XXVYXXXX DD
Latitudetiongitucle soumIr. MPS DrOP0918010 Map
(location of well must be sbotm on a USGS tolso nM anda#ached to !
this form/f not using GPS) V:
11 0 Nvrt-h� CQU"ul.itY,� A�t1b3,lY�— '� —t Y'
S,WELLOWNER t,1rl�VeYJI�y ,F .
—r
Owner Name
� I I(V�r� �4cti�L•I V I
Street Address !
CltyorTrnm Stab Zip r'Otie ,•_,.�
Area code .Phone number : 12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: 4L/
b. DOES WELL REPLACE EXISTING WELL? YES L] NO p 1 DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N4
c. WATER LEVEL Below Top : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
of Casing: : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use-+°fI Above Top of Casing) : PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 16 FT.Above Land Surface 1 �] / ij /�
"Top of easing terminated at/or below land surface may require i�G
n variance in eccordhnce with 15A NCAC 2C.011& SIGNATURE O CERTIFIED WELL CONTRACTOR DATE
e. YIELD(spm):, (Z METHOD OF TEST
f. DISINFECTION:Type. Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form QW"1a
Rev.2MQ

CC,%„a RATE,y
,LZ )ENTIAL WELI,CONSTRUCTION RECORD
North Carolina Depet<rtXnt of Environment and Natural Reaonroes-Division of Water Quality
a•'+•••+0r WELL CONTRACTOR CERTINCATION#
B- WATER ZONES(depm): Boltem__—.
1.WFr t CONTRACTOR: Bottom. Tap
l c i_11 i'11i1711-M S Tap Bottom _ Tom "'
(Well Contractor Qndlgv—iduel)Neme p t' To Bollorn _ _..
�11 p l n I ) t 1'( p ThIcknesal
it ntractor Company Name Diameter Weight Material!
x) CASING;: Depth
l��ddtltlrreees To Bottom FL
J : Top Bottom k-
City or Tooalnt Stab Zv Code Top m Botto Ft
R. GROUT: Depth ((++��� Material t� ,1 Method`
Area code Phone number
T'np_�_— Bottom q A�
2.WELL INFORMATION: �f��(�/v�� Topes_ Bottom Ft
Wrl_I_CONSTRUCTION PERMIT# �L) F� �,"`!-'—�--'-- Bottom FL
OTHER ASSOCIATED PERMIT#(If appltmhle)._.—.------------ lnp,.,__
SITE WELL IDtifllappncahle) -- 9. SCREEN: Depth DHanehr BIOtlIIZa MaYHaI
Bottom
3,WELL USE(Che(k AppticabPb-/Box): Residential Water Supply❑ Tnp
B _,ottom_ Ft. In. __ b•
DATE DRILLED .��aU( Top__.__
: Topes_.Bottom_Ft._Nt- _. In.
TIME COMPLETED AMO PM
10-SANDtORAVEL PACK: lNRa MaMrlal
4.WELL LOCATION: Depth
C(Ty11�t� [� JJ �yy `r(��� COUNTY till( Top Bottom �-
SM� A �1 M `i i 1 J Ll ToP Bottom Ff.
(Street Name,Numbers,comma ,RUMMBlcn,Lot No.,Petceb ZIP Coda) : Top_Bottom FL
—
(Street I LAND SETTING: (check appropriate pox) : 11 DRILLING LOG
❑Scope !]Valley OFlat ❑Ridge []Other Top Bottom FomrationDesediptlon
LATITUDE 3$3s"ate'Sia47 tv ^pMS OR 3X.X700(XXXXX DD
LONGITUDE'3'' oW if I- DMS OR 7X.XMDMXXXX DID : _.L---j�=u'—• .
Latitudellongitude source' 03M Dropographir map ._vrY� ( OrYN It(e
flocabon of wall must be shown on a USGS ml o map andbrecned to i.:zQ -"'r'
this form if not asklg CPS)
s-WELL OWNER 1IhtV0-0j4 OF N" 4' CfA,rvi AOwner
— -r
e SU-S Pht lltpl i-kQ�14 D _r
Street Address /
Cay or Town SNIa Cade —1
Area code Phone number 12. REMARKS:
fi.WELL DETAILS-
a.
a. TOTAL DEPTH, 400 •
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO LT i p0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED X4
a WATER LEVEL Below To of Casing: : ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
P FT' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(use. .ff Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASINO IS FT.Above Land Surface' •—r - / /n I �
'Top of casing terminated at/or below land surface.may r"ft `"�p'p�'7 1"
H variance in accordance with 15A NCAC 2C.011It. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METNOD OF TEST
I. DISINFECTION:Type Amount------ PRINTED NAME OF PERSON CONSTR z TW THE WELL
Form GW-1a
Rev.2M9

05"'
RESjDEiNTJAL WELL CONSTRUCTION REC
North Carolina Depstiment of Environment and Natural Resources-IIiviaion of Water Quality
WELL caNTRncTOR cERT>;mcnTtan#
g. WATERZONES0e04 -.
1.Nff1l CONTRACTOR: 0ottom Tnp
v t C lop_ Bouam
Wellontraemr(Inc!Mduelj)Ne na Top _Baltom Tep
_Bottom Top Botom
fop`___ ssl
{ �II�p ntrector Company Name Weight MMeNe1
CASING: Depth -
],
sa 1 ' f T Bottom Ft
�Tn rV 5 N aa-►`•t'.� Top Bottom
Cyty or T Slab Zip Code Top Bottom Ft.
(07lo�� - '1��1 t
8. GROUT: Depth Material
2.W LL I Phone number Sottom 1 t YN 1 Ft 1C ��,.+ -
Z.WELL INFORMATION: Top t��.-n, l
\n 16 f"l Top _Bottom Ft
W ELL_CONSTRUCTION PERMITlI_ Tnp Bohm Ft
,,,_.._.
OTHER ASSOCIATED PERMIT"f sppllrattz) 6 Dlamelet' amBW „At
SITEWELLID#(Ileppacehte) — 9. SCREEN: Dept
Tnp Bottom Ft. In. _ In.
3,WELL USE(Check Applicable Resitliel eM Weler Supply❑ __Bottom
DATE DRILLED `� 7// Top Bonom__.,Ft._
kL in-
TIME COMPLETED
70.8ANOfORAVEL PACK 8112e Mnlerlel
4-ALL(LOOCALT,ION: (� 1L�� Depth
CrrYt, (->,]l 1PV( � �,Y COUNTY J 11 roc? Top Bottom R-
: TOP BOhom Ft
U 1 c(��D,l i eonom R.
(Street Name,Nu nbam,Common ,SubtaMM,LW No.,Parcel.Zip Code) Tnp
TOPOGRAPHIC/LAND SETTING: (cheek apP(oPriate box) 11,DRILLING LOG
❑Slope []valley []Flat ❑Ridge pother Top Bottom Formation Descriptlon
LATITUDEQu
3J•�tP •S'13`fA% .DMS OR 3X.X)0 =XXX DD
LONGITUDE7.6�-zej� •t�t-jf�l''W "DMS OR 7X.X)OIXXXXXX DD .J
Latitude/longhudasoorce: EppS [)fopogrephfornaP yre" It LC,
ffocadon of weN must be shown on a USGS topO map andadached to LXti.a�—
this form if not usklg GPS)
5.WELL OWNER UIl1�1 f.Y 51�y QFOwner Name
f
F c�l�+f� 4 �•n rn �'im5 _�
Street Address n �
City or Town St9le 71p Code
J
Area code Phone number r 12. REMARILS:
6.WELL DETAiS: .. .
a. TOTAL DEPTH:__qD0__
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ll I fl0 HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED N
c. WATER LEVEL Below To of Casing: ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
P �' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(use'+"K Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Sudece• •T, �
"Top of rasing termhieted at/or below lend surface.rnay require SIGtdATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in ac onisnon with 1SA NCAC 2C.011 B.
c. YIELD(gpm): _METHOD OF TEST
f. DISNIFECTWN:Type Amount PRINTFD NAME OF PERSON CONSTRUCTING THE WELL
go Farm OW-1a
Rev.2109

RESjDE1VTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Ettvitonmeat and Natural Resourcea-Division of Water Quality
WELL CONTRACTOR CERT117CATiQN#_-r
g. WATER ZONES(depth):
1.WELL CONTRATR: : I- Bottom TOP �
! 1 arr�t�Y QP — - T� Boadrt
Top____Bottom
all Contractor Qndtgv-ideal)Nem1e ,f Tqt Bdttom ._.
l ����,•�1� )(�A 1 {'.1� lA 1 ? l A IJIn �� 1 1 Y i iop._.---Bottom Dlematar WMg Mate"
ell ntratxor Com{xtny Name
CASING: Depth FL ----
1 Street 11��d,dress /' r1C Bottom
1 ,f)h rVI S �t l Ot U Top Bottom FL
(;011y or T Sig* ZIP Code Top Bottom FL
t lrl•� "'�) R. GROUT: Depth , FL Material
Area e Phone ,L J
2.WELL INFORMATION: Bottum
�n
WELL CONSTRUCTION PERMff#��.v.�.N+�+---- T.np Bottom-Ft, -
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID#(it applfratxe! S. SCREEN: Depth
Disallow Slot SLU Malarial
PPhI Ll Top_ _Bottom_Ft.•__in. _ In.
3.WELL USE(Chadf Applicable Residential Water Su Bottom__Ft. in. — �•
DATEDRILLED 3��'�/ � Topes_ In.
Top—_Bottom Ft hL ,�
TIME COMPLETED AMCI PM"
10,sANDrGRAVEL PACK= 91" Now"
4,VIELL.LOCATION:/ I - Depth
CI'M' C ('V 1 1 e COUNTY L.I.d-].triC-� TOp Botom Ft.
� � ��( ��L/(��� /9 �� r�t ToP Bottom Ft._
_ �6d Y.. Q \ 1 Jv1 S�I J Ul� Bottom Ft.---
(Sheet Name,Numbers,Commune',8ut>�Webn,Lot No.,Parch,Zip r-ode) - Top___
TOPOGRAPHIC/LAND SETTING! (check appmPrlate box) 11.DRILLING LOG
❑Slope ❑Valley oFlat gRidge ❑Other Top Bottom Formation Description
LATITUDE DMS OR 3X.X)=)CXXXx DO
LONGITUDE DW OR 7X.XXXXXXXXX DO _�--.�-y—'�--
Latitudehongaude source: MPS {]Ydpo9raphic map + r -4[a P rY\1 t[P
(bration of well must be shown On a USGS topo mfip addarlachad to
this form If not us/n1g,GPS) AAlb3t)�
s.WELLOWNER t�l"�IV�YJt�y OF (�iuY1i'1 �1Y1 y�.s�rs f —S
��1141fP 4 flf ra WEIS /
Owner Name
Phtlll�,
Street Address
_)
Cityor Town Stets 71p Code
Area code .Phone number 12. REMARKS:
6.WELL DETAILS: ' ` ^a,
a. TOTAL DEPTH. ` 00
h. DOES WELL REPLACE EXISTING WELL? YES❑ N0 Cl 1 DC HERESY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below To of Casing: ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
P STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use-+^rf Above Top of Casing) PROVIDED
/PTO THE WELL OWNER.
d. TOP OF CASING IS Ff.Above Land Surface`
-Top of casing terminated etl ce
or below land surfa ,may require
o variance In accordance with 15A NCAC 2C.0118. 3RaNATIIRE OF CERTIFIED WELL CONTRACTOR DATE
a YIELD(gpm): METHOD OF TEST
I. DISINFECTION:Type Amount : PRINTED NAME OF PERSON C MSTR�-NG THE W ELL
Form GW-ta
Rev.2f69

r�:.:.RnTCp
y !�
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
r4 WELL CONTRACTOR CERTMCATION# L4 11J I "
g. WATER ZONES(depth):
1. L CO O : t.op Bottom TOPS--
� `;lNTRAC� �I RGI71<YY�lS
Welt ContraGorQMlviduai)Neme Top__Bottom Top Bothom_--
T OP—_—_
Bottom Top Botto m
llxhire Thickness/a� X u 7. CASING: Depth Diameter Weight Material
]Street ress TOP Bottom FL
Top Bottom Ft.
Cit or Tahn state Z p Code Top Bottom Ft
Area code Phone number 8. GROUT: Depth � �ry-� material Method
2.WELL INFORMATI(N1: Top�_Bottom�id_LFt. (1�('XaY1- 0 4" ilAV)d
WELL CONSTRUCTION PERMIT# till Top Bottom FL
OTHER ASSOCIATED PERMIT#(Nappticehle)
lop Bottom Ft.
SITE WELL ID"I appllcahle) 9. SCREEN: Depth Diameter Slot SLIM MaYtlai
3,WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.^In. _ In.
DATE DRILLED Tnp Bottom Ft^in. Tin.
TIME COMPLETED AN,❑ PM D Top_Bottom Ft in. _ In.
10.BAND/GRAVEL PACK
4.ALL LOCATION: ` �'^ materialCITY`. ( Top Depth BFL
111 Bottom Ft.
Top Bottom Ft.
(Stiast Name,Numbers,Community,subdivision.Lot NM.MOM.ZIP Code) Top Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Scope ❑Valley ❑Flat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE y 3S •3l ,,S(p/,,.A/-13MS OR 3X.XXXXXXXXX DD j
LONGITUDE
'f -3y -_2LV6ra%-DMS OR 7X.XXX)IXXXXX DDLY-�--
/
Latitude/longitude source: EIGPS []fopographic map uy _J __ (P
(location of well must be shown on a USGS ropt OW andalladhed to
this form/f not usMg GPS) , U
S.WELL OWNER l.�niver,-:i1ry QF Nur1-l'� C�'olirf� J t fP 4 rA 1101S J
Owner Name
30-S P hl lIl 1IC t1 CV�Q :�4�D _
Street pAddress
1n T /
city or Town Stake Zip Code J
Area code Phone number : 12. REMARKS:
S.WELL DETAILS:
a. TOTALDEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ ; I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use•+^y Abe"Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP C IS FT.Above Land Surface
"Topp of rasingIng r
in temated allot b ce
elow land surfa .may require r✓i'1l� f/ w
a variance in accordance with 15A NCAC 2C.0118. a SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e, YIELD(gpn):. METHOD OF TEST
f, DISINFECTION:Two Aroatnt PRINTED NAME OF PERSON CONSTRUCTING THE WELL
a
Form GW-1a
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•4'"" WELL CONTRACTOR CERTII/ICATION# U 1 J 1 - A
1.MiELt CONTRACTDR: g- WATER ZONES(depth):
`�•one ct i C'17vi Y d l S Fop Soom Top Bottom----
WellCOntracor(IrMMdual)Nam`epagg (��,, Top—Boom Top Bottom
___
A- 1n�,d,A (,�! : lop____Bottom Top Bottom
)Nell�px I y Or Company Name Thickness/
JI—IV 1I4Ljj A T. CASING: Depth Diameter Weight Material
Street dreaS TO
p Bottom—FL—
.L� Top Bo om Ft.
City or state Slate Zip Code�S( Top Botom Ft
>Areuac�tt-e P�Mnrenumber 8. GROUT: Depth Materiel Method!
2,WELL INFORMATION: ^ram /� � Top _Bottom�,�Ft.�(3}"[ji�L+ T CL.I.I`
WELL CONSTRUCTION PERMIT# Y�j��,x J�`1� Top Bottom Ft. JJ�—
OTHER ASSOCIATED PERMIT#(If applicable) Iop Boom Pt.
SITE WELL ID4(ifappI,") .
S. SCREEN: Depth Diwnmw Riot sin Mtitarial
3,WELL USE(Check Appkceble Box): Residential Water Supply[D t Top Bottom Ft.—in. _ in.
DATE DRILLED �z 3L���} Top Bottom Ft_)n. In.
TIME COMPLETED ,---- AM❑ PM❑ Top BDftw Fi in. _ in.
4.WELL LOCATION. 10.SAND/GRAVEL PACK
Clr , I �C COUNTv,. Ili ]L-Cd) Dept Site Malarial
Top Bottom FI.
Top Bottom FL
(sweet Name,Numbers,Cmnm nu",SubdWion,Lot No.,Parcel,ZIP Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑SIOPe []Valley OFiat ❑Rkige []Other 11.DRILLING LOG
�LATITUDE 35-•.3G' 5113dN' Top Boom Formation Description
DMS OR 3X.XXXXXXXXX DO
LONGITUDE .DMS OR 7X.XXXXXXXXX DD I (90C)
Latitude/longitude source: MpS Qropographic map
flecaden Of well must be shown on a USGS ropo map andattached to Q'KD—) ZjQa-- Cr-Fv t(.P
this form if not ushV GPS) ��.v,.., A,� If
S.WELL OWNER UnivfYt5lfV � N r+h CW01li-Cn f4l lNoti) l t "00
F190ft )7lC J
Owner Name eOpal)
r �'
510� Phi Ilr��� ltx II D 14LD
Street Address ""'T"
loo �2�Ssi
Crtyor Town - State Zip code /
Area code Phone number
&WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH: 400_
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•If Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING is Fr.Above Land Surface
*Top of cesing terminated atlor below land surface,may require
a variance in accordance,with 15A NCAC 2C.D11a. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): VJ METHOD OF TEST
I. DISfNFECTION—TType— Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Z�
Form GW-la
Rev.2109

W. RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanment of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# a 1 1 3
I-lacnVMACTno. 9. WATER ZONES(depth):
-RAfA PA S Iop Bottom Top
, ` Bottom
Well Contractor(individual)Name rop Botom Tap RottornfX 1T - r AA
( ) y� Top__—_Bottom Top Bottom__.
)yVell,antradw Company Name T
Thlcknessl
1l It 1. CASING: Depth Diameter Weight Material
Street ddress
LLB Y�rl �5 (�1Ct Gt����j Top Bottom FL -- --
CityorT SIND Zip Code ---- _--
Top Bottom FL _
(iA een codJ a Phonee number 1 8. GROUT: Depth Material Method
2.WELLWELLINFORMATION: � ` C l Top, _Bottom 11 .
'' l.+Ft. ,�
WELL CONSTRUCTION PERMIT# Y\l i l.. l�DI�01 Top, Bottom Ft,
OTHER ASSOCIATED PERMIT#(ifapplicable) Top Bottom Ft.
SITE WELL ID#fd appllceble) '
9. SCREEN: Depth Diameter Slot Slip Material
3,WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.—in. in.
DATE DRILLED �/ : Top Bottom Ft in. in.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft in. P. _
4.WELL LOCATION: - 10.SAND/GRAVEL PACK:
CITY`,_ , ih�yl i I�' COUNTY� r Depth She Materiel
- �p V '/� (lj� s�,� o r Top Bottom Ft.
y A l`M i n�.t� Top Bottom Ft.
(Shaet Name,Numbers,C rums ,SuedNolon,Lot No.,Parcel,Zip Code) Top Bottom FL—
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Slope OVailey pFlat ❑Ridge ❑Other 7 11.DRILLING LOG
LATITUDE �gg3S e�lr S(r Yl�tV Top Bottom Formation Description
.,L _ DMS OR 3X.XXXXXXXxx DD
LONGITUDE/ -34-,r59344.'"DMSOR7X.XXXXXXXXXDD
Latitude/longitude scame! CGPS Qfopographic map
(location of well must be shown on a USGS topo map andadached to aria r rXy t c e-
this form if not using GPS) '
5.WELL ull
OWNER i�IfYt'S1}y � Noy+h [J2�1ail-ric Tf1}t)
Owner Name �
r 0� l�hI lla Hftd I g. ' D .1HL r
Straet Addreas
lam 1lP NC _
Cdy or Town State Zip Code )
Area code Phone number
6.WELL DETAILS: ' 1 12. REMARKS:
a. TOTAL DEPTH:-00 11
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use.+^'d Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
P VIDED TO THE WELL OWNER.
d. TOP CASING IS FT.Above Land ay require
'Topp —si
ng sing tennineted aHor below land surface may requiui re
a variance in accordance with 15A NCAC 2C.n118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): �' _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
2 S
Form GW"1a
Rev.2/09

{;,.AATFo
RESIDENTIAL WELL CONSTRUCTION RECORD
Wy North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�°°" WELL CONTRACTOR CERTIFICATION# u 1 3 1 " A
1.W,EL.eil L CONTRACTOR: g. WATER ZONES(depth):
W
i Coonttrractor ct (d( a 711 YY�I S op Bottom TOp Bottom
(Itxitvidual)Name p 1 (��� ` Top Bottom Top Bottom 1,�A A LLI I 1 4 Top Bottom Top Bottom
.7 11 fftractor Company Name �-
Thleknessi
T. CASING: Depth Diameter Weight Material
Sheet dress
< A 1/I rip--I,
I I � Top Bottom Ft
C or T i '\/l nt(lY-State Zip
Top Bottom Ft _
Lkl a _ '� r><`i-� P TOP _,Bottom Ft
Area code Phone number
A. GROUT: Depth Materiel Method
2,WELL INFORMATION! lop—t_Bomom-4M Ft.
S4CQaj1'AuC} 4
WELL CONSTRUCTION PERMIT# Top _Bottom FL
OTHER ASSOCIATED PERMIT#(Ifapplimble) lop Bottom FL
SITE WELL ID#Pf sppprepj,l
9. SCREEN: Depth Diemetar Skit Stu MtlterBl
3,WELL USE(Check Appikable Box): Residential Water Supply Q Top Bottom—___FL_fn. _ In.
DATE DRILLED �;L31 Top Bottom FL_,in. in.
TIME COMPLETED AM[] PMD Top Bottom FL_hL _. in
a
4.WELL LOCATION: - 10.SAND/GRAVEL PACK:
Cm•\ Depth Site ahtetlei
CCOUNTY u ' Top Bottom Ft.
—���^ M 1 i l 1 Li J Top Bottom Ft.
leaser Name.Numbers•Common ,Subdivision,Lot W.Parcel.Zip Code) Top Bottom___Ft.
TOPOGRAPHIC/LAND SETTING' (check appropriate box)
❑Slope ❑Valley, pFlat DRIdge ❑Other 1 11.DRILLING LOG
LATITUDE -46 3S•31F.5�. S/� ^DMS OR 3X.XXXxICXXIIX Dp 1op Bottom Formation Description
LONGITUDEL49;1 •3'1 '643" "DMS0R7X.XXVJOD XDD _-�_/ ODD 0,V- I `t- lY
Latitudelbngitutle sa nm: BPS Qiopographic map / 'I
(focaann of welf must be shown on a USGS topo map andadached to
this form lfnot ushV GPSi /
s.WELLrnaNER U),iVerSi}4 OF Nash GkYDIitY �415+) tart?yll V
� Irv � 1I71C /
Owner Nettie
�lU� l�ht Ilt�� 1-FQII , D 1�4 ,D
Street Atltlresg
QdyorTown N �`� )4 �
day or t Sreoe Zip Coda /
Area code Phone number /
S.WELL DETAILS: 1 12. REMARKS:
4
a. TOTAL DEPTH:_ W
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(use'+^g Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASMdG IS PROVIDED TO THE WELL OWNER.
FT.Above Land Surfaces
'Top oT casing temnfneted at/or below land ve Land Su require ��J
A variance in aOcorian with 1SA NCAC 2C.0118. 2`
SRMA.fiURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
C DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Ll.
Form GW-1a
Rev.2109

