WM0301152_GW-1 records and wells location Monitoring wells_20220801

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COLONIAL PIPELINE
PO BOX 87
PAW CREEK NC 28130
ATTN: MR JEFF TITUS
dwr/ew 10/26/21
11IIU'llpli!IIhWIiY@I ki III V!VIII
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COLONIAL PIPELINE
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PAW CREEK NC 28130
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WALKER -HILL ENVIRONMENTAL
4 SOUTH POPLAR STREET
FOXWORTH MS 39483
ATTN: MR FRANCIS HARRINGTON
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CASCADE DRILLING, LP
251 NC HIGHWAY 24 W.
MIDLAND NC 28107
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PARRAT-WOLF, INC.
501 MILLSTONE DRIVE
HILLSBOROUGH NC 27278
ATTN: MR KEVIN WHITE
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WALKER -HILL ENVIRONMENTAL
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FOXWORTH MS 39483
IITiN: MR FRANCIS HARRINGTON
dwr/ew 13/26/21
NIInNtlRillltl Vlllullll RI IilYill III
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CASCADE DRILLING, LP
251 NC HIGHWAY 24 W.
MIDLAND NC 28107
ATFN: MR JAMES HALL, JR
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HILLSBOROUGH NC 27278
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ROY COOPER
Cil1l'nl'l]S7/'
ELIZABETH S. BISER
SecretczrV
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
October 26, 2021
Certified Mail #7018 3090 0001 2319 0154
Return Receipt Requested
Mr. Jeff Titus (also via email)
Manager, Operations
Colonial Pipeline
P.O. Box 87
Paw Creek, NC 28130
RE: Monitoring Well Construction Permit
Permit # WM0301152
Colonial Pipeline
Huntersville Release Site
Mecklenburg County
Dear Mr. Titus,
In accordance with your application received on August 13, 2021, with additional information
provided including on October 21, 2021, we are forwarding herewith Monitoring Well Construction
Permit Numbered WM0301152 and issued for the construction of one hundred and forty-six (146)
monitoring wells located near the subject site in Huntersville, Mecklenburg County. Ninety-one (91)
of the wells have been installed prior to the issuance of this permit, leaving up to fifty-five (55)
additional monitor wells that are permitted to be installed if necessary.
This Permit will be effective for one year from the date of issuance and shall be subject to the
conditions and limitations as specified therein.
Should you have any questions, please contact Edward Watson at [phone], or by
email at edward.watson a(�,ncdenr.gov.
Sincerely,
L4.444tW
DocuSigned by:
HA
F161FB69A2084A3...
Andrew H. Pitner, P.G., Assistant Regional Supervisor
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources
CC: WQROS, Central Office (via Laserfiche)
Andrew Street, Apex Companies, LLC (via email)
North Carolina Department of Environmental Quality Divisor of Water Resources
Mooresville Regional Office I b10 East Center ,Avenue. Suite MI I klooresville. North Carolina 28115
%t) {,b.-,• .lb'14

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
Colonial Pipeline (Apex Companies as Agent)
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one hundred forty-six monitoring wells owned
by Colonial Pipeline near the subject site, in Huntersville, Mecklenburg County. This Permit is issued in accordance with
the application received on August 12, 2021, with additional information provided on October 21, 2021, in conformity with
specifications and supporting data, all of which are filed with the Department of Environmental Quality and are considered
integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well Construction
Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon
written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming to
Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail Service
Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being installed as
part of an investigation for contamination from an underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Resources' Information
Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C .0113 and a
well abandonment record (GW-30) shall be submitted to the Division of Water Resources' Information Processing
Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the well
shall be grouted within one day after the casing is set or the well abandoned.
8. Temporary wells must be permanently abandoned or converted to a permanent well within seven days (168 hours)
of completion of drilling the borehole.
9. Adequate permits shall be obtained from Mecklenburg County Groundwater and Wastewater Services.
Permit issued the 26th day of October, 2021
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
—DocuSigned by:
A4440w H P:z* 4
`—F161FB69A2D64A3...
Andrew H. Pitner, P.G., Assistant Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. # WM0301152
North Carolina Department or Environmental Quality Division 1r ✓ i:i r Re sources
Mooresville Regional Office 610 East Center \venue. Suite 301 I tleores, ille. North Coralina 23115
70.1.663.1699

GW-1 FORMS
\M-‘010 1152
I 4-G

Table 1
Summary of Parcel Ownership
Colonial Pipeline Company
2020-L 1-S R2448
Huntersville, North Carolina
NC PIN
Parcel ID
Property Address
Property Owner
Wells on property.