'r^`A'VEa
lIESIDE'NTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�"" WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WATER ZONES(d"J:
lop Bottom(Wall Contmotor(Indwxival)Name Top
t_A Y(] Q/�\1�3�� 1 �/1�' ��r�('�— Top To
Bottom ToP Bottom
dell ntractor CxmPany Name I °p--- nnu—
Bow' ToP Bottom
Thlcikaeast
Street ddress I. CASING: Depth Diameter Weight Mabrlei
(1� �_ Top Bottom FL
O �Kw To -"611>e! 1\!t_J Ot f`t Top Bottom FL
L�1iLS.lJ Uri d - -�a�-► ZIP Code
Top Bottom FL
Area code Pflone number
2.WELL INFOR A. GROUT: Depth Maw( Method
MIATION: n--/-� 1oP _Bottom�Ft.
�f" 'Ct Ld(WELL CONSTRUCT"PERMIT# � Top Bottom FL
OTHER ASSOCIATED PERMITp(if applicable) Top Bottom Ft.
SITE WELL(D Mapplleable)
- 9. SCREEN., Depth Diameter Scot She Material
3,WELL USE(Check Applicable Box): Residential Water Supply PP Y❑ C Top Bottom___Ft._in. _ In.
DATE DRILLED o TOP Bottom___
TIME COMPLETED AM 0 PM❑ Top Bottom---Ft
_kL _ In.
4.ALL LOCATION: 10.SAND/GRAVEL PACK:
CITY, COUNTY_.` jIYTf,UYI Dept, She Material
Top Bottom R.
L�'s Top Bottom FL
Subdivbbn.Lot No.,PatcK 21P Cogs) TOP---80I Ft.
TOPOGRAPHIC/LAND SETTING: (dasck appopnela box)
OSbPe ❑ValIeY ORat (jRidge ❑Other 11.DRILLING LOG
LATITUDE - j S• (o.S(i,�J(2N^ppag OR 3x,lCC,Dkbtxfoc DO
Top Bottam Formation Description
LONGITUDE T SF •3t1-Cg30t--'+ !
, _._ DMs OR 7x.X0000DODot DO .�_/ �Ob _ Qt- ll 4- i rr+-
Latitude/longtbidesoutce: 03pS {r�gmprylo�p
(locetioh of we#must be shown on a USGS tope map ardattached to !,
this form if not using GPS)
S.WELL OWNER Norl+-) CWainr,c AI`dh)
Owner Name 1-'II>�+Arn
Strom Address !
�i�"YUIIle
Gty or Town State ZIP Code !
Area code F'hone number !
s.WELL DETAILS: f 1 t^a, 12. REMARKS:
a. TOTAL DEPTH: 400 74
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
c. WATER LEVEL Below Top of Casing; FT. ' ACCCCORDANCE HER WIITnH 15A NCAC 2CW WELL CONSTRUCTIU�CITED IN
(Use"+"if Above Top of Casing) STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASWO 1S FT PROVIDED TO THE WELL OWNER.
.Above Land Surface*
^T-P of casing tertnfrmted et/or below land surfacemay require
a variance in accordance wmh 15A NCAC 2C.0118_
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):. f/,' __METHOD OF TEST
f. DISINFECTION:Type Amount _ [ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
- L7
r,. Form GW-la
Rev-2109

*"s,STNio�
��n rye D
RESIDENTIAL WELL CONSTRUCTION RECORD,
Noah Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#_2.+ 13
1.�(¢/�LL MNTRjr/n�rtrno. g. WATER ZONES(depth):
—•r r�X ' Oi )S top Bottom Top Bottom_____,
�Weil
(contractor(irxfividual)Name
am`e6B
---_ T( 1 Bottom Tap Bottom
nredor Company Name Dyl Top----Bottom Top Bottom
Thickness/
_
I T. CASING: Depth Dlamsaar Weight Material
TopStreet tlress t� (' u _
�rl (�^L�. Mc �"J ` 3 Top Bottom FL w t P
y�y ry )�') i � slate Zr Code Top Bottom FL
Area code Phone number A. GROUT: Depth Material
2.WELL.INFORMATION: 1 Method
`,, •�� �y/'� : Top�_8otmm� Ft. t+
WELL CONSTRUCTION PERMIT# V\I (I I I H J�''1`"1 Top__Bottom FL
OTHER ASSOCIATED PERMIT#(If appiicahie) lop Bolmm R.
SITE WELL ID#fd appllcede)
9. SCREEN: Depth DlemeMr Pont Sim Material
3,WELL USE(Check Applicable Sox): Residential Water Supply❑ Top Bottom FL_in. _ in.
DATE DRILLED 4 : Top Bottom FL_in. In.
TIMECOMPLETED AMf7 PMO TOP Boaam Ft—_in. _ in.
4.WELL OCATION: 1o.SANDfORAVEL PACK:
CITri COUNTY ,_ 11 Yl('t Depth Sift Materiel1
Li top Bottom Ft.
(atreet Nartfe,Numbers,Commrmky,SUMMsion,Lot No.,Parcel,Zip Coda)
Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (clock appropriate box)
❑Slope ❑Valley OFlat ❑Ridge []Other 11.DRILLING LOG
LATITUDE _2d.•&v,jr,f 7A) TOP / Bottom Formation Description
OMS OR $X.xxxxxxxxx DD
LONGITUDE Mlb 2 .3y .U9yyi.,.DMS OR 7x.ID000)O=DD .�_( c900 OYCL.[lI �F.
Latibtde/longitude source: IMPS Qfopogrephic trap /
(location Of"I/must be sham on a USGS topo map andaaachea to
this form ifnot using GPS)
S.WELLOWNER Ull"i�fCrSi}y QF uY{h ((�Yul.ii'f� ( 1 1 f tll� ��Q�lt f'�
F a w.0 4-
OwnerNama /
o� hilltQS Hat' I are14aD
Street AddressP
Urm Ile N( 2�LI2j
Dty or Towrn !
State Zip Coda /
Area code) Phone number
6_WELL DETAILS: y t^� 12. REMARKS-.
a. TOTAL DEPTH: `t_ l O -
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(I IsO'+^K Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS PRO)IDED TO THE WELL OWNER.
FT.Above Land Surface• �(/ r {�n � 7��/
'Top of casing terminated aVor below land surface may require `-��, y�' y�
e variance in accordance with 15A NCAC 2C.011 A. SIGNATURE OF CEFITIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_.(Z METHOD OF TEST
f. DISINFECTION:Type Amount
PRINTED NAME OF PERSON CONSTRUC77NG THE WELL
ZY
Form GW-1a
Rev.2fDg

{.RsAArEo
RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Department of Environment and Natural Resources-Division of Water Quality
ra WELL CONTRACTORCERTMCATIOY# L41161
1. C WELL ONTRAC OR: g. WATER ZONES(depth);
'i op Bottom Top Bottom__
-'•Wellll/contractor(Individual)Nam�e I'op Bottom Top Bottom
()(yV�ell��Jpntraclot
y nY Name1 p Top-----Bottom Top Barom
LCl k ntra -.� Thidmessl
Sleet remM0, r�fG}-7 - T. CASING: Depth Diameter Weight Meeerud
rSta
or r — C( 1 Top Bottom FL
�Ll _ ro �P CAB TOP ,Bottom Ft.
Area code Plane number l d`Y 1 8. GROUT: Depth M�aterilat Method
2.WELL,INFORMATION: ` I ^ (� � Top _eottom�ffi Ft.,�(' )(J
WELL CONSTRUCTION PERMIT#— � �(i�I�l IIN� Top Bottom Ft.
OTHER ASSOCIATED PERMIT!!(Itapplirable) lop Bottom Ft.
SITE WELL ID*g ppllcaWe)
9. SCREEN: Depth Diameter Slot Size Materiel
3.WELL USE(Check Appfical��): Residential Water Supply Top Bottom Ft—in. in. _
DATE DRILLED Top Bottom Ft_ 1n. v in.
TIME COMPLETED Apt p PM r TOP Sotrom R In. ^ In.
ALL
4.p�ELL LOC(A�TION; 10.SANDIGRAVEL PACK:
CITY`.,8n i,& ' ie COUNTY_,Y1(�C'l/Y1 N? Depth gtre pea(yrisR
n P� �s Top Bottom Ft.
: Top Bottom Ft.
(Street Nave,Numbers,Common ,Subdlviabn,Lot No.,Parcel,21P Coda)
Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
OSlope OVelley OFlet ❑Ridge ❑Other 11,DRILLING LOG
LATITUDE 3r+3W�SGBiN'• Top Bottom Formation Description
DMS OR 3X.)COOMXXX DI)
LONGITUDE 76—'4 ^3`f �G�I.�OF>r DMS OR 7X.)=XXXXXX DD O�Y�ZCII e, �-
Lafitude/longltude source: IGPS Qropograph c map ( Y
(lDCat%nn of welt must be shown on a USGS topo map andadached to { / �('l� _(�1'`P\11
this form if not usi g GPS)
S.WELLOWNER U{livCr QF'bit N%x+h CQ1riil l-a � Olt-
4 •
Otw,ner Name
Seet Address
i'�"ll ��t�� f IU�' t � t�•�'�Q
ME 1WN
City or Tmn State Zip Code
Area code Phone number
6.WELL DETAILS; 12. REMARKS:
a. TOTAL DEPTH:_ 4C�D -
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use•+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
" PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 1S
Ff.Above Land Surface � � /� Ll�')'✓, ui
"Top of casing term{natal actor below land surtace,mey require ��f
»vaAance in acrardence with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e' YIELD(9Pm):. (Z METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON OONSTRUCTINGTHEWELL
Rev.2M9
Form GW.Ia

4pY�P�
9 RESIDENTIAL WELL CONSTRUCTION ON RECORD
North Carolina Depardnent of Environment and Natural Resources-Division of Water Quality
•!`�" WELL CONTRACTOR CERTIFICATION# Q 113
1. 1 rONTR 9. WATER ZOOMS
11C1D111J Top Brxtom TOp_ __ Bnttom
f�Well Contractor(Individual)Nam 7-Op BOI[Orn Top Bottom_
_l �PI I,i� V\ I,u�-`�1�� : Top ____Bottom Top Botlam
yellC ntact Company Name --..
1 fy !OJ Thlcknessl
1'. CASING: Depth Diameter Weight Material
ttr�ee. adress t Top—---Bottom Ft.
City,or
OG ` 3 .. _
��/�� ^� /�� ( I Slaw z Top Bottom Ft
LWLLIfJ _Sk_rl� ` 1 [j mot'f P Code - Top-_ _--.Bottom Ft.
Area cotle Plane number R. GROUT: Depth Matedat Mentor[
2.WELL INFORMATION: � ,1 < t -
^t-�t/� Topj __Bottom� Ft.!JCJ'(�'j + + C)CJ-I' 6
WELL CONSTRUCTION PERMIT# E��,� R J IK�' Top_-__-Bottom Ft rr TT
OTHERASSOCIATEDPERMIT#(Ifap ,Mble) Top Bottom Pt.
SITE WELL ID#(d appllcabie) '
---�— 9. SCREEN: Depth Diameter Slot Size Material
3,WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft—in. In. _
DATE DRILLED /a•- Top Bottom FL_in. _ in.
TIME COMPLETED AM G PM❑ lop­Bottom Ft.—,—In. _ In.
4.WELL LOCATaN: 10.SANDIGRAVEL PACK:
�yl ' 1(r CDUNTY ' :f)4 I T m Depth Size Materiel
� 6C L.1� Botto Ft
f
A `� Li J Top Bottom Ft.
(-beat Name,Numhers,cammurlay,SubdhOion,Lot No.,Parcel,Zip Code) Top Bottom Ft. -
TOPOGRAPHIC/LAND SETTING (check appropriate box) - - —--_—.-
❑Slope OValley OFlat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 3C•�cb tuv)K. Top Bottom Formation Description
_ DMS OR 3X.XXXXXXXXX DO : /
LONGITUDE •3Y .fX(S y;w •DMS OR 7X.XXXXX)DRXX DO
Latitude/Iongkude source. MPS ❑Topographic map /
(location Of weH must be shown on a USGS topo map andattachad to P . j t C.C
this form!f not using GPS)
S.WELL OWNER Uvmv ert51}}-l/(QFF N'x4rh cov-t'hi-Cn f1b�)
Owner Nam _
Sheet Address
City or Town State Zip Code /
Area code Phone number
6.WELL DETAILS: r� 12. REMARKS:
a. TOTAL DEPTH:_ 4DO -
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
tl. TOP OF CASING IS VOVIDED TO THE WELL OWNER.
FT.Above Lend ay require
, �^,n
'Top of casing terminated aVor below land surface,may require `iP/fl! (
a vadanoe in accordance with 15A NCAC 2C.011 a. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD{gpm): METHOD OF TEST
C DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

e^�SATfP
lIESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- ty Division of Water Quali
WELL CONTRACTOR CERTIFICATION# 6 113
1.7LL CONTRACTOR: 9. WATER ZONES(depth):
1 op Bottom Top Bottom___
(�Wellll�C�on�trractor(IMividual)Name p{� f / To _Bottom Top Bottom
"'"r''�"--� ��� °`5)➢ .Dy 1 �-1 µ-_ Tnp Bottom Top Bottom
r}yy���\ell��Jp ntr.M C�pany Name i
k j Thickness/
Street dress Y. CASING: Depth Diameter Weight Material
'1 1 [ Top Bottom Ft
C' or T Top Bottom Ft.
(u� r' S'lete ZIP Code
a, - -I Top Bottom Ft.
Area code Phone number
8. GROUT: Depth Top , 'Bottom Ft. Material Method
Z.WELL INFORMATION: Top_ _Bottom_M Ft A.�-f J- `iJ(,`�f'
WFLL CONSTRUCTION PERMITif ��; (��'I)�l JfNJ
OTHER ASSOCIATED PERMIT#(ff applkeNe) Tap Bottom Ft
SITE WELL ID#(aappifcede)
9. SCREEN: Depth Diameter SW Shia MQWRI
3.WELL USE(Check(/Applicable Box)Residential Water Supply❑ Top Bottom Ft,_in. In.
DATE DRILLED 7�� Top Bottom Ft___In, ^_ In.
TIME COMPLETED AM 0 PM Top Bottom Ft In. , in.
a
4•41-L LOCATION: 1r�,: 10.SANDfGRAVEL PACK:
CITY`,��' ,h(� ( I COUNTY.-�1.C1r�G Top Bottom FL Depth Material
Lit S : Tap Bottom Ft
k ac rvema,Numbers,Cornmurd j,SubdJAsion,Lot No.,Parwi,ZIP Cade)
: TOP-Bottom- Ft.
TOPOGRAPHIC/LAND SETTING: (diteck appropriate box)
❑SIOpe OValley ❑Flat ❑Ridge []Other 11.DRILLING LOG
LATITUDE W5-=-;Ia. 3-&wTA/DtAS OR gx.xXxxXXxXx OD Top Bottom Formation Description
LONGf1UDEAV2- 13�' -047UkJ „ - l
DMsort7x.>oona>ocxuDo _1l000 (y{-
Lalitude/fongifuds source: BPS [japographic trap / J
(location Of we#MEW be Shown on a USGS topo map andaltachod to
this form if not using GPS)
S.WELL OWNER Un',Iver;;idddty c����f' Nvr+h ClArW( Aq)"i
Owner Name
s�o-a\��Aad'' ,nh, lisp NQ �PD i4�C
city or Town State Zip Code -
(--_) /
Area code.Phone number /
8.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH.,
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
a. WATER LEVEL Bebw Top of Casing: FT. : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+^'If Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS VIDEO TO-jHH/E�WELL
fOWNER.
Ft.Above Land Surface- // -Y f kCU fA�t U//+
11
*TOP of nccasing in terminated agar below land surface,mey require
a variance in accordance wph 15A NCAC 2C.n118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm)..�_METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
31
Form GW-1a
Rev.Z%

R]j
ESIDENTIAL WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�`�" WELL CONTRACTOR CERTIFICATION#
1.tluFItt cotiTRacZOR: g. WATER ZONES(depth):
1l�>CL rlt(individual)
'roP Bottom Tap BoUom
Well Contractor(IrMmtlual)Nerve
/1 & T Bottom op
Y/\A 1/b i P ✓ lA_1 0 d roP T Bottom___
—'—'�acaor ump " �`�•-- op____Bottom Top Bottom_ _
O(yNell(C�Jpntraaor Company Name
Thlcknessl
Street ddress 1'. CASING: Depth Diameter Weight Material
l ^� Top Bottom FL
,}.or Top Bottom Ft. __
f , l Stefe Zp Cotle
( '�) .U)a'ot _ '� 1 I 1 Top Bottom FL
Area code Phone number f�'CL_
2. S. GROUT: Depth material Method
W WELL,INFORMATION: TOP _Bottom FLf�Cl`� a1�"1 �`{- '4 F�_
WELL CONSTRUCTION PERMIT# Top m-Bottu Ft
OTHER ASSOCIATED PERMIT#(Ifaporable) lop Bottum F[.
SITE WELL ID#(if eppllcahle)
S. SCREEN: Depth Diameter Sent Still Mai l
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. _ In.
DATE DRILLED 7k � Top Bottom Ft. In. in.
TIME COMPLETED AM I] PM❑ Top Bottom Ft_in.
4.WELL LOCATIDaL 10.SAND/GRAVEL PACK:
CIT1'.� V 1 , j Y COUNTY �� / b,p Depth SIM MaNdat
�`^ l�C� Top Bottom Ft.
TOP Bottom Ft.
t ac mm�e,Numbers,Common ,aub4Mefon,Lot No..Para,f,ZIP COO,)
Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING (check appropriate box)
❑Slope OValley OFiat ❑Ridge 00ther 11.DRILLING LOG
LATITUDE - -•jIP S(oYdJJ DMS OR 3X.xxxxxxxXX DO Top Bottom Formation Desciiptlon
LONGITUDE frZ .3f ,fFl 7z w , l 7�fi__ DMS OR 7X.XXXXXXXXx DD �,L (j,.
Latitude/longkutle source: pGpS Qfopographic map
(tocatron of well must be shown on a USGS topo map andattached to !
this form if not using GPS)
s,WELL,OWNER Ul-�i veroi}y QF t\vt9 h Cok!(>tita A uta,l -lar(l I�t :E
F iul /� Q � (p iCYI� f J
Owner Name /
D
Street Addressi hlfll* }4Q1� �D i4�D ;
Sfffie Zip Code /
Area code) Phone number /
G.WELL DETAILS; �^ ( 12. REMARKS:
a. TOTAL DEPTH; ql j`)
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED tN c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
Nee"*"It Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP CA�NG 6 FT.Above Land Surface PROVIDED TO THE WELL OWNER.
"Topp of d mi
ing ternated with below l e,may require
A vadance in accordance with 15A NCA 2C.0C 2C.011 a. SIU'NATURE OF CERTIFIED WELL CONTRACTOR DATE
e' YIELD(gpn}:_z METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3�
Form GW-la
- -- Rev.2/09

s AN£a
RD
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# L4 16 I - A
1.WF1L CONTRACzOR: g. WATER ZONES(depth):
l) G17Vil'YV Top Bottom Top B06013
Weil Contractor(Individual)Name
�I ,I'� �',, Top Bottom Tap Bottom
-> ntr�s�ctorcw�n yName�p A A Din f I 1 (YA Top_--Bottom rap Boliwn
\ .. � Thiekeesaf
Street 4 ... t� �7 T. CASING: Depth Diameter Weight Material
t -I\J�I A 1433 Top Bottom FL
ran
("City or T State Zip Code Top Bottom FL
Top ,Bottom Ft•
Area node Pnone number : A. GROUT: Depth l Materiel Meth
od
2,WELL INFORMATION: 11//�� I op-A—Bottom�l Ft. [,�
WELL CONSTRUCTION PERMIT# f�)1 Top _Bottom Ft__
OTHER ASSOCIATED PERMIT#(tfapplielible) Top Bottom FL
SITE WELL ID#iu epolceble)
9. SCREEN: Depth Diameter Slat Size Material
3,WELL USE(Cheok Applicable Box): Residential Water Supply[] Top Bottom Ft.—In. in.
DATE DRILLED_ j�/�� Top Bottom Fi_ ln. — In.
TIME COMPLETED AM PM Top Bottom Ft—in. In.
❑ —
4.ALL
�LIOCATION: 10.SANDiORAVEL PACK:
CITY'_[1; �)(r COUNTY , ` , Depth Size Me(arkti
Top Bottom R.
Top Bottom Ft.
tbtmet Name,Numbers,commuft Subdivision,Lot No.,Parcel,Zip Code) Top HoltOm F},
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope CIValley ❑Flat ❑Ridge []Other 11,DRILLING LOG
LATITUDE 35%3v. SZ�frYN. Top / Bottom Formstlon Description
-. VMS OR 3X.XXXXXXXXX DD
LONGITUDE �2 "3'f -0R 1-' DMSOR7X.=000XXXXDD
Latitude/longitude source: [33PS Qfopographicmap /
(!oration of my must be shown on a USGS topo map andartached to t,2�(�/�� l yiey t c e-
this form if not using GPS}
S.WELLOWNER Y,rt�iVfrO�}y OF Nor+h Ci�11'DYitY:; UI�L� am ull V
,a.e Y19 4r t` y[a rims /
Owner Name
Street
l ft�j J_113.1 I t`i-L
1�IYNA 1lt T�Mc a�i�
City or Town State Zip Code /
Area code Phone number /
6.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH; 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Bebw Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+^if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
I. TOP OF CASING IS PROVIDED TO THF�NELL OWNER.
FT.Above ace, Surfequ (`-
•Top of casing tennfnetetl allot below land ve Land Su require
a variance In accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm}:z—METHOD OF TEST
L DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.209