4660199946
1921203
14108 Huntersville-Concord Rd
CPC
MW-08, MW-13, MW-14, MW-14D, MW-39, MW-44, MW-45, MW-46, MW-
47, MW-49, MW-50, MW-51, MW-60, MW-62, MW-62D, MW-73, MW-76,
MW-86
4660291710
1921215
13937 Asbury Chapel Rd
Bellet, Marc L
N/A
4660296960
2104102
14226 Huntersville-Concord Rd
Brown, Jeffrey Wilson
MW-64, MW-65, MW-65D, MW-70, MW-74, MW-75
4661201097
1921230
14015 Asbury Chapel Rd
CPC
N/A
4660291878
1921231
13945 Asbury Chapel Rd
CPC
N/A
4661103003
1921212
13926 Huntersville-Concord Rd
Whitby, William E
MW-28
4660193695
1921204
13900 Huntersville-Concord Rd
Whitby, William E
MW-16, MW-16D, MW-17, MW-19, MW-21, MW-23, MW-31, MW-31D,
MW-40, MW-77, MW-78, MW-79, MW-79D, MW-80, MW-81, MW-82, MW-
83, MW-84, MW-85, MW-81D
4661202203
1921233
14130 Huntersville-Concord Rd
Razon, Carlito D
MW-11, MW-42, MW-66, MW-67, MW-68
4660292908
1921299
N/A
CPC
N/A
4661210470
1940102
14511 Huntersville-Concord Rd
Mecklenburg County
MW-01, MW-02, MW-03, MW-04, MW-05, MW-06, MW-07, MW-07D, MW-
09, MW-10, MW-12, MW-15, MW-18, MW-20, MW-22, MW-24, MW-25,
MW-25D, MW-26, MW-27, MW-29, MW-30, MW-32, MW-33, MW-34, MW-
35, MW-35D1, MW-36, MW-36D, MW-37, MW-38, MW-41, MW-43, MW-
48, MW-52, MW-53, MW-54, MW-55, MW-56, MW-56D1, MW-57, MW-
57D, MW-58, MW-59, MW-59D, MW-61, MW-61D, MW-63, MW-69, MW-
71, MW-72, MW-36D, MW-87, MW-88, MW-89, MW-90D2, MW-91D2, MW-
92,MW-93
Notes:
CPC = Colonial Pipeline Company
MW = Monitoring Well
N/A = Not Applicable
1 = Bedrock not encountered, boring abandoned before completion. GW-1 form not created due to well never being completed.
z = GW-1 form not included because well is an uncompleted, open borehole.
Page 1 of 1

This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
14. WATER ZONES
PROM.. Tt1_
ft.
ft.
IWSCRIPTiON
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (l.e. County, Stale, variance, Injection, etc)
3. Weil Use (check well use):
Water Supply Well:
°Agricultural
CGeothennal (Heating/Cooling Supply)
Clndustrial/Commercial
°irritation
°MunicipaUPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
IEMonitoring °Recovery
Injection Well:
°Aquifer Recharge CGroundwater Remediation
°Aquifer Storage and Recovery CS. linity Barrier
❑Aquifer Test ❑Stormwater Drainage
°Experimental Technology °Subsidence Control
°Geothermal (Closed Loop) °Tracer
©Geothermal (Heating/Cooling Return) °Other (explain under #21 Remarks)
4. Date Well8/24/2Os) Completed: Well ID#MW-1
5a. Well Location:
Colonial Pipeline
Facility/Owner Namc Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laulnng is sufficient)
610872.421 N 1461603.523
01940102
6. Is (are) the well(s): @Permanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or BNo
1f this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this farm.
1
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY wtih the same construction, you can
submit one form.
9. Total well depth below land surface: ()
For multiple welts list all depths if different (example- 3(a 200' and 2(a,100')
10. Static water level below top of casing: 28' 20 (ft)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8 (in•)
Auger
f
ft.
15. OUTER CASING i'or waltl•c
FROM TO iit,ttd
OR LINER of a aplicable _,,,
THICIZNE:S.s MATERIAL
ft. ft.
ER CASING OR TUBIPIG Geothermal eloscd-l+1nt1
FROM
TO
DIAMETER
i
THICKNESS
MATERIAL
+3
R.
ft.
19
ft.
ft.
2
in. i Sch 40
PVC
in.
12. Well construction method:
(i.c, auger, rotary, cable, direct push, etc.)
34.0
0
22 ft.
ft.
FROM TO _ MATERIAL
17 ft•
ft.
34
#2 Sand
17. SCREEN
FROM ? TO
19
ft.
5.
DIAMETERR SLOT SiZE
in. .010
THICKNESS 1 MATERIAL
Sch 40 £ PVC
18. GROUT
FROM TO
0 ft 15
ft
15
ft. 17 rt
MATERIAL EMPLACEMENT METHOD & AMOUNT
Grout
Bentonite
Tremie
Pour
ft. ft.
19. SAND/GRAVEL PACK $if applicable)
EMPLACEMENT METHOD
Pour
ft.
20. DRILLING LOG (attach additional sheets if weltsary)
F$tit>t........ TO DESCRIPTION tc^rtec itardoc dUrvcie iep , aaia sis+e, rtr
22.0 ft. Data available from boring log SB-37
34 ft.
Dark Gray silty Sand
ft.
rt. ft.
ft.
21. REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b. Disinfection type: ...._. ___
Amount:
22. Certification:
Signature of Certified Well Contractor
Date
By signing this form, 1 herehy certif}+ that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 154 WCAC 02C .0200 Well Construction Standards and that a
copy of This record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Wolf Contractor Certification Number
S&ME inc
Company Name
2. Weil Construction Permit #:
List all applicable well permits (i.e. County, Stale, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
Olndustrial/Commen ial
Irrigation
Non -Water Supply Well:
t Monitoring °Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Geothermal (Closed Loop) °Tracer
°Geothermal (Hea intt Cooling Return) °Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/25/20 Well DU MIN-2
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDt1(if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
awe!' field, one fat/long is sufficient)
610823.419 N 1461424.282
14. WATER ZONES
FROM
TO
DESCRIPTION
It.
R.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO DIAMETER ' TntCKNFA
MATERIAL
ft.
it. be.
16. INNER CASING OR TUBING tgrotbermal closed -loop)
FROM
TO
DIAMETER i TflICKNFSS
MATERIAL
+3 «•
19 fi.
2 In- Sch 40
PVC
ft.
ft.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS MATERIAL
19 ft-
34 e•
2 In.
.010
Sch 40 1 PVC
ft.
ft.
in
18. GROUT
FROM
0 n•
TO
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
15 ft•
i5 it.
17 ft.
Bentonite
Pour
19. SAND/GRAVEL PACK (1f applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
17 it•
34 tI•
#2 Sand
Pour
ft.
ft.
0.liifllItit12t)€1
(attach addili sf tsIfeerxsser3)
1 ROM
TO
DLSCiitt ION (color, balminess, soUtrock 1. pe. islet Sim etc.)
0 ft.
23.5 ft•
Brown Sandy Clay
23.5 fr•
34 ft.
Light Gray Silty Sand
ft.
ft.
ft.
ft
ft,
ft.
ft.
ft.
R.
f1.
21. REMARKS
leNe SJC!"? rt ,
22. Certification:
Ft: of Certified Well Contractor
6. Is (are) the well(s): tilPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ®No
1f this is a repair•, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this farm.
8. Number of wells constructed:
For multiple injection or non -water supply welts ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft•)
Far multiple wells list all depths if different (example
e-- 3(w200' and 2C100')
57
10. Static water level below top of easing: -9 9 __
1f inter level is above casing, use "+"
11. Borehole diameter: Q (In.)
12. Well construction method: Auger
(i.c. auger, rotary, cable, direct push, ow.)
34.0
(ft)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) _..._ Method of test:
13b. Disinfection type: Amount:
Date
Ily signing this form, 1 hereby certify that the wen(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Marl Service Center, Raleigh, NC 27699-1636
24c. For Water Supply Sr Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

This form can be used for single or mulliple wells
I. Weil Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
GAg icultural
GGeothermal (Heating/Cooling Supply)
D Industrial/Commercial
irrigation
Non -Water Supply Well:
RMonitoring DRecovery
Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Injection Well:
CAquifer Recharge
CAquifer Storage and Recovery
Cl Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
CGeothermal (Heating/Coolinn Return)
DGroundwater Remediation
D Salinity Barrier
C1Stonnwater Drainage
L�Subsidence Control
GTracer
DOther (explain under #21 Remarks)
14. WATER ZONES
FROM DESCRJpT10 V _ _
ft.
ft.
15 OUTER CASING (for mulf -eased walla} ORLIN1 R (if applicable}
E tttsst Its tztMVI'.ER THICKNESS MATERIAL
ft. ft.
SING OR 1 UBING (geothermal closed -coop)
FROM
TO
DIAMETER THICKNESS
MATERIAL
i +3
ft•
ft.
17
ft.
ft.
2
Sch 40
PVC
)
)
{
1 17. SCREEN
FROM TO
17 ft•30.0 ft.
ft.
DTAMETER
SLOT STD: , THICKNESS
.010
Sch 40
MATERIAL
PVC
18. GROUT
ft.
13 ft.
13
ft.
15 ft.
MATERIAL
Grout
Bentonite
EMPLACEMENT METHOD & AMOUNT
Tremie
Pour
ft. rt.
19 SAND/GRAVEL PACK ;If applicablei
FROM TO _.—., MATERIA1.
15 ft. 30 ft. #2 Sand
ft ft.
EMPLACEMENT METrtOD
Pour
20. DRILLING LOG (attach additional sheets if peerssar§')
M TO DESCRIPTia uS feeler, hardness, soiUrock t e. gran ar , etc.}
ft13 ir•� Brown Sandy Clay
FROM
0
4. Date Well(s) Completed: 8/25/20 Well LD# MW-3
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610971.458 N 1461854.757
•
6. Is (are) the well(s): ®Permanent or OTemporary
7. Is this a repair to an existing well: DYes or EINo
If this is a repair, fell out known well construction information and explain the nature of the
repair under 021 nenutrks section or an the back of this form.
1
8. Number dwells constructed:
For multiple injection or non -loafer supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below Land surface: "' "
For multiple wells list all depths if dt,(jerem (example- 3@200' and 2Q100')
_ ft.)
10. Static water level below top of casing: 22.78 (ft.)
If water level Is above casing, use "+"
11. Borehole diameter: 8 (in•)
12. Well construction method:
Auger
(i.e. auger, rotary, cable, direct push, etc.)
13 ft. 30 ft.
ft. ft.
Light Gray Silty Sand
FOR WATER SUPPLY WELLS ONLY:
Method of test:
13b. Disinfection type:.._.. _„_p,. Amount
ft.
ft.
ft.
0
21-REMARS
rt.
ft.
ft.
ft.
22. Certill Lion:
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and That a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. for All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

111L1 ibrni Carl el', llsea IOr Single or rn W Rple Wens
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Numbcs
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
[Agricultural
❑Geothermal (Heating/Cooling Supply)
Olnd ustrial/Commercial
Mutation
❑Municipal/Public
DResidential Water Supply (single)
[Residential Water Supply (shared)
Non -Water Supply Well:
©Monitoring [ Recovery.
Injection Well:
OAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
[Experimental Technology
❑Geothermal (Closed Loop)
OGeothennal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
OSubsidencc Control
[Tracer
()Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/28/20 Well ID# him-4
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610775.085 N 1461415.603
W
6. Is (are) the well(s): i3Permanent or ❑Temporary
7. Is this a repair to an exisdng well: [Yes or EINo
If this is a repair, fdl out known well construction information and explain the nature of the
repair under #2l remarks section or on the back of this form.