�VQ y�r tl P�
RESIDENTLIL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTWICATION# L I I 61 - A
1.it1'�LLC�O1NTRAC�T)O1 R: g. WATER ZONES(depth):
LI' tC'fYIfYY1fIS rob Bottom Top Bottom_____
Weill Contractor(Individual)NE I , 1 I Top Bottom Tap an Botho _____
I 11(1�VSV FI � Top_-_Bottom Top Bott
omII rotor C W; opyame Thickness/
T. CASING: Depth Diameter Weight
Material
��,Stre�afcgq��dress �^ 1/
1 Pw or ­Bottoim�FL
�)C) Top Bottom FL
C�or T State Zip Code �
,S( >1 -1 i1{ 1 I Top Boffa Ft.
Amu-acodt_e P�hotna number
o(`Y 1 R. GROUT: Depth Material Method
2.WELL INFORMATIpN: Top —Bottom�\\zFt. l::rJ:.{ `fit
WELL CONSTRUCTION PERMITi/,y�� F(,�1` Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(Itappuorbe) lnp Bolmm Ft.
SITE WELL ID#(d applimble)
9. SCREEN: Depth Diameter Slot Stu Material
3,WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.—In. In.
DATE DRILLED/ L�� Top Bottom Ft. )n. In.
TIME COMPLETED AM Ll PM D Top Bottom Ft—in. _ in.
4.WELL LOCATION: 1e.SANDIGRAVEL PACK
` 1! .- Depth MaMrel
ClTY`:� �/j I �t�(�/�r�� CCL`OUNty ��,)119 1( � Top Bottom Ft.
M ' 1 1 J Lei J Top Bottom Ft.
(street Name,Numbers,cammun ,Subdivision,Lot No.,Parcel,21p Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ORat ❑Ridge DOther 11,DRILLING LOG
LATITUDE �'S•3 $'7pIN•. Top / Bottom Formation Description
�' OMS OR 3X.xx)o=XxX DD
LONGITUDE WF-3f 0q'f50N 4 DMS OR 7X.XXXXXXXXX DO _Iitt ODD
Latitude/longitude source: 03PS Qfopographic map /
Oncatidn of well must be shown on a USGS topo map andanached to : {.?�•�/ ")Q t' CP
mts form if not usMv GPSj /
S.WELL OWNER Ur�lvcr-6 V QF Nvr4h CYz Uii-rh M>Otil lfl--)L—A�k 1—"00 _Gi'((tLll fJ'
Owner Name AMC(�, - W rA U-L
-- ht��( Lt e i42o
Street Address
I&YU I le
Cityor Town State Zip Code /
Area code number
G.WELL DETAILS; 12. REMARKS:{� (
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+"d Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WE L OWNER.
d. TOP p CASING IS FT,Above Land Surface`
'Top ri casing accordane"Imtedce
at/orwith below land sur2C.0 18. require
a variance in ac�co,/rdance with 15A NCAC 2C.D118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_(/' METHOD OF TEST
f. DISINFECTION:ToeT-- Amount _ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3,F
Farm GW^ta
Rev.2M

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
0 WELL CONTRACTOR CERTIFICATION# t9 113
1.(W,�E LL�CONTRACTOR- g. WATER ZONES(depth):
—r-1e-J' `10 ell Ca-nl ADS Top Bottom Top Bottom___
(Individual)Name Top Bottom top Bottom
MCo7V )n11i' _
`) P { �j'(Y�ar— Top Bonn Top Bottom
ell Vntractor Company Name I Thickness/
X ) A l : 7. CASING: Depth Diameter Weight Material
11Street dress (� l/�� �( �,j _
�~T ' `L �`�� ` S T p Bottom Ft.
or T 1 Stale Z� Code �
_�r�l ,� � _ 1 /)I t + p Top Bottom Ft.
Area cotle Phone number t O(�t'f : 8. GROUT: Depth - Matelot L ,t Method
2.WELL INFORMATION: _
`, Top _Bottom Ft�'� T Cf
WELL CONSTRUCTION PERMIT# '(�) t l i l l�l Top_Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom F9.
SITE WELL ID#(if applcable) : 9. SCREEN: Depth DlntWar Set Slaw Mawal
3.WELL USE(Check Applicable Box): Residential Water Supply O Top Bottom Ft_in. In.
DATE DRILLED��l 7 �y Top Bottom Ft_in. T in.
TIME COMPLETED AM E1 PM p Top Bottom Ft in. _ in.
4.WELL LOCATION; C 10.SAND/GRAVEL PACK-
CI Pth site Mab111W
De
1 (� COUNTY Top Bottom Ft.
Top Bottom Ft.
(street Neare,Numbers,Communay,Subdivlebn,Lot No„P&oel,Zlp code) Top Bottom Ft—
TOPOGRAPHIC]LAND SETTING: (check apprapdete bm)
❑SIOpe [Valley ❑Flat ❑Ridge []Other 11.DRILLING LOG
LATITUDE 38`3r•.367 S73.ZN • Top Bottom Formation Description
DMS OR 3X.XXXXXXXXX DO /
LONGITUDE;S�' DMS OR 7X.XX DW-'O XX DO : 1/2
Latil de/b dude source:n9 [j;PS []Topographic map
(location of well kraut be shown on a tlSGS rope map ardeaeched to 6!LQ 'xQ ft-ey t c e-
this form if not using11 GPS) r� �,a. /
S.WELL OWNER �.lil I v erol'�'y of Nur+4-NCJ�YI%I(ra A11411=T , I
Owner Name - /
►itps Hit * d D 14LU ,
Street Address — /
�Sk'�w Ile 1\1 '
Cdyor Town State Zip Corse /
Area code) Phone nwfttter /
6.WELL DETAILS: 12. REMARKS:
A. TOTAL DEPTH: �
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use'+'a Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
z
ED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
`Top of casing temminated at/or below land surface me re uire1 /�-t/da variance in accordance with 15A NCAC 2C.0118. Y 9 ' " i'd&w
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
mt� Form GW-1a
+ .,. - Rev_2109

/ri1.AArFO
�5{ RD
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# LI I ,r6 1 " A
1.711 CONTR OR: S. WATER ZONES(depth):
( ,L 1 ( fjs7yl•C l S top—Bottom— Tap Botlom---
(�Wea Contractor(Indtiv-idual)Name Top Bottom Top Bottom
( �.-�(� �) 1 ,1r �1-d.1 (.LIli1 � •—_ TIP---Bottom Top Bottom
II nvector Company Name I Thleknessl
pp
(� X 1^ �I T. CASING: Depth Diameter Wnlght Material
Street tldress To Bottom Ft_ --
. P --
`� - Top !?ottom Ft
City or T Sisk Zip Code Top Bottom Ft
Area code Phone number S. GROUT: Depth Material ,1 Methock
2.WELL INFORMATION: `,, �y ; I'op_� Bottom,Ft. CI () al, + 't- -Al
WELL CONSTRUCTION PERMIT# Y\� t�� I"l� _ : Top_Bottom Ft
OTHER ASSOCIATED pERAAIT"appl'rdabla) TIp Bottom Ft.
SITE WELL IDff(dapplleaNe) 9. SCREEN: Depth Diamobr Slot Sire Mom"
3.WELL USE(Check Applicable Box):1 Residential Water Supply❑ Top Bottom Ft. In. _ In.
�
DATE DRILLED i16o 4 d--- Top-_Bottom Fl in. in.
Top__Bottom Ft.—In. ! In.
TIME COMPLETED AM❑ PM❑
10,SAND/GRAVEL PACK:
4.1AELL CATION; , p Depth Site MderMl
CITY4..'F rev` l I'd COUNTY11,a tbTop Bottom Ft.
DtIS : Top Bottom FL
(Street NaMm,Numbers.Comma ,Subdivblon.Lot No.,PNcal,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropdam bon)
❑Slope OValley, ❑Flat ❑Ridge ❑Other : 11,DRILLING LOG
Top Bottom Formation Description
LATITUDE .'hi`'3`r• •S7(YLV^DMS OR 3x.X)D o=xK DD : /LONGITUDE g�Z DMS OR 7x.m000000ot DD sa0t)ue— -ant
Latitude/longitude source: i-ppS Qfopographic map ���nn
(location of well must be shown on a USGS topo map andetlached to tzs.aM/ t�Y Pa,/t[e-
this form if not ushg GPs) If 1�
S.WELL OWNER lrlliVeYSt�y �" (�llvlitlf� lfdt) ! Qlllll
Fki IfP d f�r�ora buftS f
Owner Name /
90,2 1P l la�2; 1 , tea 1'4&
Street Address
------
Mc,
Cily or Town State Zip Code /
Area code phone number = 12. REMARKS:
S.WELL DETAILS: ' 1
a. TOTAL DEPTH: 40D _
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ `
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use"+^if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE�IrylELL OWNER.
d. TOP OF CASING IS Fr.Above Land Surface' 'I' /
'Top of casing terminated atlor below land surface.may,require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Typa Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

RMDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
�I �A
WELL CONTRACTOR CERTIFICATION# M 13
1.7LL CONTRACTOR- g. WATER ZONES(depth):
(--k ly�P[� ,'�l J fop Sotfom Top Bottom _
Well lC�onhtrractor Qndhddual)Name g Top Bottom Top Bottom .
_t_L 0 - n 1 p,r ' fl aYn ��2_. : Top Bottom Top Bottom .
,11y 111'C}pntracftor Company Name ' Thlckanessl
V k X J n t T. CASING: Depth Diameter Weight Material
Street ress P
'ran I �JC A143 Top � F!
.�Cityor To, rt stale lap Coda
4t1 ,7' 1 n � _ 1 241 : Top Bottom Ft.
tAn.'am%ode Phlolne number t 8. GROUT: Depth 1 l Materal d Method
x.WELL INFORMATION: \'` I ^� /' Top^�Bottom_�M FL 01
WELL CONSTRUCTION PERMIT#� 1,21 Y XJL3 Top--Bottom Ft.
OTHER ASSOCIATED PERMIT#(ff applicable) : T op Bottom Ft.
SITE WELL ID#(itepoleable) 9. SCREEN: Depth Diameter Slot Sin Material
3.WELL USE(Check((AIl pp&cable Bo1u): Residential Water Supply❑ Top Bottom Ft. n. ^ In.
DATE DRILLED T/q _ Top Bottom Ft._In, In.
TIME COMPLETED AM[]qMp PM Top Bottom Ft_in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
$ ����,/� Depth Size Meuriel
CITY: p(f1'( V( I COUNTY l--11J..eYl l 141 Top Bottom -_Ft
Fop Bottom Ft.
(Street Name,Numbers,CommunO,SuddMWn,Lot W.Pe I,Zip Cade) Top Bottom Ft._
TOPOGRAPHIC/LAND SETTING: (check appmpdote box)
❑Slope OValley ❑Flat ❑Ridge pother 11.DRILLING LOG
LATITUDE $3S^* '—SIA't N^ Top Bottom Formation Description
DINS OR 37(.)000tXxXXX DD )
LONGITUDE70A ^3`�' Oq7'V'' "phq$OR 7X,)00(XXXX)DC DO (gob
Lalihrde/IongHudescurea: Q"..^PS QTe re Ph� P tcma
Po9
(location of we#must be shown on a USGS topo map andavached to
this form ifnot using GPS)
S.WELL OWNER �It,'t V 0-01 ty of �(vur+h f:�lt"a.trr� F1 �Pdt l 1• �lt�L� (an�r%,1 '
Owner Name
r
�o� nh, utnnL t I -Pa 14& ;
Stiles!Address I !
1i1_Lte Mr,
QlyorTown State Zip Code
(---) f
Area code.FiRine number
B.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH; 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: IT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+^ff Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS FT.Above Land Surface PROVIDED TO THE WELL OWNER.
casing
'Top of terminated at/or below IarM surface,may requis re
s variance in accordance with 15A NCAC 2C.0178. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
31
Form GW-1e
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�°"� " WELL CONTRACTOR CERTIFICATION#
1.ta�LL CONTRnc�oR: 9• WATER ZONES(depth):
t 1 I Gt71iY�ll S Top Bottom Top Bottom___,
Wall Contractor(Individual)Name 1 Top Bottom Top Bottom__,
Top _Bottom top Bottom _
1)yJell�pntreGor COfnpany Name I Thickness(
L fk/X l{ 7. CASING: Depth Diameter Weight Material
`�,St`relet ddress p 1 �1G-7 1�tj Top Bottom FL
1\1 I Ot O I Top Bottom Ft
Slate Zip Code Top-Bottom FL
Area rode Phone number S. GROUT- Depth `` 11 Material Method
2.WELL INFORMATION: \� Top _Bottom�MFt.-Q LC 1L
V\ITop_-
WELL CONSTRUCTION PERMIT# t n I l ri J��'t�' Top-Bottom FL
OTHER ASSOCIATED PERMITI!Qlappecable) 1bp Bottom Ft.
SITE WELL ID#(ri appllcahle) 9. SCREEN: Depth Diameter Well Slam MM&dal
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. In.
DATE DRILLED 4f�����' Top Bottom FL_In. T In.
TIME COMPLETED Apt D PM Q Top Bottom FL In. In.
4.41-1.']140C(A,T10ft 10.8ANDlGRAVEL PACK:
Depth Cm, f 1.1 l 1YU�� ,COUNN_,�, No T Sonorr Ft. Size Malarial
V.yTA w n I )us : Top Bottom Ft.
(Street Name,Numbers.Commun ,SOAM im,Lot No.,Parcel,ZIP COda) : Top Bottom FL.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope OValley ❑Flat ❑Rklge pother 11.DRILLING LOG
LATITUDE 3S.3m,.S(�,7riN. Top Bottom Formation0eacdptlon
-3K �„ DIAS OR 3x.xKmcxxxxx DO j
LONGITUDE7.K&A -N 1 0g99te"DMS OR 7X.)OOIXM)0(DD
Latitude/longitude source: DGPS []Topographic map / _
(looatior)of welt must be shown on a USGS topo map andattsched to C.?' 1 — (�Y V t L
this form if not using GPS) 1
S.WELLOWNER Ut�iverbi}y Qf I�ior1-h G�1r'nlitY� A`kw?t)' /,�('Z arn rt l je
F trrre,rn�Q�y m In-L /
Owner Name /
Stre
g2oet Address 2h, Ulpzi3n ILti W UD .14LD
Lax ) 1ae M0 ate_
City or Town State Zip Code )
Area code Phone number
12. REMARKS:
6.WELL DETAILS: 11
' 1 i^�
a. TOTALDEM; `t\/O
b. DOES WELL REPLACE EIDSTMG WELL? YES❑ NO O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use'+•if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO LL OWNER.
d. TOP CASING e•IS FT.Abate Land Surfeo
*Top
cas
ing sing terminated attar below IarM surface,mey require
a variance in accordance with 15A NCAC 2C.0116. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_�._METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3�
Form GW-1a
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
: a North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 6113
1. LL CONTRACTOR: 9. WATER ZONES(depth):
lop Bottom Top Bottom___
^Well�C�ontractor(Indlviduat)Name pp II Top Bottom Top Bottom
Ski)�P T-� 1� z A ��1 (n : 'fop Bottom Top Bolcom
r ( )ell{V?mractor Company Name
1)" " T J4 11 T. CASING: Depth Olamew wel r Material
Sheet dress
-� ' ( .-� : Top Bottom Ft
�Cay or T SYale Zp Code : Top Bottom Ft.
I 0%) —} )`i'
_ ! tI
i : Top Bottom Ft.
Area rode Phone number 1 O( 8. GROUT: Depth Materiel Method
2.WELL INFORMATION: Top__Bottom 1(-j
WELL CONSTRUCTION PERMIT# Top_-Bottom FL
OTHER ASSOCIATED PERMIT#(If appliceNe) lop Bottom FL
SITE WELL ID#(HapplO ble) '
9. SCREEN: Depth Diameter SW Sba Meta l
3.WELL USE(Check Applicable Box): Residential Water Supply❑ TOl Bottom FL_m. in.
DATEDRILLED 4 (D '' Top Bottom FL_In. T in.
TIME COMPLETED AM❑ PM❑ Top Bottom FL_In. in.
4.WELL OCATION•
�� ��(��-,,r,�{�p 10.SANOfGRAVFI PACK
CITY,
COUNTY JSd1� l d� IriG Depth $lu MMeAeI
( Top Bottom Ft
t1 Top Bottom Ft
(Street Name,plumbers,Communill SubdMslon,Lot No.,Parcel,Zip Coat) Top Bottom FL
TOPOGRAPHIC I LAND SETTING: (checkapproladabebox)
❑Slope OValley OFtat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 3S•�'• S7l�AJ . Top Bottom Formal Description_ OMS OR 3X.XXXXXXXXX DD
LONGITUDE 7$F� .3y ,Oc19y`DMS OR 7X.X*OX'O X DD ._1�I �U LtY.Yk..Cll - T!- itf
Latitudellongitudesarrce: EBPS propographicmap If
(location Of"At must be shown on a USGS topo map andstleched to _/ �-jC
this form if not La ft GPS)
S.WELL OWNER kAn'iver-i;ity t400 . tarn t;-)i 1E',
Emamcp K t
Owner Name
p I lit t C C) 14&
Street Address --
TOO
ctry or Town Stale Zip Code
1
Area Gods.Phone number
S.WELL DETAILS; tom( 12. REMARKS:
a. TOTAL DEPTH: 40
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOO `
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+"B Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
7ED TO THE WELL OWNER.
d. TOP OF CASING 1S FT.Above Land Surface- ,
*TOP of casing terminated atfor below land surface.may,require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gil _METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
39
Form GW4a
Rev.2J09

n
�'� RESIDENTIAL WELL.CONSTRUCTION RECORD
4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
«^0° WELL CONTRACTOR CERTIFICATION#
g. WATER ZONES(depth):
1 WELL CONTRACTOR: Bottom ToP Bosom
-T-.ch t ,,...�...r•.f�S -fo(r Bottom
-
well ;rl 1 11'[ f � t Bottom Top-
Well Contractor(Individual)Name top .
° �� Top Bottom Top Bottom
�f r �� '. ,nYa ,i ,^ r, Q
S A X/ Y X Y\/l X 1 1 A t'` 1�t +� Thickness/
Well�pntrsctor company Name Diameter Weigh Material
)1l� I jx j ( I 7. CASING: Depth
Street dress �}Q'') l,, Top Bottom Ft
Top Bottom Ft.
hoq
yCCiity,or T (fin`] �] State Zip Cone Top Bottom Ft.
(�J m t/ f "` Xy - 1 �+� 8. GROUT: Depth �y"� Material L ,1 Met
Area code Phone number �_Bottom tt__.n � Ft,S (_` T..
2.WELL INFORMATION: nn top
Top Bottom Ft.
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHERASSOCIATED PERMIT#(if applicable)
SITE WELL ID#(d appllcahle) g. SCREEN: Depth Diameter Slot Size Material
ToP Bottom Ft,_in. _— in.
3.WELL USE(Check Applicable Box): Residential Water SUPPIY❑ _ Top gotom FL in. _ in.
DATE DRILLED TJ`1�l°L ToP Bottom FL__in. ` im-
TIME COMPLETED AM❑ PM❑
10.SANDIGRAVEL PACK: Size Materi®I
4.ALL LOCATION-- ` f � �� Ib Depth
cny1 A--)h'np V l I �r�e r� `COUNTY L_LLL�'�C� TOP Bottom Ft.
Ft.
(Street Name,Numbers,Commun' ,Subdvcswn,Lot No.,Parcel.21p Code) lop Bottom Ft,
TOPOGRAPHIC/LAND SETTING: (check aPPrM)deta box) 11.DRILLING LOG
❑Slope ❑Valley ❑Flat []Ridge Othar Top Bottom Formation Description
LATITUDE 3�cs� r5Y��a�'"'DMS OR 3x.xxxxn_=DD
LONGITUDEn,ru"3q' bU) "AMS OR 7X.XXXMXXXX DD
Latitudellongitude source: EPPS []topographic map /`r"tell� P
(location of well mist be afrown on a USGS mpo map andattached to
this forth if not using GPS) �yy
5.WELL OWNER Urwjcr0i+4 �F. �icYFh („(i1,rl;(ir8:c /
14Xi`y r' Y' ra ,l QD 1 )
Owner Name
303 nhmlps `i 1aO ('u%f)
Street Address /
City or Town ' State Zp
( )
Area code Phone number : 12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"t"K Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 6i.Above Land Surface' 1�� cpc"— _/
'Top of casing terminated at/or below land suftea,may require 1 T"
a variance in accordance with 15A NCAC 2C.0118. SIG ATURE OF CERTIFIED W ELL CONTRACTOR DATE
e_ YIELD(9pm): �METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
'i
Foam GW-18
Rev.2/09
Y re �

�+ 'o°SFATFp.
� RESIDENTIAL WELL CONS RUCTION RECORD
S North Carolina Department of Environment and Natural Resources-Division of Water Quality
✓�'0k�« WELL CONTRACTOR CERTIFICATION# 1
g. WATER LANES(depth): go0om
7.1WhELL CO TnOR: Bottom T°P
. Top Bottom Top Bottom
Well Contractor(Individual)Name 10p
Top Bottom— Top Bottom
-
Top_
ell Qntractor company Name Diameter Weight Material
�<�JA T. CASING: Depth
Street Address ^ n ' + -,
Top­Bottom Ft
rx �"F� Top Bottom FL
Street
State Zip Code Top Bottom Ft.
( ? Material Method
8. GROUT: Depth 1 ,1
Area code Phone number 1 l Y'1'� (-t 't' ua
2.WELL INFORMATION: l"ap�_Bottom ti--A l Ft C
V� i !(711`�u!aq i rep Bottom Ft
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if epos able)
SITE WELL ID#('d applicable) 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft._in. —- in.
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft_in. _ is
DATE DRILLED Top_ Bottom FL__in. __ in.
TIME COMPLETED
10.SANDIGRAVEL PACK: Size Material
4.WELL LOCATION: Depth
II ttom Ft.
GITY,�.' 1�1I`1PV 1 1 ll I L COUNTY �I jC-, Top Bo
t- CWN cow rep Bot[om Ft
J Ft
(Street Name,Numbers.Common",Subdiviswn,Lot No.,Parcel,7Jp Code) TOp Bottom
TOPOGRAPHIC/LAND SETTING: (check appropdate box) 11.DRILLING LOG
❑Slope ❑Valley OFlat ❑Ridge {(]Other Top Bottom Formation Description
LATITUDE DMS OR 3x.)(XXXXXXXX DD I _
LONGITUDE T� J 1lt�� �DMS OR?X.XXXXXXXXX DD r
Latitudeilongftudesource: COPS Ofopographicmap �`�' (��j�— Ore 1L� �
(location of well must be shown on a USGS mpo map ande#ached to f
this form if not using GPS) t) _ ( (iYY2 4li -ICE
S.WELL OWNER t—�tliVEr"51}l, �F � � lll�.i rP��.' �
Owner Name
30-,2) Pht ttlps "0'0 ULNA �
Street address /
City or Town - Sfate Zip Code l
t
Area code Phone number : 12. REMARKS:
6.WELL DETAILS: ' 1r�(�
a. TOTAL DEPTH: `+L It i
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ L DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ON
G. WATER LEVEL.Below To of Casing: ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
P �' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+'N Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface" �� p xv, _
-Top of casing terminated aUor below land sudace,may require Q •W G
a variance in accordance with 1SA NCAC 2C.0118, SIGNA URE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f_ DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
41
FormOW-1a
;y Rev.209

RESIDENTIAL WELL CONSTRUCTION RECORD I
` E
� North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 31
g. WATER ZONES(depth): Bottom
1.WELL CONTRA�jTOR: c Top Bottom Top;
�cSh `'�'� J
Tap Bottom Bottom
Well Contractor(Individual)Name top Bottom Top Bolton
DO I � Y'a Top
Thickness)
ell ntreJ or omp N Diameter Weight Material
} )A I : 7. CASING: Depth
Stretet ddress 1 I Top Bottom Ft
r 1 ��ss Top Bottom Ft-
Cy ��� ( State Zip Code Top Bottom Ft.
(n?--(,r1�,t ILLI Method
Gy-- 3. GROUT: Depth � ������'� Material L
Area code Phone number Bottom `.tt n ii Ft (-1
To
2.WELL INFORMATION: 1 Top Bottom Ft.
WELL CONSTRUCTION PERMIT# � ,l Top BOttcm Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID ft(t appllcable) : 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft- n. _ in.
3.WELL USE(Check ApplicableBox): Residential Water SupPly❑ Top Bottom Ft. in. — in.
DATE DRILLED=/�3 Top Bottom FL in. __ in,
TIME COMPLETED� AMP PM11
1a.SANDJGRAVEL PACK: Size Material
4.WELL LOC
A
T
ION: ` } ��j)����r� Depth
CIT1(' 11 l�Ul I I COUNTY—�,1iLL L)b� Top Bollom Ft.
'Top Bottom Ft.
SAC' _ t`t1 US Ft.
(Street Name,Numbers,Communny.Subdrv�sbn,Lot No.,Parcel.Zip Cod ) 'Tap Bottom
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11.DRILLING LOG
Formation Description
❑Slope OValley OFlat ❑Ridge ❑Other Top Bottom
LATITUDE A3j- 3�-5MN"DMS OR 3X.XXXXXXXXX DD
LONGITUDE 7Ar °� ' �4�� ^DMS OR 7X.XXXXXXXXX DD
Latitudeilongitude source: ❑GPS DrOpographic map
(location of well must be shown on a USGS ropo map andaltached to /
this form if not using GPS) DI
S.WELL OWNER �niVerii�ty pF ivit'1-h Cal1°lirtirtl U�
Fcc+fn 4 „�rah /
Owner Name /
303 phlll( Ins 111 CAD
Street Address
City or Town State Zip Code /
�—)
Area code .Phone number : 12. REMARKS:
6.WELL DETAILS: 4W—
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,W ELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: Ff. STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'+^'rf Above TOP of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated atlor below land surfaca,may require SIGNATURE OF CERTIFIED WELL'CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.011B.
e. YIELD(GPM): METHOD OF TEST
L DISINFECTION:Type 00Amoun1t-1 ,
PRINTED NAME OF PERSON CONSTRUCZING THE WELL
0m �Mf
FormGW-la
Rev.2109

d.SFArEQ,
a �AA
RL+"gIDENTIAL WELL CONSTRUCTION RECORD
g North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
�T3
L TOR: g. WATER ZONES(depth):
1. CON
Botom
Top 8olrom
Top Bottm Top Bottm
Well Contracto aN Bottom
Z ma Top Bottom Top
1 Ic.
Thickness!
( all Antra JGor Company Name Diameter Weight Material
7. CASING: Depth
Street dress ^r'� � (( Top Bottom FL
Top Bottom FL
' __T —���1---- State 2p Code Top Bottom FL
'7y Vs' Material Method
Area code Phone number T GROUT. Depth ���''yy �
Bottom yrr A 11 Ftl'�- '(
2.WELL INFORMATION: lop
Top Bottom Ft.
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if appicable)
SITE WELL ID#(rt applicable) 9. SCREEN: Depth Diameter Slot Size Material
PPS' Top Bottom Ft--in- — in.
3.WELL USE(Check Applicable Box)- Residential Water Su Top Bottom Ft._in. _ in.
DATE DRILLED Y (' Top Bottom FL--in. in.
TIME COMPLETED AM 17 PM
10.SANDfGRAVEL PACK: Size Material
4.ALL LOCAATIOON\:/ n Depth
CITY' �1, it �/l -� COUNTYl,..4t—L1 Top Bottom Ft
lop Boaom Ft
Ft
(Street Name,Numbers,Community.Sub?rvrsan,Lot No„Parcel,Zip Coda) -!op Bollom
TOPOGRAPHIC/LAND SETTING: (check appropdm box) 11.DRILLING LOG
❑Slope ❑Valley OFlat ❑Ridge ❑Other Top Bottom Formation Description
3�� `J�o)S�"DMS OR 3X.XXXXXXXXX DD :
LATITUDE °_ a-n S _ d-- 1Y �'
LONGITUDE 7''g �"3f- i014k "DMS OR 7X.XXXXXXXXX DD .�—�—�y--
Latimde/longftudesource: 02PS Oropogmphicmap r / iba (�LremI, LC'
(loca#on of welt must be shown on a USGS topo map andattached to t- -l— —
this form if not using GPS) rL . -><< PAV6,)>i / v
S.WELL OWNERu unlverbt+ N"r '(t /
`ut�n 4- f�r�n�mAtLY�.S i
Owner Name " ���) , �� /
so Ph% i� /
Street Address
)\ks,ug\AIle h1C o24S�S1) /
City or Town State ZIP Code /
(--)
Area code Phone number : 12. REMARKS:
6.WELL DETAXS: I '
a. TOTAL DEPTH'
b. DOES WELL REPLACE EXISTING WELL? YES O NO❑ : 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use's'if Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface"
"Top of casing terminated atior below land surface,may require
a variance in accordance with 15A NCAC 2C.D118. SI NA RE OF CERTIFIED WELL CONTRACTOR DATE
e_ YIELD(gpm):i—METHOD OF TEST
f_ DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRU�C NG THE WELL
a - Form GWAa
Rev.2109

TION RECORD
..� D
�ESIDENTIEIL WELL CONSTRUC
5
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:, g. WATER ZONES(depth): Top Bottom
Top Bottom
pS(1 (�I. fn YIDn 5 Bottom Top Bottom
Well Contractor Qndividual)Name Top
!`t ,n.t^. ., 1� °, n 9 1 V YA Top Bottom
Top_ Bottom
—
[)VI `+ I
Thicknessl
�)yVell 99nnactor Company Name T. CASING: Depth Diameter Weight Malarial
fop Bottom Ft.—
Street Top Bottum Ft
(01ity�xorT /} State Zip Code : Top Bottom Ft.
(!1 P�i l) 8. GROUT: Depth
� �rr''y`i�'� Materiel Method
Area code Phone number BbttOm `ttA 11 FLL� '(
Top ._
2.WELL INFORMATION: Bottom Ft.
WELL CONSTRUCTION PERMIT# : Top
Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if appicable) Materiel
SITE WELL ID#Td applicable) 9. SCREEN: Depth Diameter Sbt Size
Top Bottom Ft. It. _ in.
3.WELL USE(Check Applicable Box): Residential Water SuPPIY❑ Top Strom Ft. in. _ In.
DATE DRILLED �� D 1 ToP Bottom Ft�jn. in.
TIME COMPLETED AMO PMD
Ia.SAND/GRAVEL PACK: Size
Materiel
4.WELL LOCATION: + „�/����� h�. Depth
Cl 1'(1�PV/i1����l� COUNTYEW]L.111-.1ob� , Top Bottom Ft.
U.T-1 1 l� Tap Bottom FL
� ( Ft
(Street Name.Numbers.COmman .Sut>dwsxm,Lot No.,PareBl,ZIP Code) 'fop Bottom
TOPOGRAPHIC/LAND SETTING: (check aPPropnate box) 11.DRILLING LOG
p Slope ❑Valley ❑Flat ❑Ridge pOUter Top
Bottom Formation Description
LATITUDE Y]YYr9���33���'���,3U- 5l iSN-DMS OR 3X.XXXXXXXXX DD
LONGITUDE Te 3 1p1* -DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS []Topographic map , _
(location of avail must be show on a USGS topo map andattached to )
this torn if not using GPS) k,;y I ) U(�(� 11 _------
s.WELL otaNER Unwe.r'5ity gF' �' }4� CC,drtalitCt
RI+IrM[°1(P 4 i nn M hMS
Owner Name t,
3U3 nht hips ,
Street Address I
LLWhIle 1� I / r
City or Town State 2tP Code
Area code .Phone number 12. REMARKS:
S.WELL DETAILS: ' 1r
a. TOTAL DEPTH: 41)
b, DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED g4
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: —FT STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use's'H Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' _�
'Top of casing terminated ayor below land surface.may require 9A/Vl {. DATE
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR
e. YIELD(gpm): METHOD OF TEST
f_ DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Now; Rev.2108
.>� rt
A ._ ..

y�
St
RESIDENTIAL WELL coxsTRucTlox REcoen
North Carolina Department of Environment and Natural Res0mces-Division of Water Quality
W �31�3
WELL CONTRACTOR CERTWICATION#
g. WATER ZONES(depth): Bouom
T Bottom TOP
r!rTh a Top Bottom
{ Top Bottom
Well Contractor(IM}i�ri-dual)Name ( �` 1' ) \!� Top Bottom Top Bolton
c� P n V/Vt)r i 1 k- 1 � )�.�—•---rr TLlcimeaW
���ell VIA
C ntractor Company Name Diameter Weight Material
l�x J� 'I I 7. CASING: Depth
cirm"s _ Bottom Ft
1Sr<}t �i � S — top Bottom Ft
C or T State 2tp Coda Top Bottom Ft.
X a 2] I Method
^�` q. GROUT: Depth t y� Material L
Area code Phone number Bottom^A l Ft .#Fl)C�V�I:A�(l '(
Tap„ _
2.WELL INFORMATION: Bottom Ft
WELL CONSTRUCTION PERMIT# I t I-�1 iop
Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if ap)licable) Diameter Stet Size Matadal
SITE WELL ID#(rf appileahle) 9. SCREEN: Depth
iop
Bosom Ft. in. _ in.
3.WELL USE(Chen Applicable Boil):. Residential Water SuPPN Bottom Ft. in. _— in.
Top­DATE DRILLED Top Bottom FL In ---- in
TIME COMPLETED_-- AM G PM❑
1fl.SANDIGRAVEL PACK: Size Material
4.ALL LOCATION: ��// ���``�� Depth
CITY.�c,' ��11�U1 41� COUNTYJS�Llu�'�C Top Bottom Fi.
Top Bottom Ft
i A 1 U C7 n,Lot No.,Panel,21p Code)
Top Bottom Ft
(Street Name,Numbers,Communky,, — tsw
TOPOGRAPHIC/LAND SETTING: (dwk appr000ts box) 11. DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge�``❑Other_---- Top
Bottom Formation Description
LATRUDE °�' T1 "I DMS OR 3X.XXXXXXXXx DD : I Git_CE.CI l �_ I-
LONGITUDE, .34 .10400 -DMS OR 7X.XxXXXXX)dt DO .— ---��-Y-- �—
Latitude/longitude source: 133PS [(Topographic map
(location of well must be shown on a USGS mpo map ands#ached to =��
this formrf not using GPS) y) t 1(7( /11r'R Gil
S.WELL OWNER
1lnlveY5lt� off +�h YclifY:i ( fie /
-
F.ti
Owner Name
�U3 phtll(� I
Street Address ^CI I /
l��tm\rt le Kul( X`1 t)�
City or Town State Zip Code I
I
(--)
Area code .Phone number : 12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 4 '
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ j DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 1 SA NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing:,._._----FT. STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'+•it Above Top of Casing) pR VIDED TO THE
1WELL OWNER
d. TOP OF CASING IS FT.Above Land Surface' q,
.Top of casing terminated allot below land surface,maY require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 1SA NCAC 2C.0118,
e. YIELD(gpm): _METHOD OF TEST
f_ DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRU SNG THE WELL
... . „„ .., -. .�. .. :. Form GVtl-1a
Rev.2M9
e

01ATION RECORD
NorthCarolina Department of Environment and Natural ResourcesDivision of Wa[er Quality
WELL CONTRACTOR CERTIFICATION#
g. WATER ZONES(depth):
1.WE1L C NTRACTe Bottom Top Bottom
T
Top Bottom
-
Well Top Bottom
Well Contractor(IrMusl)Name Bottum
-
Top—/�t . �� .�. i la.l� iV•� A A �Y ' 1' ) 1 I Top T°P
ay Thickness/
)Nretl ntraetor Company Name Diameter Weight Material
� - 7. CASING: Depth
1'�V VIA J n AL T Bottom FL_
street dares °p
-�;� r-; ) Top Bottom Ft. --
(,City-,�orT Stale Zip Code : Top Bottom Ft.
a. GROUT: Depth Material ,1 Method
Area code Phone number _ Bottom_LM Ft.
�l
2.WELL INFORMATION: Top
Top Bottom Ft.
W ELL CONSTRUCTION PERMIT# NCI E� T.OP Bottom FL
OTHER ASSOCIATED PERMIT#(if appkAble) Diameter Slot Size Materai
SITE WELL ID#(if applleaNe) 4. SCREEN: Depth
1'op
Botom Fla in. in.
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.---mn. — in.
DATE GRILLED "c� o Top Bottom FL_in. — �n'
TIME COMPLETED AM Cl PM[:'
16.SAND/GRAVEL PACK: Slza Material
4.ALL LOCATION: I ,� Depth
ClT1f r1--11 IPV I � I e r C.OUNTY (l( rdllh ., T°p Bottom Ft.
Top Bottom Ft
Pl 1 A.� FL
(Street m
eet Name.Numbers.Comon .Suhdlvimn,Lot No.,Parcel,Zlp Code) Top Bottom
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 91.DRILLING LOG
❑Slope ❑Valiey ❑Flat ❑Ridge OOther Top Bottom Formation Description
LATITUDE 3s°3e .51S"GN -OMS OR 3X.)O=XXXXX DO
LONGITUDE "'3 y' i .DMS OR 7x.xXXXX)O=DO Latitude/longitude source: EPPS Elropographic map r era }r f P
(location of mall must be shown on a USGS topo map andatfached toy—��'—'
this form if not using GPS)
S.WELL OWNER univet 6;ty QF NtXA-h
Owner Name " 1 '!��
-303 phmlpI s —� 'I—T f
Street Address ;(�, 'as�I )4
City or Town Slate Zip Code /
(—)
Area code Phone number 12. REMARKS:
S.WELL DETAILS: I 'rtam�
a. TOTAL DEPTH: 4V
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ (DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use*4'H Above Top of Casing) PROVIDED TO THE L7OWNER.
d. TOP OF CASING IS Ff.Above Land Surface' �,l/(,L`�
'Top of casing terminated at/or below land surfaoe,may require ,,,!!✓VV✓" ���...
a variance in accordance with 15A NCAC 2C.0118. SIG UHL OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):, ,METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
e` 40 Form GW-ta
Rev.2/09

RESjDElYTjAL WELL CONSTRUCTION RECORD
y . North Carolina Department of Environment and Natural Resources-Division of Water Quality
LA
WELL CONTRACTOR CERTIFICATION It
g. WATER ZONES(depth): Bottom
—
Top_WELL C0 RACTOR: : Top_
op Bottom_ Top
Y\ fop Bottom Top Bottom
Well Contractor(Individual)Name p Bottom
1 D O f/ti)n y- I' W ] � ll �V1 , 4 Y;+ Top Bottom ToP
7ldcknessl
ell C9 ntractor company Name Diameter weight Material
X
() \ ( - � �-1 : T. CASING: Depth
l t. 1 /dress ' �'1G I Top—Bottom Ft.
1 `Snkt94YlY-� Top Bottom FL
'T Sty Zp woe Bottom Ft.
City or : Top
1.1J r, t[)� �`Y1 a. GR+OUT: Depth Material Method
Area code Phone number Tcp_-7---Bottom t l ry'� Ft /�((�7,(7 I ,l
2.WELL INFORMATION: BotMrrk � j
WELL CONSTRUCTION PERMIT# iop
Top_Bottom Ft.
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID,#(ifapplleable) 9. SCREEN: Depth Diameter 31ot Size material
Top_Bottom Ft_m. _._ in.
3.WELL USE(Check Applicable Box): Residential Water Supply❑
I�1 Toopp
Bottum Ft._in. in.
DATE DRILLED�' �/�" cop__Bottom FL in. is
TIME COMPLETED
AM❑ PM❑
10.SAND/GRAVEL PACK: Size Material
L ALL1�LOCATIONt ` ¢�/�r���i Tx Depth
CITY f�SYIP V 1 i I td r� `C.OUNTY.�A 1 t[..�t�'�c' Top---Bottom Ft ----
a ' ' a Cl� t J U J Top Bottom Ft.
r FL
(Street Name,Numbers, m
ComunV,Subdwsan,Lot No.,perm].Zip Code) Top Bottom
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11.DRILLING LOG
❑Slope oVal� �ley ❑�Flat ❑Ridge ❑Other Top Bottom Formation Description
LATITUDE - d�° ' 011 N •DMS OR 3X.)()=XXXXX DO
LONGITUDE 7,6 �°3`f D(T��•DMS OR 7X.XXXXXXXXX DD
_ _
r
Latitudellongf ude source: ❑GPS Qropogmphic map +
(location of well must be a~on a USGS topo map andattached to
this form if not using GPS) 11
s.WELLOWNER urwverolty
r
Owner Name
Street Address
) City
or Town�l State Zip Code ( .
(
Area code Phone number : 12. REMARKS:
S.WELL DETALLS: I 1
a. TOTAL DEPTH: 40
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: Fr. ACCORDANCE WITH 15A NCAC 2C,: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Usee Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 15 FT.Above Land Surface' —nn
Top of casing terminated aHor below land surfaee,may require
a variance in accordance with 1 SA NCAC 2C.0118. SIGNATURE OF CERTIFIED W ELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
A
Rev.2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIk7CATION#
CONTRA OR: 9- WATER ZONES(depth):
'Fop Bottom Top Bottom____
Well Contractor(Individual)Name AA II I ���///11)''' Top Bottom Tap Bottom _
C1_� t A A� �X �w � Top Bottom Top Bottom_ _
�) \11 nirector Company Name Thickness)
7. CASING: Depth Diameter Weight Material
St�reet dress l� Top Bottom Ft
�n i {,.4�� '\, I t���43 Top Bottom Ft
Cl
ly or Tom— 1 State Ztp Code
(;>1'L) + as Top Bottom Ft.
(Arrea—cod)e Phhcrie number 8. GROUT' Depth Material ,i Methock
2.WELL INFORMATION: �` Top _Bottom Ft. ) .� 'Y �k.( YJ
WELL CONSTRUCTION PERMIT# 'ICJ F(il�^AJI"\� : Top Bottom Ft ("4f'1'.Cal'C)
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(d appllrahle) 9. SCREEN: Depth Diameter Slot Site Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom FL in. _ in.
DATE DRILLED�L lop Bottom FL_in. _ In.
TIME COMPLETED AM El PM lop_Bottom Ft�in. _ In.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY It, n�y i/'+ ,�Pn p COUNTY_;_ 111"1(�a� )bi, Top BBooaom Ft Size MAeAei
Top Bottom Ft
(Street Name.Numbers.Common ,Subdivision.Lot No..Parcel.Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (Glick appropriate box)
[]Slope DValley OFlat ❑Ridge pottier 11.DRILLING LOG
f, Top Bottom Formation Descdpticn
LATITUDE a3v"155N^DMS OR 3X.XXXXXX)=DO ,
LONGITUDE2!�S&"jI" L19- "DMS OR 7X.)D=X)O=DD rCenl `k- yy-
Latitude/Iongi ude source: BPS Qfopographic map
00caWn of wet/must be shown on a USGS topo map andaftached to `x(-1 --X0a L rry i CC
this form if not uslrig GPS)
S.WELL OWNER llniVEr51}t( QF N"a" Cwolitl(~' PA)Wii / UL?l� nrn rl V,
Owner Name
30 S Ph, hip HaAl &D 14ao ,
Street Address ,
kgym ue m( as,<61-A ,
�r—li. i_t-41-P
City or Town State Zip Code ,
Area code Phone number
6.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE W 'OWNER.
d. TOP OF CASING IS FT.Above Land Surface"
"Top of rasing terminated at/or below land surface,may require L(}/1—v\ (�(/ )'>✓'
e variance in acmrdance with ISA NCAC 2C.D118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
�b 4� Form GW-la
'sF Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4� 371
1.WELL CONTRACTOR. C g. WATER ZONES(depth):
� � Y�Cf�1tr ��1J Top Bottom Top Bottom
Wail Contractor(Individual)Name
/ Top Bottom Top Bottom
i�I(1 ")AnI r WJ I ADU Top Bottom Top Bottom
yyeit Vpntractor company Name i
Ik{x 1p i Thickness/
A 1 T. CASING: Depth Diameter Weight Material
�I1� Street Ndre,, (�1 To Bottom Ft.
Ft.
(
`J` 1 A143 TOP Bottom Ft.
CI or T
State Zip Code Top Bottom,_Ft.
Area code Phone number 1 0. GROUT: Depth Material Method
2.WELL INFORMATION: Top�_Bottom
WELL CONSTRUCTION PERMIT# N"J F t)I t) / Q Top Bottom Ft. T
OTHER ASSOCIATED PERMIT#(If,ppliable) Top Bottom Ft.
SITE WELL ID#(r applicable) a. SCREEN: Depth Diameter Slot Sire Metal
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. in.
DATE DRILLED q Q._S- ,)- : Top Bottom Ft._in. _ in.
TIME COMPLETED AMD PM Top__Bottom Ft�m. _ in.
4.ALL LOCATION: 10.SANDIGRAVEL PACK:
aTY` tr�tr�'�PV(S[(�' ce g COUNTY_;_ unccr' )bit Top Bo Depth Ft. size Material
l`M 1 l�u� Top Bottom Ft
(Street Name,Numbers,CammunN,Sut>a vision,lot No.,Parcel,ZIP Code) Top Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge 00ther 11.DRILLING LOG
LATITUDE , [9u`jf�J Top Bottom Formation Description
p DMS OR 3_,),,.X.DD /
LONGITUDE 9 dl ' '�)Q 7 k'^DMS OR 7X.XXXXX)D= DO
Latitudenongitude source: DaPS Orepographic map / `)
(location of well must be shown on a USGS topo map andatlached to r." l _ P reel l CC
this form if not using GPSI
6.WELLOWNt7t Univer.5i}� uF Iva't-h C rutIr-c, AMxa11 lei- �I U[�L^ nrn I -t ,
F;�ern 4 Ck�or�pitxl� i
Owner Name
1 1`4A)
Street Adtlrass /
City or Town State Zip Code /
Area code) Phone number /
6.WELL DETAILS: 12. REMARKS:
a, TOTAL DEPTH: 400
.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'a"rf Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE 0.L OWNER.
d. TOP OF CASING IS FT.Above Land Surface' //
*TOP of rasing terminated atfor below land surface,may require aa4- `
e variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(9pm):,� METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
• Rev.2109
W v _act