1
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form. �}
9. Total well depth below land surface: " ® ( )
For multiple wells list all depths if different (example- 3 00' 2 a1100')
10. Static water level below top of casing: 3 (ft)
',Twofer level is above casing, we "+"
11. Borehole diameter: 8 (in.)
Auger
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
r FROM
DESCRIPTION
ft.
ft.
ft.
15. OUTER CASING for
mutt -cased we8a) (?Ii l flstF.R iN a. lleabie
FROM TO
OIA Mt ibtt ttIIC`K?iE 4 MATERIAL
ft. ft.
In.
16. INNER CASING OR TUBING
eothermal closed -Won!
FROM
DIAMETER
THICKNESS
MATERIAL
+3 b•
R.
10 ft.
ft.
2 in-
t0.
Sch 40
PVC
17. SCREEN
FROM TO
DIAMETER
SLOT SITE
.010
THICKNESS MATERIAL
Sch 40 PVC
10 it. 40 ft.
2 in.
ft.
ft
in.
18. GROUT
FROM
TO
MATERIAL EMPLACEMENT METHOD & AMOUNT !
Grout Tremie
6 mm� ft•
0 ft*
6 ft.
8 ft•
Bentonite
Pour
ft.
ft.
19. SAND/GRAVEL .PACkg applleablet
FRO
TO
MATERIAL
EMPLACEMENT MET1tob
8 ft•
40 •
#2 Sand
Pour
ft.
ft.
20. DRELL%N#
;LtX (attach
additional sheets if accessary)
FROM
TO
F&F'- i`S8T1'r20N {cu8or. her inrs r iU'rack f+I e. gala uie, etc.;
0 f.
14 ft.
Brown Sandy Clay
14 ft-
40 ft.
Gray Brown to Gray Silty Sand
a
ft.
ft.
_
ft.
ft
ft.
ft.
Ft.
15.
.... .
R.
it.
..._......
21. REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) �. Method of test:
13b. Disinfection type: Amount:
22. Certcation:
r,
Signature of Certified Well Contractor`
Ily signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Welts Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Welts ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 276994636
24c. For Water Supply & Injection Wells:
Mso submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
14. WATER ZONES
r inOim
DESCRIPTION
ft.
It.
2907-A
NC Wall Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
LLvt all applicable well permits (i.e. County, Slate, Variance, Injection, etc,)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irril,ation
Non -Water Supply Well:
©Monitoring
OMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
°Subsidence Control
❑Tracer
❑Other (^xplain under #21 Remarks)
4. Date Well(s) Completed: 8/28/20 Well 1D# MW-5
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDI: (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
ft. rt.
15 OUTER CASING (for multi -cased wean OR LINER dfsppllcablel _m
FROM .T #
O ii1AT,t11Trrr i THICKNESS KNE_SS 'NATFRtAL
ft. 1IL
16 INNER CASING OR TUBING eothermal closed -loop) -
FROM TO T. DIAMETER ° THICKNESS MATSATAL -
+3 ft• 9 ft. 2 in• i Sch 40
•
17. SCREEN
FROM
18. GROUT
FROM
(0
5
ft.
To
5
ft. 7
DIAMETER
PVC
SLOT SIZE t THICKNESS MATERIAL
.010 Sch 40 ? PVC
_M.tTERIAI EMPLACEMENT METHOD &AMOUNT
Grout Tremie .-.._...
Bentonite Pour-
ft. ft.
19. SAND/GRAVEL PACK tf applicable)
FROM...-.... TO w.•- MATERIAL
7 ft. 39 #2 Sand
ft. ft.
�20 DRILLING LOG attach additi
"{t€oi ; TO
0 ft.
22.5
ft.
21. REMARKS
01940102 ( Pe (i)
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610997.941 N 1461596.988
6. Is (are) the well(s): Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or No
If this is a repair, fill nut known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
1
5. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one.frxm,
9. Total well depth below land surface:' 0:
For multiple wells list all depths if different (example- 3 00' and 20i 100')
10. Static water level below top of easing: 2 7' 04
If water level is above casing, use "+"
1 I. Borehole diameter:
12. Well construction method:
8 0.0
Auger
(i.c. auger, rotary, cable, direct push, etc.)
(ft.)
- (ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _...._.__._ Method of test:
13b..Disinfection type:
Amount:
22. Certification:
rc of Certified Well Contractor
`—EMPLACEMENT METHOD
beets If necesary)
Pour
/color. horde s soil/rock hpe, grain c, eta./
Brown Sandy Clay
Brown to Gray Silty Sand
ICJ!/16, /
By .signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 154 NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standants and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well.
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Sujipiy & Infection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

1. Well Contractor lnformatiou:
Thomas Whitehead
14. WATER ZONES
Well Contactor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e, County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
❑Irrigation
Non -Water Supply Well:
OMonitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Mtnticipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
DStonnwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Retum) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/29/20 Well ID# MW-6
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
PhysicalMAddress, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610954.120 N 1461495.917
6. Is (are) the well(s): WiPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or HNo
If this is a repair, fill out known well construction Information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one farm
9. Total well depth below land surface: 40 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2 r@r 10O')
10. Static water level below top of casing:
If water level is above casing use "+"
11. Borehole diameter: 8 0n.)
12. Well construction method:
27.04
Auger
(ft.)
(i.e. auger, mtary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ,_,_ Method of test:
13b. Disinfection type: _._._..
Amount•.
FROM TO
ft.
ft.
15. OUTER CASING (for multi -eased wens) OR LINER If licsble
FROM TO DIAMETER THICKNESS MATERIAL
fit.
s.
in.
16. INNER CASING OR TUDJNG (geothermal closed-tair)
FROM TO DIAMETER THICKNESS
+3 ft. 10 ff.
ft.
!7. SCREEN
2 iH-
tn.
Sch 40
MATERIAL
PVC
FROM
110 R.
DIAMETER
SLOT SITE TRICKNESS 1 MATERIAL
0 ft.
ft.
ft.
2
In.
.010
Sch 40 PVC
le. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
6
ft.
ft.
6
8
ft.
ft.
ft.
ft.
Grout ; Tremie
i
Bentonite Pour
19. SAND/GRAVEL PACK (If applicable)
FROM TO MATERIAL
R.
40
ft.
#2 Sand
EMPLACEMENT METHOD
Pour
ft.
i 7ti, DRILLING LOG tsttacb additional sheets If necessary)
DFSC'RW fRitti (color, hardness,soWnock tips. main we etc.]
FROM
0
5.5
13
ft.
ft.
ft.
TO
5.5 ft.
22.5 ft.
ft.
40
13
ft.
22.5 ff.
ft.
Brown Silty Sand
Gray Sandy Silt
Gray Silty Sand
ft.
ft.
Gray Sandy Silt
ft.
21. REMARKS
5)o'n
22. Certification:
of Certified Well Contractor
a;'tG �l
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
SUBMITTAL INSTITUTIONS
24a. FQr Alt %ells Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health deparment of the county where
constructed.

1. Well LAM tractor InterMation:
Thomas Whitehead
Well Coutracmr Name
29'07-A
14. WATER ZONES
FROM TO
DESCRIPTION'
ft,
ft.
NC Well Contractor Certification Number
S&ME Inc
15. OUTER CASINGLfor mold -eased wed ORLINER jtf a limbic",
FROM 10 DIAMETER THICKNESS 4r,pJttRIA
ft.
ft.
m.
Company Namc
2. Well Construction Permit #:
List all applicable well permits (Le. County, State, Variance, Injection, etc.)
3. Well Use (check weft use):
16. INNER CASING OR TUBING j eothermal closed -loop)
FROM TO DIAMETER THICKNESS
+3
ft.
20
ft.
2
1*.
Sch 40
MATERIAL -
PVC
a
11. SCREEN
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cdoling Supply)
❑lndustrialJCommercial
❑Irrigation
Non -Water Supply Well:
CrlMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (; splain under #21 Remarks)
4. Date Weil(s) Completed: 8/30/2 Weft 1D# MW-7
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Addreas, City, and Zip
Mecklenburg
01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is sufficient)
610983.987 N 1462042.726
6. is (are) the well(s): ®Permanent or DTemporary
W
7. Is this a repair to an existing well: ❑Yea or MNo
if this is a repair, fill nut known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one form.
1
❑Municipal/Pubfic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
9. Total well depth below land surface:35
(ft.)
For multiple wells list all depths if drfferenr (example- 3(4200' and 2©100'
10. Static water level below top of casing: 31.77 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
Auger
12. Weil construction method:
(i.e. augur, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
20 ft. ° 35 ft.
FROM 1 TO DIAMETER
is
SLOT SIZE THICKNESS MATERIAL
.010
Sch 40
PVC
ft.
ft.
18. GROUT
FROM
0 ft.
TO
16
ft.
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
16
ft.
18 fa
Bentonite
Pour
1L
ft.
19. SSANDIGRAVEL PACK 111 applicable)
.....FROM TO MATERIAL
18 n 35 cr. #2 Sand
ft. ft.
EMPLACEMENT METHOD
Pour
20. DRILLING LOG attach additional sheets if necessar
FROM TO nt»SCRti't7CS t r, l3stdaa
10 ft' 8.5
18.5 ft• 16
ft,
Orange Sandy Clay
Brown Clayey Sand
raie sire. etc.)
35
ft.
Gray Silty Sand
ft.
1. REMARKS
22. Certification:
Si Certified Well Contractor
ore ofCcrG
atO
D047
By signing this form, 1 hereby certj that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction :Stumlards and that a
copy of this record has been pmvided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTUCTIONS
24a. For All Wel : Submit this form
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply &erection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
within 30 days of completion of well
Form GW.1
North ('orniino rlane.n..,-nr _c air-. - n_

1, Well Contractor Information:
mcutivED/NCDEQ/DWI
Well Contractor Name
Y3 61
NC Well Contra'etor Certification Number
Wet / kar Hill E, Y (ro e h �
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (t.e. U1C, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
.Agricutnital
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
()Municipal/Public
QResidential Water Supply (single)
()Residential Water Supply (shared)
rJRecovery
Aquifer Recharge 0Groundwater Remediation
•!Aquifer Storage and Recovery E3Salinity Barrier
Agaffer Test GStormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop) ()Tracer'
Geothermal (Heating/Cooling Return) rlOther (explain under #21 Remarks)
4. Date Well(s) Completed: 02/20 20 Well lD# Tfll4/- D 9 D
5a, Well Location:
ColeofIa/ f'p e tCIE
Facility/Owner Name . Facility ID# (if applicable)
Nanit rIv 1lc - £'o, 'ord Rd ye�
Physical Address, City, and Zip 2 P 0 tft
frit c k ten d urj 1"10102
County Parcel Identification No, (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well.fietd, one lat/long is sufficient)
6, Is(are) the well(s) Permanent or Elrremporary
7. Is this a repair to an existing well: ()Yes or )No
1f obis tx rr repair•, fill out !mown well construction information an eaplatn the nature of the
repair under n21 remarks section or on the back taf thtr fr7Ytn,
$. For GeoprohelDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 G -1 is needed, Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface: 9t9
For multiple wells list all depths tf different (example- ,4(o?20t1' and 2@i00 )
10. Static water level below top of easing:
If water level is above casing, are "* "
Borehole diameter:
12, Well construction method: `,0,C
(i.o. auger, rotary, cable, direct push, etc.)