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
z
WELL CONTRACTOR CERTIFICATION#
I.WELL CONTRAC R: g. WATER ZONES(depth):
�1 'cfyY�cl& ) Top Bottom Top Bottom
Well Contractor(individual)Name
R y ` �) �— TOP Bottom Top Bottom
��XrV�)(' �`�a- � P 9 a Vl � i ya : Top Bottom Top Bottom
(( ell�Jpntractor Company Name
l) ` k x iX I : 7. CASING: Depth Diameter Thickness/
Weight Material
�St�re}et dress {� �(. Bottom_Ft.
"'-"—'• `�� { LS `� , �� `'. Top Bottom Ft.
Ct or T Slate Zip Code P
Top Bottom Ft.
(Area ;code Phonenumber a( : 8. GROUT: Depth Metelial Meth
2.WELL INFORMATION: Top_ Bottom-�M Ft. t L
WELL CONSTRUCTION PERMIT# ��� F�� ri J I"1�` Top Bottom Ft
OTHER ASSOCIATED PERMIT#(fappicebie) TOP Bollom Ft
SITE WELL ID#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom FL_in. _ in.
DATE DRILLED L�oc�0��- : Top Bottom Ft. In.
TIME COMPLETED AM PM O Top Bottom Ft in. _ in.
0.WELL LOCATION: 10.SAND/GRAVEL PACK
Cl
t� \ '�j(��/(/I{ f�('^t'� COUNTYLJJ hid, Top BONom Ft. Size Material
1 17{�� : Top Bottom Ft
(Street Name,Numbers,Common ,SubdlWsion,Lot No.,Parcel,Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
DSIOpe DValley OFlat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 'a.�ti(p' (�a�� Top Bottom Formation Description
p 344
_'( DMS OR 3X.)O=XXXXX DD /
LONGITUDE 7SO a2 °�'I• 4-74A k DMS OR 7X.XXXXXXXXX OD _I/ C ) ay otni
Latitude/longitude source: BPS []Topographic map
(location OfWel/must be shown on a USGS topo map andattached to
this form if not using GPS)
S.WELLOWNER llntver ,}y qF Nixi-1'� C'iYt;tir-C� l ,t � ul�L: r�r<z t1I �P�
Owner Name
_90-) P ), 1i(PS POA
Street Address /
� LY UI I IP_ WE Zd- SO4 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS;
6.WELL DETAILS. �^
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1 SA NCAC 2C,WELL CONSTRUCTION
(Use-4-if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface
"Top of casing term led aVor bel iow land surface,mey requis re
a variance in acdordance with ISA NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpn): `METHOD OF TEST
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
A
a '
Form GW-1a
Rev.2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
y` North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTMCA77ON# L} � f7]— J-)i-
1.WELL CONTRACTOR g. WATER ZONES(depth):
Top Bottom Top eotom
/�wait Contactor(Individual)Name
t A Y t� to )n ri Q A �I I i far ToP Bottom Top Bottom
Lyat]C ntractor Company Name Top Bottom Top Bottom _�ttNJ� jp�, �t
4 k 1 i Thickness/
Sheet dress T. CASING: Depth Diameter Weight Material
City
10 5 r� R N Fop Bottom FL
Cityor i '\ l State Zip Code Top Bottom Ft
Top Bottom Ft
Area code Phone number 8. GROUT: Depth Material Met
hOq
2.WELL INFORMATION: _ TOpj Bottom Ft. CICl
WELL CONSTRUCTION PERMIT# � � nC op
Bottom Ft,
OTHER ASSOCIATED PERMIT#(If 1pglcabie) Top Bottom Ft.
SITE WELL ID#(rfappllrable)
9. SCREEN: Depth Diameter Slot Size Materiel
3.WELL USE(Check Applirabb Box): Residential Water Supply(I Top__Bottom FL in. _ in.
DATE DRILLED 4 'gc) Top___Bottom Ft. in. _ in.
TIME COMPLETED AM PM El Top_ Bottom___FL In. In.
4'WELL LOCATION: 10.SAND/GRAVEL PACK:
e COUNTY Ih j, Depth Fop Bottom Ff. Sms Kate"
Top Bottom Ft
(Sheet Name,Numbers,commur tr,Subdivision.Lot No.,Parcel Zip Code) TOP Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
LATITUDE Bott-8,j�¢ 'C(G I fv •DMS OR $X.)O=XXXXx DD Fop / Om Formation Description
LONGITUDE.t`S_d-3'f' i l IQ "DMS OR 7X.XXXXXXXXX DUD
Latitude/longtude source; (SPS Qfopogaphic map _
(location of weft must be shown on a USGS topo map andattached to t2 / .boa _[�y_'p�/t(e
this form rf not using GPS)
S.WELL OWNER ver,5t}y pF NLX+h Ctbrulu'Cr f,`11bo)
Owner Name /
�0 S HUAI t Pry 4t D
Street Address
Cry or Town State Zip Code
Area coda) Phone number
6.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH: 40D
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
a WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(use-4-If Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS PROVIDED TO THE WELL OWNER.
FT.Above Land Surface'
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): i/i METHOD OF TEST
f. DISINFECTION:Type__ _ Amount_ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Mall '
?R 3p�days of^ f Water Quality- imam a#o�Procgys(
1&17 Nrall Sen+tco Canter, R. t- Form GW-la
g qne807-f3l)0 Rev.2/09

S RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WATER ZONES(depth):
�1�i SI'1 � 1YY -Y15 Top Bottom Top Bottom
(/�We�ll�C�ontyra�ct�or�((I1n�diviipdual)Name p Q ' n'n Top Bottom Tap Bottom
A- tl 4�ILI' Top Bottom Top Bottom
L'�N`ell I�ono-a ydor Company Name
K � Thickness/
` ,Street dress 7. CASING: Depth Diameter Weight Material
n 10 f Top Bottom Ft-_
JT 1\ l �F' : Top Bottom Ft._-__ _
State Zip Code
�� , '"� rl 41
Top Bottom Ft---
CM
Area code Phony number oS R. GROUT: Depth Material Method
2.WELL INFORMATION: /� Topj_Bottom J
FL t5C�1
WELL CONSTRUCTION PERMITtF � � I D I(�C)1�1� Top Bottom rL
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(dapplirable) : a. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. _ In.
DATE DRILLED_ Top Bottom Ft._In. In.
TIME COMPLETED AM 0 PM 0 Top Bottom Ft__In. _ in.
4.ALLjLLOCC`A-T�InO`N:' ` � � 10.SAMD0RAVEL PACK
CITYL1_7I�1. )1N� V 111nP� tcCOUNTY_ 11 Y11�r7/'(�bi, .ra, °aI'tl' FL St:e Material
1�� AJ : Top Bottom Ft
(Sheet Name,Numbers,Communay,Sub*wsion,Lot No..Parsal,Zrp Code) : TOP-Bottom FL
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Sicpe ❑Valley ❑❑Flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE ,sd 0'3('C'q 5 v ^DMS OR 3X.XXXX%um DD Top Bottom Formation Description
LONGITUDE I�G'(•+% °DMS OR 7X.XX JMM(X DD , I_/ - �i )" I �- t7(
Latihidell ongdtrde source: BPS Qfopograph)e map
(location of well must be shown On a USGS topo map andattached to tx)o o re-y i c P
MIS form if not usiv
OPS) .
S.WELL OWNER UnIVt°Y0i}ll ((UF "NiA'1h �rLl1fYti 1lf (IV-t-7 11 V
Owner Name r 1 P d r .
, y- t �w ra bmn J
;S1C�� ph. Ili�S 1�11 , VAC 14�,G �
S<t�re��et qAdtlress /
Cdy or Town State Zip Code
) /
Area Dods Phone number -
6.WELL DETAILS: �^ 12. REMARKS:
a. TOTAL DEPTH: 4 %(
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ +
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: Ff. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+-if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TP THEW L OWNER,
d. TOP OF CASING IS FT.Above Land Surface`
"Top of casing term)nated at/or below land surface.mey require
a vanance in accordanee with 1SA NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sub� z
Form GW-la
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
its
?� North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELLCONTRACT g. WATER ZONES(depth):
��SYILQ-p"Y-�Y'�1pt1 Top---Bottom Top Bottom
Well Contractor(Individual)Name
� OAA1 I �/ Top—_—Bottom Top Bottom
.LC l�).Q�JL_I__]_�J Top_ Bottom TOP Bottom
ell mraetor company —
Thickness!
S treet`dress 7. CASING: Depth Diameter Weight Material fffjjjtltltl
1 ��4 Top Bottom FL
-
,Mr
T )I / 1\ '� TOP Bottom Ft.
State Zip Code
�t f I Top Bottan Ft.
Area code Phone number `Y 8. GROUT: Depth Material Met
2.WELL INFORMATION: /��1 Top _Bottom Ft. il.�
WELL CONSTRUCTION PERMIT# )�j F CL L QCi�` C Top Bottom Ft
OTHER ASSOCIATED PERMIT#(Ifappiimbia) Top Bottom Ft.
—
SITE WELL ID#(ifapplicable)
a. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.—In. in.
DATE DRILLED_ SZ2 /�- : Top Bottom Ft.—In. in.
TIME COMPLETED AM Ej PM TOP__Bottom Ft—in. — in.
4.WELL LOCATION: - ; 10_SAND/GRAVEL PACK:
CI � � � � {gyp Depth Size Material
'T�.� �(�'n (1 COUNTY 1 JV Top Bottom Ft.
Top. Bottom Ft
(street Name.Numbers.Community,Sub&islon,Lot No.,Parcel,Zip Code) TOP Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope OValley OHM ❑/R}idger�❑�Other : 11.DRILLING LOG
LATITUDE XjS- (OL—1 .DMs 3 x.xxx xxxxx Do
Top / Bottom Formation Description
txt x
LONGITUDE MS,2 DMS OR 7x,xXXXXXXXx DD �_/ C G\t`Cc(l I Z- i V
LatitudellongRudesource: BPS Qfopogmphiemap /
(location of well must be shovm on a USGS topo map ands#ached 10 (_P
this form if not using GPS)
5.WELL OWNER 91F
I—i4OC'1('� r� 1 tfX15 J
Owner Name
�o S fShilll S it L� 14&
street Address /
-AsfyU1Ile U`
City or Town ' State Zip Code /
Area code Phone number
6.WELL DETAILS: 1 12. REMARKS;
4�^
a. TOTAL DEPTH: 0
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+•t Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS PROVIDED TO THE WELL OWNER.
FT.Above Land Surface- ���
"Top of rasing terminated atlor below land surface,ma require
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
53
Form GW-la
_. Rev.2109

aRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTMICATION# I l
7. L CONTRACT g_ WATER ZONES(depth):
Top Bottom Top Bottom
/ q ry �'� Top Bottom Top Bottom
Well Contractor(Individual)Name
1 ���n')C�r�Y Name1� A A Dyi l h [4) Top Bottom Top Botto11 m
- Thickness/
7. CASING: Depth Diameter Weight Material
strel7et dress ^ rTop Bottom-Ft-
��C]��(rT. State Zip Code Top Bottom Ft.
: Top Botom Ft.
Area ale Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top _Bottom .L Ft rl t1
WELL CONSTRUCTION PERMIT# V (' I )t JI�� Top Bottom Ft
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL IDfappllrabie) 0. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ 1'op Bottom FL_in. _ In.
DATE DRILLED 1 : Top Bottom Ft._in. _ In.
TIME COMPLETED AMO PMD Top Bottom Ft_m. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY. Depth Size Material
I�\I,/ �/� Top Bottom Ft.
�_A 1 A� 1 ' �� : TOP Bottom Ft
(Sheet Name,Numbers,Comonm ,Subd Im".Lot No.,Parcel,Zip Code) Top Botom Ft
TOPOGRAPHIC/LAND SETTING: (dwk appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Omer 11.DRILLING LOG
LATITUDE DMS OR 3X.XXXXXXXXX DD
35°?10,1�6StJ ° Top / Bottom Formation Description
LONGITUDE 7,5 3A-3 ' ,(a-7 t.J •DMS OR 7X.XXXXXX)=DID t oLnI 1 V
Latitude/longitude source: pGPS ❑(opographic map f
(location of well must be shown on a USGS topo map andeBached to G.2Yil � (I rev i C e-
this torn if not using GPS)
S.WELL OWNER 1 lniver5l}4 uF Iv xFh C'1 YDlifY, l xyal j�L 1�r(II�1 i'
Owner Name '
street adnress !
Cityor Town State Zip Code
Area code) Phooe number J
S.WELL DETAILS; 1 - 12. REMARKS:
a. TOTAL DEPTH: 4
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+•if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS Above Land Surface*
'Tdp of casing terminated aVor beloww land surfece,rnay require
a variarx)e in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
_ �11
Form GW-1a

U4.
DRESIDE'NTIALLWELL CON TRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 41 31— IN
I.WELL CONTRACTOR: 9. WATER ZONES(depth):
Top Bottom Top Bottom__
Well Contredor(individual)Name Top Bottom Top Bottom
�_3'V�)('I 11 r WJ P 1 A Vl i v'
.ell ntractQor Company Name Top Bottom Top Bottom
f ll� I I Thickness/
S treet dress 7. CASING: Depth Diameter Weight Material
�n ) ^ V' Top Bottom Ft.
C, or i I/ '\ State Zip Code Top Bottom Ft.
Top Bottom FL
Area Code Phone nurriber - A. GROUT: Depth Material
d Method
2.WELL INFORMATION: ToPj_Bottom Clt 1 )Ft. 1 + T b(1_I
WELL CONSTRUCTION PERMIT#_ Y\J Top Bottom Ft
OTHER ASSOCIATED PERMIT#(UaPpicable) Top Bottom Ft.
SITE WELL ID#(d applimi L)
9. SCREEN: Depth Diameter riot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. _ in.
DATE DRILLED- / \ Top Bottom Ft._in. _ in.
TIME COMPLETED AM PM Top Bottom Ft.—in. _ in.
4.WELL LOCATION: - 10.SANDIGRAVEL PACK:
C(TY ` y) ` I(' COUNTY__ 11���F'N��Z ,i, Depth Sine Material
Top--—Bottom Ff.
Top Bottom Ft.
(SCaet Nertre,Numbers,Communay,Su6tl'ivision,Lot No.,Peroel,ZIP Code) Top Bdtldm FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑SIOpe ❑Valley DFlat ❑Ridge pother 11.DRILLING LOG
LATITUDE T,�(35.3trf�4�tc l i Top Bottom Formation Description
,L DMS OR 3x.XXx c0(XXX DO : /
LONGITUDE 75`77�cZi !,3 ��(fr '-°DMS OR 7X.XXXXXXXXX DD �_( ., Gironi
Latitude/longitude source: [30pS Qfopographic map
(location of way must be shown on a USGS fopo map andatfached to ( l (GYP\I l P
this form ff not using GPS)
s.WELLOWNER UbiVerot}4 .AIL OF NcT4hCt�lCilirY � t) / (3Cldtli �E'
Owner Name
O t 4D
Street Address /
11 Y�\;1 SIP hid' 19 S116-1 q l -;
N / 1
q or Town State Zip Code
Area Code ,Phone number
6.WELL DETAILS: 400
12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use-+•if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface"
"Top of casing terminated odor below lard surfaoe may require
e varia oe in accordance with 15A NCAC 2C.0118. : SIGNATURE OF C 11FIED WELL CONTRACTOR DATE
e. YIELD(gpm): `METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2/09

K R
RESIDENTIAL wELL coNSTRucnoN RECORD
,,� North Carolina Department of Environment and Natural Resources-Division of Water Quality
°m WELL CONTRACTOR CERTIFICATION# 4� - P,
1.WELL CONTRACTOR. g. WATER ZONES(depth):- t_ Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top bottom
(➢ V�)($ 1 t- g �u{f Y _ Top Bottom Top Bottom
ell ntredor Company Name
77 Thickness/
1 I : T. CASING: Depth Diameter Weight Material
�street M dress Top Bottom FL
`�'--'-s 1•+>� �! 1 �� ` � fop Bottom Ft.
ItY9r' � 111 State Zip Coda�41
: Top Bottom FL
—
Area once Phone number R. GROUT: Depth Material Method
2.WELL INFORMATION: 7op�_Bottom—Ft. C({() j J+ �- CA.I..
WELL CONSTRUCTION PERMIT# J1"1/�q : Top Bottom Ft
OTHER ASSOCIATED PERMIT#(ifappicable) Top Bottom Ft.
SITE WELL ID#(Kapp4cgw) : 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom FL_in. in.
DATE DRILLED �f�� /.) : Top Bottom FL in. In.
TIME COMPLETED -�— AM❑ PM❑ Top Bottom Ft^in. in.
4.ALL LOCATION: 10-SAND/GRAVEL PACK:
CITYtt°1_Ir�({�h(�Pyl(l, 1��n r� C.OUNTY-lira. rl.-• � tt Ft.
Size Meferfai
Tap
,D �t Top Bottom Ft
(Street Name,Numbers,Common ,Su601visbrL Lot No.,Parcel,2lp Coda) Top Bottom ft.
TOPOGRAPHIC!LAND SETTING: (check aWopdate box)
0Slope ❑Va.l,le�ry�❑Flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 2`6`35°�G''CIS�/� ^ Top Bottom Formation Description
DMS OR 3X.XXXXXXXXX DD
LONGITUDE 16s7-°�J`I'' «Z. t'-'•DMS OR 7X.XVAXX)DO(DD I 00C) aiYca—)l ie, �- 1V
Latitude/longitude source: p3PS Qfopographie map !
(location of"I/must be shown on a USGS topo map anda#ached to { 1 X' _f -�Oa Lr rtoy l (.e
this form if not using GPS) :.
S.WELLOWNFR Univeroi4V OF N06h C/AAnAirlCi l lbdil � Ulili �Yl�111 '
Owner Name
nStreet Address—�
MC. 05AI-24
City or Town Slate Zip Code !
( --)
Area code .Phone number
12. REMARKS;
6.WELL DETAILS: ^:f'�
a. TOTAL DEPTH: 4U 14
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing; FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(use•+°if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
: PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land e
"Top of rasing tertnineted alandor below Ie surface,maySurface*
ey require
re -�
a variance in atx�brdance with 15A NCAC 2C.0118, SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gprrt):' METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-ta
,, Rev.2109
s .-.:=s ri: .' ..,

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION f/ (4 k -b l
I-WELL CONTRACTOR: g. WATER ZONES(depth):
�)��1 1 LEY SIV YlII �S Top Botom Top Bottom
/^WI ell/C'ontractor(IiWtiv-idual)Name p 1 Top—Bottom Top—Bosom _
12767�ti�)(�!1 A- Vl 1.Q A A DI( 1•nq Top Bottom Top Bottom
L y✓ellnVacWr Company Nama �^
Thickness/
7. CASING: Depth Diameter Weight Material
1 ,Street ddress l� Top Bottom FL
MC �14 Top Bottom Ft.
uJJLt.L.I � ' SUMZip Code
-1 241
Try Bottom Ft
Area code Phone number 8. GROUT: Depth `` 11 Material ,r Method
2.WELL INFORMATION: Top _Bottoms Ft. + T 5C`tl
WELL CONSTRUCTION PERMIT# ��) E(^I 11I"\q : Top Bottom FL
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
—
SITE WELL ID#(I applirahle) 9. SCREEN: Depth Diameter Not She Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom FL—in. _ in.
DATE DRILLED_S���/ Top Bottom Ft. in. in.
TIME COMPLETED AM PM O Top Bottom Ft.�in. in.
t.ALL LOCATION: 10.SAND/GRAVEL PACK:
CITY`�I�I1�Y) i e COUNTY- . UL •C'A)bIi, Depth She Material
Top__Bottom Ft
Top Bottom FL
(Street Name.Numbers.Commumly,Subdivision,LOI No..Parcel.Zip Code)
Top Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat []Ridge LlOther : 11.DRILLING LOG
LATITUDE 35-� �SD N• Top Bottom Formation Description
_ DMS OR 3X.XXXXXXXXX DD /
LONGITUDE 76S,2 6`E �-tty(,L%•DMS OR 7X.x1o(xxx)00(DD �}_/ acc at-ant
Latitude/lOngitude source: BPS Qfopographic map
(location of well must be shown on a USGS topo map andanached to (. 1 _ L Y?V'
this form if not using GPS)
5.WELL OWNER L,ntNeriji}Y 9F NiXW' (Art;I.ir1G, f 1tl?t)� �( _ �(/yll
1 cr�orNP 4 fora ha-n /
Owner Name .r /
Phillip H0,11 tCVD14au �
(Street Address /
Guy or Town State Zip Code /
Area code).Phone number
12. REMARKS:
S.WELL DETAILS: I I
a. TOTAL DEPTH: 4 J
14
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+•N Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP CASING IS Ff.Aboveland
sur Land Surface-
*Top•Top ofkt casing termated aV be
low bw lend surface,mey require L
a variance in accordance with 1SA NCAC 2C.011 B. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
L DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
S7
Form GW-1a
Rev.2109

S g RESIDENTIAL WELL CONSTRUCTION RECORD
-. North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 41 ca l - Or
t WELL-CONTRACTOR..
g- WATER ZONES(depth):
Top Bottom
1�
Top Bottom(Individual)Name Top Boom Tap Bottom W1991 Mct�
171l nctor Company Name op tton Top Bottom
/� I Thickness/
Street dYre�st-sue ^�� ` 7. CASING: Depth Diameter Weight Material
iJt It YI 7 ��(t U43 Top Baroom FL
�a.n�r i "t"-1 n State Zip Code Top Bottom Ft
LU1LilJ - lLrda - I r�{41 Top Bottom FL
Area code Phone number R. GROUT: Depth Materiel
Z WELL INFORMATION: Method
Top .Bottom Ft. "1 l:{- '+- L`J(I.(-
WELL CONSTRUCTION PERMIT# Top Bottom FL-
OTHER ASSOCIATED PERMIT#(If apiocabie) Top Bottom Ft
SITE WELL ID#(i applimbe)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft. in. _ in. _
DATE DRILLED 5/ I I/ I,)- : Tap Bottom FL_in_ _ in.
TIME COMPLETED AM❑ PM Top Bottom Ft.^ir.
" a
t.ALL�LOCATION: 10.SAND/GRAVEL PACK:
CITY�.�_r 311 /S I f COUNTY � —'OP'
Size Material
Dl ` I L Top___ Bottom Ft.
1)U J Top Bottom Ft.
tbaeat Name,Numbers,Com,=fty,SuT& ion,Lot No.,Parse],Zlp Cade) Tap Bottarll IF —
TOPOGRAPHIC f LAND SETTING: (dank appnipliat,box) - ---
❑Stope OValley ❑Flat []Ridge OOther 11.DRILLING LOG
LATITUDE �•3t�,GSq N Top / Bottom Formation Desccriptbn
11c DMs OR 3x.)o=xxxla DO
LONGITUDFlrS Ci�L•3 V l-73�% •D�OR 7x�DD �_/ C(` G�Y`Cc..f l l •1- i V
Latitudenorigitude source: BPS []Topographic map �,�p,t v� /
(location Of weU must be shown on a USGS topo map anda#aohed to yn, /� )a C rev i c e
this form if not using GPS)
S.WELLOWNER 1>hiV�r�l}Y OF Iv x++ , ClzlrclirG fYti ( / Il7<7 aYQII -£',
Owner Name F`mu•n �-
iio t I l i�� 1-}Q 11 C� D /
Street Atldress /
City or Tam Sate Zip Code /
Area code) Phone number it
S.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH: 4r)�
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(use'*'if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface•
"Top of casing terminated at/or below land surface may require ��
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(Spin):METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
:: • North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3 1 -
I-WELL-CONTRACTOR- g. WATER ZONES(depth):
--`�---1 oP Bottom TOP---Bottom
Well Contractor(IrWFdtluai)Name Top Bottom Tap Bottom
t
,(- w' 1 1 A IL•!I I I Top Bottom Top Bottom
oncompany -.)yJe11 Contractor Thickk Name I - -
ness/
7. CASING: Depth Diameter Weight Material
' 1Sheet dvr�esx-s� \/} C I 1 ' Top Bottom FG_____
��� Late fop Bottom Ft. -- --
c"CllCor T 1 �� Zip Code
2 ( ) Top Bottom Ft
Area node Phone number o(`Y R. GROUT: Depth Material Method
2.WELL INFORMATION: Top Bottom Ft. )
WELL CONSTRUCTION PERMIT# ��� Et� ��i�`�1� Top Bottom Ft
OTHER ASSOCIATED PERMIT#(tapplicable) Top Bottom Ft.
SITE WELL ID#pf applicable)
9. SCREEN: Depth Diameter Slot Sin Matadal
3.WELL USE(Check Applicable Box), Residential Water Supply❑ Top Bottom Ft. in. _ in.
DATE DRILLED f I t (I : Tap Bottom Ft—in- _ In.
TIME COMPLETED AM❑ PM❑ Top Bottom Ftin. _ in.
4.WELL LOCATION- y �� �.��.(� jy. 10.SAND/GRAVEL PACK-
COU a,—`��I-tom_ NTYLmccA b' , Depth she Malachi
Top Bottom F3.
Top Bottom Ft
(Street Name,Nkanbwr Comm SubdMWon.Lot No.,Parcel.Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: tdledt aW pr(ete box)
QSlope ❑Valley ❑Flat ❑Ridge ❑Otter 11.DRILLING LOG
LATITUDE .3S•3(P�c(SS p�1 • Top Bottom Formation Description
,�__ DMs OR 3x.xxxxxxxxx tm �
LONGfTUDF A SJL-54 - I I S'V •DMS OR 7X.XXXXXXXXX DO �_( aCC
Latdudenongtudesource: ❑SPS Qfopographiemap
(location of welt must be shown on a USGS fgDa map anda#achad to r Q_1 aoa Y'P\I t P_
this form if not using GPS)
s.WELL OWNER uhiverk5i}y QP A'Fh CAlroltrC. M)u fit,
LL lornbll -P
Flow,Irn
Owner Name
�203 Phi p
Street Address �
klyxA lte MP -QSSF)4 '
Ck Town -H or State Zip Code
Area Code Plwne number
6.WELL DETAILS; 12- REMARKS;
a. TOTAL DEPTH: 4DO
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:_FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS w l Above Land ay require
*TOP of of Casing tennhkefed eUor below land surface may require
e vac ar ce in ticcordance w��15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
s�
Form GW-ta
Rev.2/09

f S RESIDENTIAL WELL,CONSTRUCTION RECORD
.. 0 North Carolina Department of Environment and Natural Resources-Division of Water Quality
R= WELL CONTRACTOR CERTIFICATION# 3
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Y-1 Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom Top Bottom Top Bonom
ell��/p ntraelor Company Name
Thickness/
7. CASING: Depth Diameter Weight Material
�Street Mdress Top Bottom FL
Top Botto
9 m Ft.
Clly or T Code
� p Tap Bottom FL
Area code Phone number `Y 8. GROUT' Depth Material Method
2.WELL INFORMATION: Top _Bottom Ft. JAJ-� `� l`J(1�( -
W WELL CONSTRUCTION PERMIT# ��� E i ��� Top Bottom FL
OTHER ASSOCIATED)PERMIT#((appiceNe) Top Bottom FL
SITE WELL ID#(I applicable) : a. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ 1'op Bottom FLin. in.
DATE DRILLED 5�/ S l c�— : Top Bottom Ft._In. _ In.
TIME COMPLETED AM(3 PM Top Bottom Ft_in. _ in.
4.WELL LOCATION:` fry 10-SAND/GRAVEL PACK
Depth
CITE(^ ,_8C(
��('11' ev I '' If
COLINTyiAi 1�C'_C i)bii° Top Bottom Ft. Sim Material
(w f)U's Top Bottom Ft.
(Street Name,Numbms,CommurrO Subdivision,Lot No.,Parcel,Zip Cade)
Top Bottom Ft
TOPOGRAPHIC t LAND SETTING: (check appropriate box)
❑SIOpe OVatley ❑Flat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE °'310'ate l N 'DMS OR 3X.Xx)IXXXXXX DO : /
LONGffUDE { 17 F W+DMS OR 7X.X7(X)OUD00(OD J_/
Latitudellongitude source: BPS Qropegraphie map /
(location of weg must be shown on a USGS topo map andattached to L?_�(
this form Nnot using GPS) /
S.WELLOWNER UhIV2Y�51+y qf Nix+h C6kroltrlG,
F cl�ocY� 4 Dno,�rl�rimy
Owner Name
Street Atldmss
m an I le hJC.
City or Town State Zip Code
Area code Pfwne number
12. REMARKS;
6.WELL DETAILS:
a, TOTAL DEPTH: 40D
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"*'It Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 15 FT.land
su Land Surface i
•Top of casing terminated aVor below land surface.may require
a variance in Accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): ^METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
410
Form G W-1 a
Rev_2f09

�a'A°�'QNj4
r Mne.
. l0 RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4t 3-1 -A
1.WELL CONTRACTOR: l g_ WATER ZONES(depth):
Li_/S�1 1�1.f'ul�lfYlC�'Y\ S Top Bottom Top Bottom
nWell Contractor(IrM{'r—ridual)Nam (�,� Top Bottom Top Bottom
l l l()V�7O 1 >9 A- U\11 j1Y 1 l l ) ry : Top Bottom Top Bo(tom_
ell ntractor CompanyName _
-x )� I Thickness/
7. CASING: Depth Diameter Weight Material
Street drr�ess ^ / '7
'\ L �1 /� ( 5 1\�l ) { {� I�-�--, : Top Bottom FL
C orT : Top Bottom Ft.
� �k�/l� _ State Zip Code : Tap Bottom Ft
Area code Phone number� ��I R. GROUT: Depth Material Method
2.WELL INFORMATION: Top_`_Bottom Ft. �� `{- (
WELL CONSTRUCTION PERMIT# \� E(i<<�1 J�� Top Bottom Ft
OTHER ASSOCIATED PERMIT#(Nappicable) : Top Bottom Ft.
SITE WELL ID#(d applicable) 9. SCREEN: Depth Diameter SW Size Material
3.WELL USE(Check
c�AAppiicebie Box): Residential Water Supply❑ Top—Bottom Ft.�in. in.
DATE DRILLED c�// V—Z..Z : Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft—in. _ 14.
4.111 LOCATbN: 1(..,� to-SAND/GRAVEL PACK:
cITY(4.N1. o f ye t'�f t COUNTYEUM'ob�, Top Depth
tt m Ft. Sisr WaaAel
`A,`�i ( t t I )LlS Top Bottom Ft
(Street Neme,Numbere, ,SLbdivisicn,Lot No.,Parcel,ZIP Cade) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope DValley ❑Flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE XST^JO • DMS OR 3x.
Teo� Top Bottom Formation Description
_ ^ )D=X)0=DO
LONGf fUDE 7€�a' =3+t •(7Qta) •DIMS OR 7%.XX%XXX)=DO _I_ C% ` y--d l l -
Latibrde/longitude source: IGPS Olopographic map
(location of well must be shown on a USGS topo map andatfached to
this form if not using GPS) If
5.WELLOWNER UhiVerOt}y QF �lix'♦i'l (
Owner Name r
�0 ph1 ilif)'S I ) 1�}Lu �
Street address
��Ifll'U11tP 1\)C' ��sFsf J4 �
City or Town State Zip Code -
(__)
Area txxla .Phone number
6.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:
It. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use••-if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP p CASING IS w l Above Land ay require
"Top of casing terminated atbr below land surface may require
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):. _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2/09

' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources•Division of Water Quality
w WELL CONTRACTOR CERTIFICATION#
1.WELL CON QR( g. WATER ZONES(depth):
` �`STff T "�1'e Top Bottom Top Bottom
Well Contrartor(Individual)Name Top Bottom Top Bottom
Top Bottom Top Bottom
CoCpnVador Company Name �—
J X•1 k 1 I Thickness/
7. CASING: Depth Diameter Weight Material
,,Stt�re�at dress I� Top Bottom Ft.
!]i TOP Bottom Ft.
CtY�rTO n State Zip Code
r I i : Top Bottom Ft.
Area code Phahe noCumber 1 o(`i' : 6. GROUT: Depth Material ,1 Method
2.WELL INFORMATION: r� Top,t_Sottom�Ft. (+ 1- bat
WELL CONSTRUCTION PERMIT# ��) E h I�,/���` _ Top Bottom Ft
OTHER ASSOCIATED PERMIT#(If applicable) TOP Bottom Ft.
SITE WELL ID#(iappllcable) : 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ElTop Bottom Ft. in. in.
DATE DRILLED_A4LE/ //c)— : Top Bottom Ft. in. in.
TIME COMPLETED AM PM O Top Bottom FL,in. _ in.
4.WELL LOCATION: 10.SAND/GRADVe EL PACK: Sire materialCITE",�p y`�bc, /l/1 )(r. couhri •Lwc b� Top Bottom Ft.
Top Rotten Ft
(Street Name,NamherS,Community,SubdNislon,Lot No.,Paroei,Zip Code) Top Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropnete box)
❑Slope OValley ❑Flat ❑Ridge (3Other 11.DRILLING LOG
LATITUDE 38, 'S P.Q SBN Top Bottom Formation Description
_ "DMS OR 3X.)D=XXXXX DD I
LONGITUDE 70-1.3q' I T,a"; •DMS OR 7X.X(XXX)D=DD _I_) acc YdnI , i di1(
Lattudenongtude source: (BPS Qfopographie map
(f ird0n of well must be shown on a USGS ropo map andaBached to L / aoa LY e\I t CC,
this form if not using GPS)
S.WELLO WNIER Uhivel`51i-1( 9F NiA' h CtzlTt%ltr6� A �dhl �, 1 U `' Gi17'd 41t -�,
Owner Name )
SUE Ph, hips 1Aafi r& ) MU ;
Street Address
kgyu I IP Mc 0�ss1_)4 �
City or Town State Zip Code
---)
Area code ,Phone number -.
6.WELL DETAILS: 12. REMARKS;
a. TOTAL DEPTH: 4
b. DOES WELL REPLACE EXISTING WELLS YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"t Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 1S w l nd sunAbove Land ay require
/
"Top of casing terminated at/or below land surface,mey require L,(/l7 L/Ls�-�
a variance in ac000rrdance with 1SA NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): I/,' METHOD OF TEST
L DISINFECTION—:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
t�z
Form OW-19
Rev.2f09

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4\ 3-1 "
1.WELL CONTRACTOR: ((''11 g. WATER ZONES(depth):
P. r=�\1 'Cl
_1_W/ CV �S TOp Bottom Top Bottom
Well COntrar3or(Individual)Name
!!� Top Bottom Top Bottom
S-^-����_v.11.L �p,t_JLLI..d� A G O I i f���r� Top Bottom Top Bottom
Zell�?mrackor Company Name I Thickness/
.t-�D-A �� 7. CASING: Depth Diameter Weight Material
Street dress Top Bottom FL
'-$-�-'-i �h Top Bottom Ft
Cft T D ' � P41 Stale Zip Code Top Bottom__Ff
tArreaa code Phone�inumber : 8. GROUT: Depth Material ,d1
2.WELL INFORMATION: �f� /� Top _Bottom Ft. '� � T bCp..l
WELL CONSTRUCTION PERMIT# ��� I h I( A)Aq Top Bottom Ft
OTHER ASSOCIATED PERMIT#(If appikeble) Top Bottom Ft.
SITE WELL ID#(d applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ : Top Bottom_. —F[._ia _ in.
DATE DRILLED Top Bottom Ft._in. in.
TIME COMPLETED AM El PM Top Bottom Ft—in. _ in.
4.ALL(LLOO,CATTIOON: - 10.SAND/GRAVEL PACK:
Depth
CITI�:h�t� COUNTY Top Bottom Ff.—Size Maberlal
Top Bottom Ft
(Street Name,Numbers,Comm ,Subdivision.Lot No.,Parcel,Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (diedr appropriate box)
[]Slope QValley ❑Flat ❑Ridge ❑Other ; 11.DRILLING LOG
LATITUDE �9'35_-3(v' [)MS OR 3X.xxlotxxxxx DD Top Bottom Formation Description
LONGITUDEXS'a-3i -1 S SW r
_ DMS OR 7X.XXXXxX)ODt DO
Lalitudenongltude source: C]3pS Qfopographic map r /
(location of well must be shown on a USGS topo map anda8eehed to — P rev t CC
this form it not using GIPS) qq,,aa
S.WELLOWNER 1,11llver�51}y {\Iir{'I'1 (J�.rl%(VYYi; tl>tn)'t^ r L{(,iV / ram tll -�
FirallotY'� fP r(1 tIS�
Owner Name
�203 Pht IIip HoAlrt&D !I4 D �
(�S`treett Address
City or Town Stale Zip Code /
Area code Phone number 12. REMARKS:
6.WELL DETAILS: 1�^
a. TOTAL DEPTH: 4 J�
b. DOES WELL REPLACE EXISTING WELL? YES O NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"If Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
*Top
of casing terminated at/or below land surface.may require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):.METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
(r 3'
Form GW-1a
Rev.21g9

0,Cyr fA�4�
5 ..: RESIDENTIAL WELL CONSTRUCTION RECORD
.+.y North Carolina Department of Environment and Natural Resources-Division of Water Quality
�Q" WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR. f� 9. WATER ZONES(depth):
- WC �tra Top Bottom Top Bottum
Top Botum Top BotomWigA Top Bottom Top Bottom
L i Vpntractcr Company Name
4
i I Thickness/
Street dress
7. CASING: Depth Diameter Weight Material
^ i 1 r-y �' f Top Bottom FL
C,Csv or 1�I r/ITW 'r 1\ ( `'r Top Bottom Ft.
SMee Zip Code Top Bottom FL
Area code Phone number r�( = S. GROUT: Depth Malarial ,1 Metlgd
2 WELL INFORMATION: To Bottom Bottom LM Ft l.+ T_ L-A o r�t_
WELL CONSTRUCTION PERMIT# Top Bottom FL
OTHER ASSOCIATED PERMIT#(0applicable) Top Bottom Ft.
SITE WELL ID#Cd applicable) 9. SCREEN: Depth Diameter Sat Stm Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom R._in. _ in.
DATE DRILLED�T����- Top Bottom Ft._in. in.
TIME COMPLETED AM PM t] Top Bottom Ft In. _ in.
<.WELL LOCATION: - : 10.SANDIGRAVEL PACK
pth
cITY1 tn flyn/l IS I�(w I P couwyli 1 b� Tap Bottom FL sm. M.tertel
�I t\! E i {DIIS : Top Bottom FL
(Street Name,Numbers,Commurft aubr8vis m,Lot No..parcel.Zip Code) Top Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑SIOPe DValley ❑Flat ❑Rktge ❑Other 11.DRILLING LOG
LATITUDE Top Bottom Formation Description
,?�'• �Q( Jl j -DMSOR3x.X)O=X)=DD : /
LONGITUDE 9P 43rt 'I!K lU) •DMs OR 7xjoo=)o=DO J_1a 001 ay ij-11 ie. 4- i tr
Latitude/longilude source: []3pS Qfopographic map
(location of well must be shown on a USGS loon map andaltached to L.? �/��Q� (�t�PV i C.19
this form if not using GPS)
S.WELL OWNERUri V erot}t(Fp�F �Iv �'N� C tzlrt lc r� f ku lJU
/��lL G1YY2 41 t iP
Owner Name EamCP�Qp w baaf /
Street Atldress /
A�tmtn IlP Nf' a�3FsIJ4 /
City or Town - State Zp Code
L—) /
Area code Phone number
6.WELL DETAILS: 1 i^f� '12- REMARKS;
a. TOTAL DEPTH: 4 /`
b. DOES WELL REPLACE EMSTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use-+-if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land may
require
� / n���—
"Top of rasing tertnlnaled at/or below IerW surtece.may require 1 /�/
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a. YIELD(gpm): / METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
't5I`►i�1>,- ' Form GW-1a
Rev.2109

a°"a�sAra .
RESIDENTIAL''.SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
®0 °• WELL CONTRACTOR CERTIFICATION# L4 131
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Jo'V\ P) Yl-V-N" G>nS Top Bottom Top Bottom
Wall Contractor(Individual)Name
Top Bottom Top Bottom
top Bottom Top Bottom
r eIt��QQntraeu Company Name
1) 1 Ilx A A I Thickness/
kk 1 7. CASING: Depth Diameter Weight Material
4 Street dressI Top FIL
u--Ci� ol, �� ) � �'`� � ` ✓ Top Bottom Ft
C j4 11 Slate Zip Code
C�•1 x ) �'1 U _ 1 Alt I`Y' Top Bottom Ft.
Area(cod)e Phone
en umber d R. GROUT: Depth Material ,1 Method
2.WELL INFORMATION: r� /� Top -Bottom Ft UdifL -tT ,(+ T' C`.Jl'-E'.I
WELL CONSTRUCTION PERMIT# V�j II_.'II�1 iM9 Top Bottom FLT�J "
OTHER ASSOCIATED PERMIT#(tappiimbie) : Top Bottom Ft
SITE WELL ID#(d epWlraNe) 9. SCREEN: Depth Diameter Sint Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.---- in. _ in.
DATE DRILLED ����� : Top Bottom Ft._in. In.
TIME COMPLETED Aryl El PM Top Bottom Ft_in. In.
y K 4.WELL LOCATION: 1O.SAND/GRAVEL PAC
` - '
COUNTYkII.a--uc()b. Depth Sire Material
�(� p � Top Bottom Ft.
n
�.I I\i .A (�� .l : Top Bottom Ft
(Street Name,Numbers,Commun ,SubdivMm,Lot No.,Parcel,Ztp Code) Top Bottom Ft.
TOPOGRAPHIC t LAND SETTING: (chea appropriate box)
❑Slope OVatey ❑Flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 3S"•3c� .y'S�?'N Top Bottom Formation Description
. __ DMS OR 3x.Xxxxxxxxx DD
LONGITUDE ?Z"34 'I kDl.-) OMS OR 7X.XXXXXXX3IX DD : aY ca-)I
Latitudetlongitude source: BPS Dropographid map f
00c9tron of watt must be shown on a USGS IOpn map end9teched to [ (-Sc zi aoa O'YPL'i C e-
this form ffnot using GPS) '
s.WELL OWNER Nor+h Ctkrcllf I f( Xuii �j ar1t411
I-i�tttf� �I (p tC> l�
Owner Name
'9U t [lips RoAl 1 D
Street Address ,
City or Town State Zip Code
Area code .Phone number
12. REMARKS;
6.WELL DETAILS: , 1I^ L�r�
a. TOTAL DEPTH: `-F,
h. DOES WELL REPLACE EXISTING WELL? YES D NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+.t Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
"Top of casing terminated attor below land surface,may,require
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): / METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
4rS
Form GW-ta
Rev.2/09