//e
14. WAT1;.R'ZON $
PROM
TO
DESCRIPTION
ft,
ff.
ft.
—' —
ft,SVILLE
REGIONAL 0
5. t)UTSIt CASING' (foranuIQ%gnced 'svcll;n)'012 LINE%t (ifapplJeaglej
FROM
To
DIAMETER
11i3CKNESS I MATERIAL
y"' 3 ft,
78 ft.Li
tn.
.SG/! Yo PGc i
lei 112;Ci;,Sliy04.1ii
1'11BU.(U/-(
etheritnii closed,laap)
FROM
'l'O
DIAMETKR
THICKN7+SS
MATERIAL
ft,
ft.
In,
ft.
ft.
In.
FROM
'I'O
DIAMETERI SI 0IME
'flilCKi eel
MATERIAL
ft,
ft,
In,
1't,
ft,
In,
i3.Gatati
FROM
TO
MATERIAL.
EMPLACRMENI'METtOD&AMOUNT
��
�>`irl�l•r�
Tlitlrrtlr
ft.
ft,
ft.
ft,
19,, *ND/4
11A VT L 1 ACK
(11' apptivablc) '
FROM
Y'o
MATERL1L
EMPLACEMENTMETHOD
fr.
ft,
ft,
rt,
'20; DRJL(INC t,r)1; (iittceh
ed lidonnl sheets ir nee ryl
r±ROyl
TO
UESCRIP'rlON j,,clior, Itarants3, tuturock1 pjreIe floe, etc,)
Q ft.
?, ft,
1 Q /C t�tc -s F ii' ' lay
2, 3ft,
17, ( a'
/
RaiS� (! c S h'
19, rt'
20 ft,
ctav grown SI l t1 Sah4/
,v ft,
27. "'
! _, J1�^h
9'7.
6 Q
°ark alda&r -rQno�
t
.Qa '
6 ft.
h�iShl/v W l-cried/ DiPrlto
ft.
aartit�.
21.RLczARS
Svrffi
22, Certification:
i ./7/20wv
Siruarute of Certified Well Contraricx Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C ,0100 or 114 NCAC 02C .0200 Well Coushuction Standards and that a
copy of this record has been provided to the well owner,
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, 1+'M' All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ftM)' -. Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c, For Water Simply & Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed,
ICE
Form GW • t
North Carolina Department of environmental Ouelity - Division of Water Reamirers

For Internal Use Only:
RECEIVED/NCDEQ/ WR-T
14. 'WA' 1' R'70NE,S
Physical Address, City, and Zip
rne,ckter) hlilr9
County
vVI±,,LL L;UiVS'f1(UCTION RECORD (GW-1)
I. Well Contractor Innformation:
t.1AetiriE?l i"7rsi(P slTvl
We;! Contractor Name
NC Well Contractor Certification Number
r %rfker l- i'1i1 12U1r.s;.jp-fr s2J/<r1
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (i.e. t11C, County, Stare, Variance, etc)
3. Well Use (check well use):
Water Supply Weil:
h Agticultural
Geothermal (Heating/Cooling Supply)
brdustrial/Cotnmercio l
Irrigation.
Nun -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
'Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
In Geothernal (Closed Loop)
OGeothermal (Heating/Cooling Return)
DMunicipaUPublic
DResidential Water Supply (single)
DResidential Water Supply (shared)
0
e
Groundwater Remediation
Salinity Barrier
Stonnwater Drainage
Subsidence Control
Tracer.
Other (explain under #21 Rcanarks)
4. Date Well(s) Completed: S x, ,?..) Q Well ID#
5a. Well Location:
tea1.eie' 1 ) pL"(J11
Facility/Owner Name
•8
Facility ID# (if applicable)
FROM
TO
ft.
ft:
i3CMPTION
WORDS
,. r r ncc
11
THICKNESS MAL
ft, ft. nArF1RGCC7i1TF"PrrnvRcvr„ICE
1$, DOTER CrtiSINC (foi multi -cased wait
MOM TO DIAMETER
ft, it, In,
16; INltfER CASING OR TUIIIrTG`fgeethern at closed -loop) - lomat sOf. DIAMETER rtllCKNESS�M1IA FRI'.
yt h ft, t7 ft. iJ In,
sei ft. ft, In. Se:
17: SCREEN
FROM TO
ft. ft,
DIA, EU.
tn.
In,
SLOT SIZE
0 /0
18.4312Qt1T
FRO
/ ft,
^r ft,
ft.
TO
ft.
/ r ft,
ft,
THICKNESS —MATERIAL
Pv
i4)AThRL{t, __- E II't_ACEMENT METHOD ttOD 3 AMO NT
CC/yi c+•tt %rt r7t h3-
19. SAND/GRAVEL PACK (if applicable)
ettos) 7'Et MATERIAL
F ft.
ft,
ft
/3?2' /1-v+/'/Lt"C(.,/ 1 r' ' C rtCU,'c e f fit. "r;tt� rr,
2,51a'),y
01172/2/2
ft.
'Y`s7
EhiPLACEMI r ttE.I IIOD
L++`trAa: it 6 c41a
20..iiRiLLitiG LOG (attach nddliiensl sheets;if neccasa
mom DESCRIPTION. (voter, hnrdrt iz, talUrrrrk t};pa, grale site, etc.
ft, `'ft i c nc�lt1 t
1. ft,22..2, i ft,
-4,44,,.r i/err
2��1 It. 3 0 ft.
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well held, one latilong is sufficient)
N
6, Is(are) the well(s)
Permanent or OTemporary
7, Is this a repair to an existing well: Dyes or No
If this is a repair, fill out known well construction inftruratton and explain the nature of the
repair under #21 remarks .section or on the buck of thirfornr.
8, For Geoprobe,DPT or Closed -Loop Geothermal Wells having the same
conattuction, only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
drilled:_,
9, Total well depth below land surface:
For multiple wells list all depths ifdifferent (example- 3 a,200`and 2(cT /00 7
10, Static water level below top of casing: !t1///4
/jwater level is above casing, use
11. Borehole diameter:
12, Well construction method: ri,ci[2tr;.
(Le. auger, rotary, cable, direct push, ctc.)
(Ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gprn) Method of test:
13b. Disinfection type: Amount:
ft,
TO
ft.
21. REMAR
S
22, Cef€cation:
Signature of Certified Well Contractor
By signing thus frrro, I hereby certffr that the well(s) was (were) constructed !n accordance
with 134 NCAC 02C .0100 or 1.14 NC.iC 02C .0200 Well Construction Standards w/ that a
copy of this record has been provided to the well owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this fore within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. Fur infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699.1636
24c. For Water Supply & Infection Wells: In addition to sending the forrn to
the addresses) above, also submit one copy copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed,

Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Ctatification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e.. County, State, Variance, Injection, etc,
3. Well Use (check well use):
! 15. OUTER CASING (for Wulff -cased wells) OR LINER jN applicable i
r FROM TO DIAMETER 'tntt'KNES% MATERIAL
In.
it ft.
MANNER CASING OR TUBING teothermal dosed-too4p}
FROM TO DIAMETER THICKNESS MATERIAL
+3 ft•
ft.
19
ft.
2
In.
Sch 40
PVC
ft.
17. SCREEN
Water Supply Well:
DAgricuitural
°Geothermal (Heating/Cooling Supply)
Olndustrial/Commerciai
Dlrrig3tion
Non -Water Supply Well:
Monitoring °Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
OGroundwater Remediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
°Geothermal (Heating/Cooling Return) DOther (explain under #21 Remadcs)
8/31 /20 MW-9
4. Date Well(s) Completed: Wen ID#
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
14511 Huntersville
Facility ID# (if applicable)
-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
610766.024 iv 1461606.198
6. Is (are) the wen(s): ®Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or EJNo
11. this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same conOr ashen, you can
submit one form.
9. Total well depth below land surface: 34
For multiple wells list all depths if different (example- 34200' and 2(4)100')
10. Static water level below top of casing: 28.82
If water level is above casing, use "+„
11. Borehole diameter: 8 aft.)
12. Well construction method:
❑Mrnticipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection types Amount:..
FROM TO
19 ft• , 34
ft.
DIAMETER
2
hi.
LOT SIZE
.010
THICKNESS
Sch 40
MATERIAL
PVC
ft. ft.
18. GROUT
FROM
TO
0
ft.
15
ft.
_, MATRRIAI. F EMPLACEMENT METHOD & AMOUNT
Grout i; Tramiel
15
ft.
17 ft.
Bentonite I Pour
ft.
ft.
19. SAND/GRAVEL PACK Pi applicable)
FROM TO MATERIAL
'17
ft.
34
ft.
ft.
20. DRILLING LOGGnr
FROM
TO
0 ft- 4
#2 Sand
EMPLACEMENT METHOD
Pour
Rrt'"i`tCss {taker. kartfnEs tuiUrae� rY,=.. ,�-nin sir., etc
ft. Brown Sandy Clay
4 ft• 29.5 It.
Red Brown to Gray Clayey Sand
29.5 ft. 34
ft.
Brown Silty Sand
fr. ft.
ft.__ ft.
f. ft.
ft.
21. REMARKS
bn
22. Certification:
tDj�J
stair o Ccrtificd Well Contractor Datc
By signing this form, I hereby cent* that the well(s) was (were) constructed in accordance
with 15A NCAC. 02C.0/00 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessaty.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27694-1636
24e. For Water Su I & In'ection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form G W-.t
North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
14. WATER ZONES
FROM
ft.
DESCRiP72ON
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Namc
2. Well Construction Permit #:
1.iCt all applicable well permits tie. County, State, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Weil:
Monitoring
❑MunicipalPublic
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heatiry;Cooling Return)
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
°Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/31 /20 Well ID# MW-10
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
0194 102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610518.259 N 1461415.944
6. Is (are) the well(s): iaPermanent or °Temporary
7. Is this a repair to an existing wen: ❑Yes or E'ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -wester supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 25 (ft.)
For multiple wells list all depths if different (example- 3 00"and 2®1001
10. Static water level below top of casing: N A (ft )
If water level is above casing, use "+
11. Borehole diameter: 8
12. Wen construction method:
Auger
(Lc. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
13h. Disinfection type:
Method of test:
Amount:
ft.
15.OUTER CASING ffor multi -cased wells) OR LINER Of a
FROM
ft.
TO
ft.
DiAMETBR
in.