J�y�rp A
RESIDENTIAL WELL CONSTRUCTION RECORD
t
North Carolina Department of Environment and Natural Resources-Division of Water Quality
°a WELL CONTRACTOR CERTIFICATION# qk -3-1- A
1.WELL CONTRACTORt• g- WATER ZONES(depths
)ncV, 4���YY`YY1�Y�S Top Bottom Top Botom
^Well
' }Coontractor(individual)Name r� {� Top Bottom Top Bottom
i n x t p v �� -� t A A Do I i ( �Y�T— Top Bottom Top Bottom__.-
r � y q
ell ntraotor Company Name I Thickness/
_Ld11_,� ( 7. CASING: Depth Diameter Weight Material
FAIT
dress �n t� G 2
I tt :T Iprl � �lyS '\�Ct a r 143 Top Bottom Ft. --
Citr_orf&4nn _` State Zip Code Top_,Bottom Ft.
Area code Phone number 6. GROUT: Depth Material ``�� Method
2.WELL INFORMATION: \' Top_j_Bottom�Ft. GN(.�CaVT ,I T" JCk.I_..��:
WELL CONSTRUCTION PERMIT#�^�j F(1I(�C iI��( Top Bottom Ft �J
OTHER ASSOCIATED PERMIT#Qf applicable) Top Bottom Ft.
SITE WELL ID it it applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicablleev Box): Residential Water Supply❑ TOP Bottom Ft. in. in.
DATE DRILLED Top Bottom Ft._in. In.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft. in. in.
4.WELL LOCATION; 10.SANDIGRAVEL PACK:
(J,C ` ' �.��,(�(� Depth size Material
CITY,.`_] lr�,f)''(���y( �' c��./\r� r COUNTY ~ll n 1 1() Top Bottom Ft.
�M 7 11 J ,t : Top Bottom Ft
(Street Name.Numbers,Contmunitil,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft
TOPOGRAPHIC/LAND SETTING: (check appropriate hoc)
❑Slope ❑Valley OF1at ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE ,,��zz�°3(P�QIt P'J • Top Bottom FormationDeacdpticn
'/�_ DMS OR 3XXC 0=)0(X DD /
LONGITUDE 10 �a`3CF '( "� -DMS OR 7X.XXXXXXXXX DO —! 00C) arani ie, Al ltf
Latitude/longitudesource: BPS OTopographic map /
(location of well must be shown on a USGS topo map andattached to C e
this form if not using GPS) : 1
s.WELLOWNER umletr64VF9F �
, NA-hCIAI` (rcA�ketl'
FIEF, l 7(��[�' 1�.) / _...
Owner Name
19DE Phlll(gs ll rCPO 14,LD /
Street Address
City or Town - State Zip Code /
Area code Phone number 12. REMARKS;
6.WELL DETAILS: ' t i^�
a. TOTAL DEPTH: `tilt
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"s"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PRQ.WED TO THE WELL OWNER.
it. TOP OF CASING IS FT.Above Land Surface"
"Top of casing terminated albs below Lend surtace,may require ,�il _
a variance in accordance with 1SA NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Affmnt PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# L4 J -v 1-
I.WELL CONTRACTOR: t� g. WATER ZONES(depth):
JCJSn t✓`c vy110("S Top Bottom Top Bottom
Well Contractor(Individual)Name
rt t p Top Bottom Top Bottum
1-U 0 'Vls ) iA.,f,l- W 1 .Q A A �l �.��A : Top-----Bottom Top Bottom
si
\ell C/pntrac(tor Company Name p�-
k X JA �I 7. CASING: Depth Diameter Wei ig Material
�street dress ^•^�fi�nnn 1� ' J Top—Bottom FL
yor I State Top Bottom Ft.
Cdy arT 11 State Zip Code Top Bottom Ft.
421
Area code Phone number R. GROUP Depth Material ,a1 Method
2.WELL INFORMATION: -�� > Top__Bottom Ft. �
WELL CONSTRUCTION PERMIT# \\� E(,l l t A liQq : Top Bottom Ft CIS 1"� a1'C .
OTHER ASSOCIATED PERMIT#(ifapplicable) Top Bottom Ft.
SITE WELL ID tl(if appllrable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. _ in.
DATE DRILLED J��! (� : Top Bottom Ft._in. In.
TIMECOMPLETED AMC] PMEJ Top Bottom R.^in. in.
4.ALL
r'LOCATION:
, to.SANDIGRAVEL PACK:
DeptCITI`.��`, 1��Py( �COUNiy ,y Beam 8W Material
1 '��C� Top Bottom Ft.
Top Bottom Ft
(Street Name,Numbers,CommunIO,Subdivision,Lot No.,Parcel,Zip Code) : TOp Bottom FL
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
OSIOpe ❑Valley ❑flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 37!-�--3(P,qWg
_ DMS OR 3X.)O=XXXXX DD
LONGITUDE);10�-3tE '(RI W "DMS OR 7X.XXXXX=O(DD �_) O(Jr. QjC£.fllie,
Latitudellongilude source: E]�;pS 01apographic map
(location of well must be shown on a USGS topo map andalleched to XX) 1 c,re I t c e-
this form ff not using GPS)
5.WELLOWNER _Llniver5t}y oP Ivcrth C'Lti1+%lcr�i �J1 UI7L �Y-!, y�l -�',
FihArtcl('� 4 fkl�f (P 1IXlS
Owner Name
nht iii�, 11 trap
street Aadrega �
�SVY'UI -IP
Chry or Town State Zip Code f
Area code) Phone number /
6.WELL DETAILS: �^ 12. REMARKS;
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXaSTiNG WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO T7ELL OWNER.
d. TOP OF CASING IS FT.land
sursur Land Surface-
*TOP
*Top of casing terminated attar below land face may require
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_ METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
(b?
Form GW-la
*&us,_. ...WN_
Rev.2109

RD
ESIDENTIAL WELL CONSTRUCTION RECORD
•y North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# L4 16-1 - A
`I.[SELL CONTRA7DR: Et. WATER ZONES(depth):
f) G'171i 1 YY l S Top Bottom Tap Bdlorn ___
�Wellll/cpon�trra�cttor�Qndividuaf)Name�g 1 (��,� � Top—Bottom Top-Bottom
-'-"�-^-a--t)A)71 Y- �,i.d,x A )L�I ��� Top Bottom Top Bottom
ell ntractor Company Name �—
.� Thieknessl
7� l T, CASING: Depth Diameter Weight Material
Street ress
'} O.
.� C Top Bottom Ft_
City or T - Top Bottom Ft.
St _ate Zip Code.> -1 Top Bottom FL
U)2� - a41
Area code PMne number : 8. GROUT: Depth Material Method
2.WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Top Bottom Ft,
OTHER ASSOCIATED PERMIT#(Bappltdabie) lop-Bottom-Ft-
SITE WELL ID#(d appllmble) '
9. SCREEN: Depth Dinamw Slot at" 1111sta l
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.—In. _ In.
DATE DRILLED tp� � Top Bottarn FL_in. In.
TIME COMPLETED AMQ PMID TOP Bottom FL in. In,
4.ALL
LOCATION- 10.SAND/GRAVEL PACK
Depth e COUNTY, . T Bottom Ft SPu MataNel
OP
Top Bottom Ft
kstreet Name,Numbers,Community,Subdivision,Lot No..Parcel,Zip Code) Top Bolcom Ft.
TOPOGRAPHIC/LAND SETTING: (check appmprlate box)
❑Slope DValley ❑FFat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE • Gta'IN Top Bottom Formation Description
_ "DMS OR 3X.)CCOMXXX DD
LONGITUDEXY2 •3'1 t:' "DMSOR7X.mOwx)oXXDD ._�_I (9Db (AP7.cnt A- ENT
Latitude/longitude souree• [BPS [topographic map /
(location Of welt must be shown on a USGS topo map andel7ached to
this form if not using GPS) '
5,WELL OWNER (.�iliveroi}4 QF Nor+h C'a]lrotirf� ?+)'GG�, (, �AQQ tarn 't V,
Owner Name /
SIU� Ohl ll(n� l� r JPC? 142D ;
Street Address /
11�U111P M�
Coy or Town State Zip Code /
AreaAfeB�code .Phone number
6.WELL DETAILS: ��^^ ((j 12. REMARKS:
a. TOTAL DEPTH: 40 /
b, DOES WELL REPLACE EXISTING WELL? YES❑ NOD
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 20,WELL CONSTRUCTION
(Use'+"if Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT,Above Land Surface'
•Top or rasing terminated atfor below land surface,may require `�
a valiance In accordance with 15A NCAC 2C.0118. 1 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1s
Rev.2/Og

.p REUDENTML WELL CONSTRUCTTON RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# LE 161 _ A
1.talF�t CONTRq���7p�R: g. WATER ZONES(depth):
—I1.J 07 I' 1GI711�Y� 'I op Bottom Tap Bottom__.
IWe`ll/ConLtr'actor(Indiivvidual)Name Top Bottom TOP Bottom _
�� V\ I f Y� Top--Bottom Top Bottom
II Fpntractar Company Name .rn
k T J J T. CASING: Dapth Diameter Weight Material
Str� eet Fj(ldress
Top Bottom FL
Ci r 98143
Top Bottom Ft.
Slide Zip Coda Top Bottom Ft.
as - -1 41
Area code Phone number A. GROUT; Depth Material <��Method
2.WELL INFORMATION: - Top_ Bottom Ft.�(ATAL -i- `I- l.�.Ll t[�
WELL CONSTRUCTION PERMIT# Y\ F l�)I) ri lI"l� Top_•__Bottom FL TT
OTHER ASSOCIATED PERMIT#(ffapplicable) lop Bottom Pt.
-
SITE WELL ID 1t(if apploabie)
9. SCREEN: Depth Diameter Slat Sire MttbNal
3-WELL USE(Check Applicable Box): Regidential Water Supply 0 Top Bottom Ft_fn. in.
DATEDRILLED (OL// )- : Top Bottom FL_)n. T In,
TIME COMPLETED AM17 PMD Top Bottom_-_Fiin. _ In.
4.ALL LOCATION: 10.SANn/GRAVEL PACK:
CITY-. �p ��..(� Depth Sh* Materiel
COUNTY ' 7-1 b�, Top Bottom Ft.
TOP Bottom Ft.
(Street Neme.Numbers,Commun ,subdWion,Lot No.,Parcel,ZIP Code) : Top Bottom FL -
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope pValley QRat ❑Ridge ❑Other 11.DRILLING LOG
•i3C �L�a N Top Bottom Formation Description
LATITUDE
_ "DMS OR 3X.Xx)O=XXX DD
LONGITUDE 36YL •3 f c?Ul hJ •DMS OR 7X.=(XX)O=DD _�_/, 0D owau1i -
Latilude/longitude source: p3pS Dropographic map r ! ry_��t C
(location Of well must be shown on a USGS topo map andarached to __rJrs.r,a— o
this form if not ushg GPS)
5.WELL OWNER UCl I V er5t}y QF �l OY CI.yrCllllCikul l /!^Ul�t� 11 l�i le,
Owner Name �
Street Address
lsyu, 1 e Mc zl�N7, 7
Cityor Town State Zip Code
Area woe) Phone number : 12. REMARKS:
G.WELL DETAILS: �^ (j
a. TOTAL DEPTH: `-}' i J_
14
h- DOES WELL REPLACE EXISTING WELL? YES❑ NO D `
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"I Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE LL OWNER.
d. TOP OF CASING IS FT,Above Land Surface*
"Top of casing terminated attor below land surface may require
e variance in aamrdenca with 1SA NCAC 2C.011d. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•� "� T WELL CONTRACTOR CERTIFICATION# LI 1 3A
1.1a�LL CONTRACzzOR: 9. WATER ZONES(depth):
�fI�L1 1�� ij7ylyylS top Bottom Top Bottom__.
Well Contractor ondividuet)Nterr� p lop Bottom Top Bottom _
VVI )�➢��.tr V\�,l 21 V �� Top Bottom Top Bottom
SNeI1 Cp J Company Name ii
Thidrxssl
te L(SSIhe�Ik) dress T. CASING: Depth Diameter Weight Marial
1�t ; V `j Top Bottom FL
r11-It'for ��� ���' Stab Zip Code Top Bottom Ft
Area code phone number 8. GROUT: Depth Materiel Method
2.WELL INFORWITION; ^^t/� Top�_BottoniFt. l-+ i�2V [l
WELL CONSTRUCTION PERMIT#�I ``�OIIRJI`-'1� Top Bottom Ft,
OTHER ASSOCIATED pERMIT1f(ifap*Ak,) Tnp Bottom Ft.
SITE WELL IDff('d eppllre61e) ---- 9. SCREEN: Depth Diameter Slot Size Material
3,WELL USE(Check Appftble Box): Residential Water Supply❑ Top Botom Ft, in. __ in.
DATE DRILLED ty S-// Top Bottom Ft.�in. In. ^
TIME COMPLETED AMO PM❑ Top Bottom FL in. in. —
4.ALL LOCATli - 10.SAND/GRAAVE PACK- 8M M4telfai
CITY Depth
COUNTY =1 triC.� Top Bottom Ft
C1 M 3 11 11�t J : Top Bottom Ft.
(Sheet Nerne,Numbers,Common ,SubdNisbn,Lot No.,Parcel,ZIP Cede) TOp Bottom Et
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley, 13Flat ❑Ridge ❑Other 11,DRILLING LOG
LATITUDE •3te, l&7 N Top Bottom Formation Description
„ „ DMS OR 3X.X OODMXX DD /
LONGITUDE DMS OR 7X.XXXXXXXXX DD _�_/_ _ Q+r �11 +
Latitude/longitude source: 03pS []Topographic map /
(!oration of well must be shown on a USGS topo map andadaobedrto
this form if not using GPS)
S.WELL OWNER Ur�ivcrai�y �'w C1�1'Dl(tYnA 1b.�,1 /i u(7f7 Qr(l b'll '
F1lsio�fA 4 f�r��IriS /
Owner Name /
510� t�hl Ilt�; Fli *CAD 14aD
Street Address /
City or Town State Zip Code
I /
Area code Phone number
S.WELL DETAILS: t�'^'aa,, = t2. REMARKS:
a. TOTAL DEPTH_'' 11` 00
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
rise-+"y Above Top of Casing) : STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP p CASING IS FT.Above Land y require
�^�—_ _ ,(
*Top of�^•ing terminated atlor below IerW surface my require ��j�/,/�!/�
e variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e, YIELD(gpi. METHOD OF TEST
C DISMIFECTION:Type Aawun PRINTED NAME OF PERSON CONSTRUCTING THE WELL
7e
Form GW-1a
Rev.2109

r(,yy^yrQ 0�
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resrnlrces-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# LI 11J I - A
1 %W�L�L��CONTRACTOR. 9. WATER ZONES(depth):
_il.i.Z�f(l IL'17y1"fl(lS Top Bottom Top Bottom__.
(Well Contractor(Individual)Name pa 11 Top Bettom Top BoBom _
_A�I wrti l(�TI I� Liu Dab-I r n : Top_ Bottom Top Bottom
lea pntraaor Company Name I -- Th gal
T. CASING- Depth Diameter Weight Material
Street
IN cress �'1 G
S NC a p—1 43 Top Bottom FL860 : Top--Bottom FL
:
,kr] K,C*yorT �1 Zips Top Bottom Ft
/veacode Phonenumber o(`Y 8. GROUT: Depth ! Material Method
2.WELL INFORMATION: ii ^^1n Top _eottom��Ft. (A( `�" Lxlf
WELL CONSTRUCTION PERMIT# V�177 I H l IN� Top _Bottom Ft J
OTHER ASSOCIATED PERMIT#(ifspoke, k) lop Bottom Ft
SITE WELL ID#(ir appllcabk) -- 9. SCREEN: Depth Diameter Slatshbe MWAKAi
3,WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft.—In. in.
DATE DRILLED � Top Bottom Ft�in. in.
TIME COMPLETED Y AMO PM[] = Top Bottom Ft in. , In.
4.WELL LOCA71ON: (t�,�./��,p: 10.SAND/GRAVEL PACK:
CITY1`.�, LL I��^ram e COUNTY L.Lb.1 tr�G Tqt Depth R SION, Material
Top Bottom Ft
(Street Name,Numbers,Comm ,S"MMelon,Lot No.,Parcel,Zip Coda) : Top Bottom R.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope gVelley, 13F19t ❑Ridge gOther 1 11.DRILLING LOG
3S,3 i,/SSA/ , Top Bottom Formation Description
LATITUDE 36` , DMS OR 3x.xX7OO=XX DO /
LONGITUDE AkA 'o`f 902J--1 •DMS OR 7x.XXXXXXX)ot DD _L/ 0 J'
Latitude/longitude source: [);PS Qfopographic map /
(bca#On of we//must be shown on a USGS topo map andaltached to L2xr�l — �Y.�t ce—
this form If not using GPS) /
S.WELL OWNER Uni QF Nur+h Ci8lrotwa A$t9hl�/^yam
ttllwelf� lit- 'mS /
Owner Name /
�o phi ►i��g 11� �'D �4LD /
Street Address
-Um
d' Ile NC
uity or Town Stele Zip Code )
Area code Phone number
S.WELL DETAILS: (r - 12. REMARKS: -
a. TOTAL DEPTH: 4Cil /
14
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED if
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1SA NCAC 2C,WELL CONSTRUCTION
(Use'+^d Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE LL OWNER.
d. TOP OF CASING IS FT,Above Land Surface* � A/
`Top of casing terminated atfor below land surface,may require
a variance in accordance with 15A NCAC 2C.0 M SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):, (z _METHOD OF TEST
I. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
�i
Form GW-ta
Rev.2109

fr�.�:FArEo
W RD
ESIDENTIAL WELL CONSTRUCTION RECORD
•.�,.'' " North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# LI 151
1.1NF1L CONTRACTOR: 9. WATER ZONES(depth):
1 i op eotpom Top Bottom___
Wall Cont ­
on tractor(1rWividua1)Ntmte Top Bottom Top Bottom _
➢ 1-,Vk )n��X- �.11sl Top__—Bottom Top Bottom
veil ntractor Company Name �—
Thicknessf
Street rsidress 1% CASING: Depth Diameter Weight Material
Top_._Bottom Ft.
Cit or Tofn/ n 9ttaa Zip Code Top Bottom FL
Top ,Bottom Ft—
Area
=cede Plane number ! `Y S. GROUT: Depth Material Method
2.WELL INFORMATION: Top-j _Bottom ,FLI_{' `� _
WELL CONSTRUCTION PERMIT# Y�J F,i•�, Top Bottom Ft,
OTHER ASSOCIATED PERMIT#(Ifappltcable) Top Bottom F.
SITE WELL ID#(X applicable)
9. SCREEN: Depth Diameter slat sin Mtlterlal
3.WELL USE(Cha(*Appltxble BOX): Residential Water Supply❑ Top Bottom Ft.----in. In.
DATE DRILLED c ram: : Top Bottom It—In. In.
TIME COMPLETED AM pM TOP Bottom--Ft 1n. _ In.
<.WELL LOCATION: I!'?h� r n�r,�,.n 10.SAND/GRAVEL PACK:
"—t Sil1JL �/i f fy COUNTY-Jc.ultlL L Al t Depth Site M.hriei
CITY` �,
�AnT1�LAs : lop Bottom Ft. _
Lstreet Name,plumbers,Coma SubdMsion,Lot No.,Parcel,Zip Code) : Top Bottom Ft.
TOPOGRAPHIC I LAND SETTING: (check appmpdete box)
❑Slope ❑VAlley ❑Flat [3Rldge ❑Other : 11.DRILLING LOG
LATITUDE 3S ' iC(SN Top Bottom Formation Description
' ' "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 76�°2 •34 a c3L- pMS OR 7X.xlootwotloi DD
Latitudeflongitudesource: p3pS Qfapographicmap
(location Of well must be shown on a USGS topo map andattachad In rev t
this form if not ashg GPSJ _yam
S.WELLOWNER Univer-olty QF.�^iuY�i'� C'L1How-T, AsV&: (S[]�/. "00 -1E'
Owner Name
street addreea --/
City or Town 3te1e Zip Code ( . .
Area�code Phone number /
6.WELL DETAILS: 400
12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use•+"#Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP CASING 1S FT,Above Land Surface 1
"Top casi
ng ing terminated aNcr below land surface may requis re yn t —
R Variance in aOmrdance with 15A NCAC 2C.0116. : 8113NATURE OF CERTIFIED WELL CONTRACTOR DATE
c. YIELD(gpm):_ METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1 W1rf��U@f 12
rffmfill I

RESIDENTIAL WELL CONSTRUCTION RECORD
alit
i
NorihCarolina DepartmrntofEnvironmeniendNawralRegout'jes-Division ofWeter Y
WELL CONTRACTOR CERTIFICATION it
g. WATER ZONES(depth): T Bottoms--
1.WELL CONTRACTOR: lop Bt>trom °P
Bottom— Top eotbm
Top—-
W ell Contractor(Individual)Name
Top Bottom
C K�(I In )n 1 w l fl 11 A (,__ ) I I)V Y I top___--Botuun Thtcknessf
yell pntractor Company Name Y CASING: Depth Diameter Weight material
�) iyJgC� S� �� I + 2 T� Bottom—
Street FL —
1`T� Top Bottom FL _--- _.
State IV Code rop Bolton Ft.
City or T Method
(, _) A. GROUT: Depth � -� Matenel .
Areacode Phone number �_BoNom_11A1-FLS `li"
/T 'lop --
2.WELL INFORMATION: Tap Bottom FL�
WELL CONSTRUCTION PERMIT# A Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(If epPiicabie) DISMOW Slot Size MSteMSt
L SCREEN: Depth
SITE WELL ID#fit apPlkaNe) In.
FL__in. __
Top--Bottom in.
3.WELL USE(Check Appfinable BmQ: Reaidenliel Water Supply❑ Bottom Ft--in —
'-1 Top,_ in.
DATE DRILLED 1 ? Bottom Ft. in.
TIME COMPLETED--•— AM PM Ll
10.SANDiGRAVEI PACK: Size
Material
4.ALL LOCATION: �) � Depth _--
cmr 1 �f lP�lt N C.OUNTYL` n '� mp 13Wtom Fl. _ ----
T Bottom Ft.
-_(Street Nee.Numbers.Cwraun ,Sub-vlebn,Lot No.,Parcel.ZIP C d.j Top
BottomFL
m _---- -
TOPOGRAPHIC I LAND SETTING: (check ewwatebox) 11,DRILLING LOG
❑SIope OValiey ❑Flat []Ridge ❑Other-_._.—__.-- Top
Bottom Fotlnebop Description
LATITUDE 7 3v•q-)111J ^DMS OR S .)D=XXXXX DD : /
LONGITUDE 7 ��' �f�'DNS OR 7X.XXXX%XXXX DD --j- — _J -
re hlc map - -�!l'_l _ � "' t
Latiwdellongitudesouree. PS [jfopog P �7 C21�w- Ir
ftocation of well must be drown on a USGS topo map andadaolted to /
Mis form if not using GPS) �
5_wELL OWNER1 �Univ:'r 5i t.y oF` L'lalri;lir-�� �
i "r ifl�nr/a AA f_
owner Name Ylt j
�U pht ll Via
street Atldress f`----
��v\
city or room Stem Zip Code -
{__)
Ares code Phone number 12. REMARKS
S.WELL DETAILS: I�
a, TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ j DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER EEse Bee Above T of Casing) ----`� PROVIDED TO THE WELL OWNER.. STANDARDS,AND THAT A COPY
THIS RECORD HAS BEEN
e7.Above Lend Surface*
d. TOP OF CASING IS I. ih/bs�� -
'Top of casing terminated at/,below land surfaee.mey require err"i ONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118, SIGNATURE OF CERTIFIED WELL C
e. YIELD(gpm /
):—Y"—_..METHOD OF TEST -.—
: PRINTED NAME OF PERSON CIXJSTRU&NG THE WELL
f. DISINFECTION:Type_ _- Amount-----
t
Form GW-1 a
Rev.2ID9

a. oen
RESjDT+jvT jAL WELL CONSTRUCTION
): North Carolina Department of Environment and Natural Resources-Divis�ton of Water Quality
WELL CONTRACTOR CERTIFICATION#T_.--------
y_ WATER ZONES(depth):
1.yYEL4 CONTRACTOR: I� Bottom
Top Bonom_._-_
C�1 I - ry v-r"1< I Top Bottom
�___Bottom
wee contractor(Individuap Nerve Top Bottom
n - .. `, - Top--_Bottom Thickness]
( ell ntra an
ctor company Name Diameter Weigh Matedal
1) �p. .j � -�I � ?. CASING Depth
-top Bottom F4
Street AAdress � l f T _Botfom FL
Zip Code Topop
6onnm Ft.
method
�Ci.U.L�>L7 ..
Material
�u 3, GROUT: Depth �� ���1'y+I �� �(-
Areacode Phone number l oP�Bottum_liM Ft._�(� 1
2.WELL INFORMATION: l'a Bottom FtJ
WELL CONSTRUCTION PERMIT# Top Bollom — —'
OTHER ASSOCIATED PERMIT#(If apgicaCk) g. SCREEN: Depth Diameter Slot Size Ma6arlak
SITE WELL ID#fIf appllcaNa) Bottom Ft.__in. .-- In.
Top
Residemiel Water SuPPN Ft._.in. __ in.
3.WELL USE(Check Applicable Box): Top Bottom
.� 3" Bottom Ft. in. _-_ in. -
DATE DRILLED - 7'op
TIME COMPLETED_.-- '4ME] PMfa
1U.SANOIGRAVE�r LPACK: Sim material
4.ALL LOCATION:
y� 4 COUNTY '1 tJ�,i Top Bottom—
Fop— R.
Bottom Ft.
_ (Street Nerve.Numeera,GOTT ay,auoo w,,Lot No.,Parcel.21p Code) Top,___--Bottom
TOPOGRAPHIC I LAND SETTING: (dledr appropriate box) 11, DRILLING LOG Formetlm Description
❑Slope pVallay ❑Flat ❑Ridge pother____--- Top Bottom
LATITUDE 31 CiV N"DMS OR 3X.XXXXXXXXXDD
LONGITUDE -zN _' `+��' )(QfoPd9PDMS OR 7x.XXx0)O DD : i'��-- —
tat•' ra hicMap
Latitudellonghudesource: PS andariachedto '
(location of well must be shown on a USGS topo map
this form if not using GPS)S.WELL OWNER
owner Name
StraMAddreds
I��YY'\n 1lr State "p
Cityor Town
(--)
Arne code Phone number 12. REMARKS:
S.WELL DETAILS: II ``��-}}
a, TOTAL DEPTH: ` 0'
h. DOES WELL REPLACE EXISTING WELL? YES LI NO❑ : j DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,W ELL CONSTRUCTION
c, WATER LEVEL Below Top of Casing: —FT' AND THAT A COPY OF THIS RECOR
STANDARDS,AD HAS BEEN
(Use-+'A Above Top of Casing) PROVIDED TO THE ELL OWNER.
d. TOP OF CASING IS FT.Above Lend Surface" T'�� �,�//
-Top of rasing terminated efor befow land surfece.may require SG 1INATURE OF CERTIFIED W C IITR
ELL ACTOR�DATE
a variance in accordance with 15A NCAC 2C.0118. S
r.. YIELD(gpm): _�.—METHOD OF TEST_,_,__
f. YIELD(gp DISINFECTION:Type--- Amount PRINTED NAME OF PERSON CtTPISTR INO THE WELL
Fonn OW-1a
Rev.2JD9

09AI��
RE IDENTIAL WELL CONSTRUCTION CORD
artment of Environment and Natural Resonrces-Division of Water Quality
Nord/Carolina Delp
y137 — l4
WELL CONTRACTOR CERTIFICATION#_
y. WATER ZONES(depth): T Bottom__
i.WEL�. �TRACT'Qg CoP eotrom °P
1(Sy\ I/�Llll�lll )f — Tnp t3ottom
-rOP Bottom Bottom
well contractorpndNtduap Nam° (' tl t ) Bottom TOp
1 l i Y A _ C°P—--- Thickness/
7. CASING: Depth
ell nvector Comparry Name Diameter Weight Maternal
` �
17 �px�n ,-°p Bottom O•
, ``Street Acd'dress p �1 �7I Ft.
Nl`1 k 1p)1 tom/) S 'I\)(1 Ot� 1`T rop Bottom —
1.]l State Zip Code fop Bottom Ft•
C ,orT Method
� a " R. GROUT: Depth ����yy'� �Ma-te�riial (}
Area �code Phone number .I.OP�Bottom rt n'� Ft.�tLr. J 11
2.WELL INFORMATION: Bottom Ft..------ "�—
I h tln1�� rop
WELL CONSTRUCTION PERMIT# N. I t Top Bottom Ft. -
OTHER ASSOCIATED PERMITII(Ir aPpicahk) Diameter Sint Siu MMedei
SITE WELL ID#f(dappllraNe) 9. SCREEN: Depth
Bottom—Ft__in. In.
TOP
3.WELL USE(Ghent Applicable Box): Residemtal Water Supply❑ .top Bottom Ft- In. __. in. -
DATE DRILLED ; j'op__-BOW
Ft. in. in.
TIME COMPLETED._— AM❑ ❑
10.SANDIGR Depth PACK:
De at" "Modal
4.WELL LOCATION: Dept
Bottom Ft•
TY 1-1�11��) ' I C.OUNIY p
Cl
• To t Bottom Ft.
--�'—
op�
___ to lit i��lsJ cod ) To Bottom FL _--
. (Street Nm Numbers.
ne. COmmanxy.SubdM .Lot No..parcel,Zip p
TOPOGRAPHIC LAND SETTING: (check allPropdm°box) 11.DRILLING LOG
❑Slope ❑Valley r3Flat ❑/Ridge ❑Other_.__-- TOP
Bottom Formation Description
LATITUDE S S• :3Li "t&9N"DMS OR 3X.XXXXXXXXX DO
I.ONGITUDEa34 !Saga DIMS OR 7X.XXXXXXXXX DD l�t�Y�f1� P.
Latimdellongitudesource: tf pS []ropographicmap -
(locatlon of well must be shown on a#ISGS topo MAP andatieloed to
this form if nor using GPSJ fix'? )t�
Ur\ive't�it� OF Ivv11-t\
S.WELL OWNER
1 r1 `AL Curti i1r EL /
Owner Name
3U phi lliG�c Via �a�r) I�k�D
Street Address
Clly or Town
Area code Phone number 12. REMARKS: .
6.WELL DLSrAILS: 1 `7�('}
a, TOTAL DEPTH: `'1',J v— '
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ j DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,W ELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing:.___ —FT' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use•+'If Above Top Of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface" /
•Top of casing terminated atfor below lend surface may require o L�9 �! DATE
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CER IED WELL CONTRACTOR
e. YIELD(gpm):�--METHOD OF TEST
Amount _ : PRINTED NAME OF PERSON CONS 1. U�C3 THE WELL
t. DISINFECTION:Type _
. . . Form GW-ta
Rev.2/09

.✓„�.SN.rFq
RESIDENTIAL wEu.CONSTRUCTION"CORD
- North Carolina Department of Environment and Natural Resources-Division of Weer Quality
WELL CONTRACTOR CERTINICATION# — —
g. WATER ZONES(depth): Top Bosom__—.
Bottom
top __Bottom Tap t3ottom
Well Contractor(IndNidual)Name
top"-- Top Bottom
(➢ %n)lzi" � '� tz � f)t� Ili�Ye roP ---Batton
Thickness!
ell ntfactar C+ompany Name Diameter Weight Material
�/ pX J� _{I 7, CASING: Depth
Top Bottom FL
Street dress Bottorrr Ft,
Nr + Y7ri nn S NC:�� ---- T� _.
State Zip Code ;� Bottom Fl.
C Method ..
g. GROUT: Depth % Meteriat (� (,.
Area code Phone number /� T9p�Bottom L Ft 1
2.WELL INFORMATION: \n 1 Gi`1111��`-1� Top Bottom Ft.�.-- —"
WELL CONSTRUCTION PERMIT# Top Bottom FI•
OTHER ASSOCIATED PERMIT#(K al`Fruabie) Diameter skit Size Ma"at
SITE WELL ID#(HeppllmNal ; s. SCREEN: DOPO ttom in
Top__
ToP_— Bottom Ft__kl. _---
3.WELL USE(Check Applicable Box): Residential Water Supply ElFt.__in. in.
_Bo
DATE DRILLED �/S_____�� — Top_.. .__Bottom Ft—Win' In
TIME COMPLETED_____— AM PMQ
10.SANPlGR Dept PACK: SI» Maw"4.WELL LOCATION: `` Depth
Clll`t I�S��P 1 1 CAUNTY, .�(1(.`CW't�}h , Top B oBottom—
Ft
rap
od Bottom Ft
(Sffeet Nine,Nwllaers,Gammon .Subs Lot No.,Parcel.ZIP Ce) Top
TOPOGRAPHIC/LAND SETTING: (dw-k aPPropdem box) 71.DRILLING LOG FnrliradOn Description
EIS" ❑Valley []Flat ❑RkW ❑Other___--- Top Bottom
LATITUDEF`�34'' q0'y A/•DMS OR 3X,XXXXXXXXX DD
LONGITUDE T a1 LI'r2G "'a DMS OR 7X.XtIXXXXM DD : —�—�— j
jam_ nr�tifP
Latitude/longitudesource: 196PS Qfapographic map
(location of welf must be shown on a USGS 10PO map andit fachad to J
this form Nnot using GPSJ
1 ntr Jar ivul"i h (TA I­. 5242—
s.WELL OWNER
n 4 Curt, k1TYl� l�—
�1
CrvnerNeme ` lG J
U hht lti� 4 -�
S,rae�1 Address
_
City or Town State 4pC r- �
Area cads Phone number 12. REMARKS: .
6.WELL DETAILS: r�
a, TOTAL DEPTH: 4,J
I, DOES WELL REPLACE EXISTING WELL? YES p NO❑ I DO HEREBY CERTIFY THAT THI3 WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c, WATER LEVEL Below Top of Casing:_____._ Ff. STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use-+"rf Above TOP of Casing) pROVIDED TO/THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface* ^ „A
-Top of casing terminated attor below land surfece.mey require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
mi
G variance in accordance with 15A NCAC 2C.011&
e. YIELD(gpm): METHOD OF TEST _
PRINTED NAME OF PERSON CENJSTR t NG THE WELL
f. DISINFECTION:Twe Amount
Form GW-1A
., Rev.2.fl)B

ty �y.if wry_
RESIDEWTIAL WELL C01 STRUCTION RECO
RP
artment of Environment and Natural Resources-Division Of Water Quality
North Carolina Dep i 112 _ A
WELL CONTRACTOR CERTIFICATION# -_l J� --
g_ WATER ZONES(depth):
Top Bottom
1.WELL CONTRACT Top Bottom -
J 5�1 ni r>1 , ,Jr)S — Bottom Tdp__—— Bottom
.fop —
well Contractor Qndividual)Name Top_.- -
t .ram_ Bottom Thickness/
ell ppntraetor Company Name ? CASING: Depth Diameter Weight Material
}) � �J.( A .,i I-op Bottom Ft—
Street Address 1
TToP Bottom Ft.
FtBottom
MethodCitry.orT —a. GROUT- Depth Material L
Top�,eottom -�nn.
Area rode Phone number �� ��� � FL ("t (
2.WELL INFORMATION: Bottom FL'�
�. t tlllll[�1��
WELL CONSTRUCTION PERMIT# Top Bottom --
OTHER ASSOCIATED PERRAIT#(If apgioabkl g, SCREEN: Depth
Diameter Slot Size Material
SITE WELL ID#Of appllnbia) pL�_In_
Top Bottom
3.WELL USE(Chedt Applicable BOXY Residential Water Supply❑ �ttOm FL in. _. in. —
rop
DATE DRILLED Top BotbXtt Ft.in. In.
TIME COMPLETED_—__--- AM O PM 0
lo.SAND143RA PACK: at" material
th
4.WELL LOCATION:
Ft.
�.��-gyp �,[�,�1Jt;✓ Top Bottom
CITYJ_1a21_JLV11�J-----{COUNTY f� B�I�t Ft.
Lot No.,P�ml.21p Code) fop Bottom
Ft
(Street Name.Ntanners,Commu ,Subdviebn,
TOPOGRAPHIC 1 LAND SETTING: (check apPrOPnete box) 11,DRILLING LOG Formation Desoriptfon
❑Slope ciVailey oRat ❑RIdge p0mer___.-._.-- Top Bottom
LATITUDE 3 ,35"%�!'�77z "DMS OR 3X.XXXXXXXXX DO
LONGITUDE T�"`�� 'a l a `DMS OR 7X.XXXXXXXXX DO r —
PS d mphicmep
Latitudellongituds source: QT P°g Vlr l = '--
ih form if met/myst be
GPS)own on a tlSGS tOpo trap andatlached to ; )fir—_ 11
1}r�tve'r t5i{y gf IvnN� Cfdttiit ;,. A' t / -
5.WELLOWNl9t11_
` 1 )
Owner Name
Street Address
i��t1°�i111r 1�1C --
CityorTown Stele ape ��--
(--) 12. REMARKS:
Area code Phone mtmber
S.WELL DETAILS:
a, TOTAL DEPTH:
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ j DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,W ELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing;.____.— FT. STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use--v W Above Top of Casing) PROVIDE[) THELt OWNER.
d. TOP OF CASING IS FT.Above Land Sudace'
`Top Of casing terminated at/or below Iartd surfaoe:may require SIGNATURE OF CERTIFIED W ELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): _.METHOD OF TEST _
L DISINFECTION:TYPe Amount__
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev.2109

��.:srnrcq
o
RTIAL WELL CONSTRUCTION RECORD
g( North Carolina DeprimentofEnvironment and NaturalResources-Division of Water Quality
WELLCONTRACTOR CERTMCATION#
g_ WATER ZONES(depth): Top Bottom
1,WE"CONTRAC": Z�op Bottom
PUl 1 Y Top—
Top_op_—Bottom Bottom_
We11 Contractor(Individual)Name Top
fl A a-. II {Y� TOp__Bottom
k t� �\ )('"I I X A T' Thfeknessl
Yweli pntfeetor Company Name Diameter Weight Material
^e. CASING: Depth
l v x Top Bottom Ft--
iSM�t �� I /t �'. c= Bottom Ft
Top
Stets XPCode lop Bottom Ff.
CI or To /�
! /f�'� , 1,11.�. Metetiat Method
y �_ : A. GROUT: Depth � ��y'l (} � �( .
Area code Phone number - -�___Booam__]lli!_Ft
lt/� fop
2.WELL INFORMATION: \n 16 I"1( 1 �`-l"1 iop Bottom Ft.,
WELL CONSTRUCTION PERMIT# Top Botlom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Diameter Slot Size MpLeltei
SITE WELL IDfappllcahle) g. SCREEN: Depth
Bottom Ft.__in. In.
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft._in. _ in. -
DATE DRILLED � : Top_.—Bottom Ft in. in.
TIME COMPLETED_._-_— AM 11 PIM Q
10,SANDIGRAVEL PACK: She Material
&WELL LOCATION: �U� �) A Top Depth Ft
5hPV .
ctTy 11 f ( t Bottom
� � t
10 .lop Bosom Ft.
Bottom Ft.
.(Street Name.Number;.Cemmun ,Subdiviaio^,Let t'ln..Peal.ZIP Code? !op
TOPOGRAPHIC i LAND SETTING: (check b m) : 17.DRILLING LOG Formation DescdPflon
❑Stops ❑Valley ❑Flat ❑Ridge ❑Other___----- TOP Bottom
LATITUDEX35',3, G C I N•Divs OR 3X.xxXXXXX)CX DO
LONGITUDE T ��' L I( 0 "DMS OR 7?SL) c>>�.OD
re hiclnap _ � c,,\Ii �e
LatitudellongitudesouLce: PS QfGS P : ,Jl`
(locadon of well must be shown on a F/SGS topo map andattached to j 1
this form if not using GPS) , ) , +z--
Ltr iv r5i{y 0V Nc+4hCtbrulirr;. R4
S,WELL OWNER
Owner Name ��--
�C)� Pht11iG7 f
Street Address
---
3fete Zip Code /
City or Town /
(--7 S:
Area cads Phone number 12. REMARK
a.WELL DETAILS: (�
n, TOTAL DEPTH: 4u
b, DOES WELL REPLACE EXISTING WELL? YES� NO❑ DO HEREBY CERTIFY THAT--THIS WAS CONSTRUCTED UJ
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c, WATER LEVEL.Below Top of Casing: FT' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+"'rf Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface" -T„,�/��� ��,yyW,�
*Top of rasing terminated atlor below la d surface may require S(,�jjg7UR- E OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with ISA NCAC 2C.011& - E OF C
METHOD OF TEST CO a. YIELD(gpm):�
f. DISINFECTION:Type Amount : PRINTED NAME OF PERSON NSTRU�C SING THE WELL
Form GW-1a
Rev,2/09