THICKNESS
Cable)
MATERIAL
MANNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER TIUCKNESS
+3 ft. 10 ft: 2 h° son 40
MATERIAL
PVC
ft.
17. SCREEN
FROM TO DIAMETER
10 ft. 25 ft. 2
SLOT SIZE
.010
RiCKNFXS
Sch 40
MATERIAL
PVC
ft.
ft.
18. GROUT
FROM
0
ft.
TO
5
MATERIAL
ft.
Grout
EMPLACYMENT METHOD & AMOUNT
Tremie
5 ft. 8
Bentonite
Pour
ft.
ft.
19. SAND/GRAVEL PACED' applicable!
FROM
8 fa 25
TO
ft.
fr.
ft.
MATERIAL
#2 Sand
EMPLACEMENT METHOD
Pour
FROM
0
2
4.5
20
Lt^iti LOC (attach, addill
TO PESCRIPTio,
ft. 2
ft.
It.
ft.
4.5
20
25
ft.
ft.
It.
ft.
ft.
ft.
11
rt.
canary)
rdaass, solProck tares. }:rain slat, etc.!
Topsoil Organics
Red Brown Sandy Clay
Red Brown to Gray Clayey Sift
PWR
ft. ft.
21. REMARKS
Pei/LOCl/1
22. Ce anon:
1C) l� �I
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards. and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this Soren within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

WELL CONSTRUCTION RECORD (GW-I)
1, Well Contractor Information;
bt`)
For Internal Use Only:
flECEIVED1 NODCQ,hD1VR
SEP 2 0 '7071
Physical Address, City, and Zip
m�to ckler1 ur
County
Well Contractor Name
8 M
NC Well Contractor Certification Number
Um C
1 �( Ti1f �-'Alf 'x >�d♦
Company Name
2. Well Construction Permit #:
List all applicable well consultation permits (i.e. UiC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
ndustrial/Commercial
Irrigation
Non -Water Supply Well:
s, Monitoring
Injection Well:
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Aquifer Recharge }Groundwater Remediation
goiter Storage and Recovery DSalinity Barrier
goiter Test OStormwater Drainage
Experimental Technology Subsidence Control
Getrhennal (Closed Loop) OTracer
Cieothet'iw l (Heating/Cooling Return) QlOther (explainunder#21 Remarks)
4. Date Well(s) Completed: 9/L / 2020 Well ID# / r Atli /1
5a, Well Location:
Facility/Owner Name
Facility [.D# (if applicable)
13 C2 6 1)4i. 1 r ,1 lit • c i C o, /
24.096,
org2/2/2.
Parcel Identification No. (?IN)
5b, Latitude and longitude in degrees/minutes/seconds or decitnal degrees:
(if well field, one iat/long is aufflieienq
6, Is(are) the well(s)
Permanent or OTemporary
w
7 Is this a repair to an existing well: EjYes or ,No
/stills is a repar, fill out known wall constmintlan tttfhmnazttan and explain the nature of the
repair under 0/ remarks srctlatt or on the back of this jin'nr.
8, For GeoprobetDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:,
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3Oa 200' and 2@ay/001
10. Static water level below top of casing: (ft)
if water level is above easing, use '
11, Borehole diameter: t3 (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
):Lc
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
DRILLING LOG' attach additional'sheats-lf neacs
TO
4. WATER zONEs
FROM TO
DESCRI PTI
Iu: DC1;
FROt42
ft.
ft,
ft'.
ft.
MOORESVILLE REGIONAL OFFICE
-R CAS'.
TO
G:;(for .multi -cased well
DIAMETER
ft. ft. In.
16, INNER CASING COR't'1fB1NG',(geatliartne closer) -loop)
DIAMETER THICKNESS 1 MATERIAL
V
y ` ft. /( f, i) In, t aTC.,4 7!0 V(.
ft, ft. in.
)`OR LINER Of 1
THICKNESS
If ROM TO
cable)
MATF,RLit,
ri7.;spRE N
FRAM 1 TO
l ar^ ft, `
ft.
Rohl TO
ft, ft.
ft,
ft,
I T1i>R SLO ST/E
In,
In,
9. S,,piDtGRAVI(L PACK (if applicable)
FROM TO MAT1iliu.A1. f h:t'. O
12. z
_ 1
rIIlctcIESS
13.h11'LACkMtYTAil
AI; 1w
Tl On qf Aatnt»1 t
ft.
ft,
ft,
(t.
ft.
ft.
ft,
21. R
ft,
ft,
ft.
ft.
ft,
ft.
22Certification
4441,441
Si_ttnature of Certified Well Contraeto
SCfi1PTIO/e (rater hardness,.SalPrink type, grata nice, etc,;
1
Se_,?...
EhI PLACES
mo i tt`t_
i i t- (/ h,"/ .1 G
CA, !Inez,,'1
Ile. tong thirlorm, / hereby cerli/y that the well(s) was (were) constructed in accordance
with /5.1 NCAC 02C.0100 or 154 N.1C 02C .0200 Well Construction Standards and that a
CON, ofthis record has been provided to the well owner.
23, Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this form within 30 days of completion of well
constriction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
2'4b, For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells; In addition to sending the form to
the address(es) above, also submit ono copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultura1
❑Geothermal (Heating/Cooling Supply)
Olndustria1/Commercial
Olniintion
Non -Water Supply Wen:
El Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
°Groundwater Remediation
❑Salinity Barrier
C1Stormwater Drainage
°Subsidence Control
❑Tracer
❑Geothermal IHeastingiCooling Return) Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/27/20 Well 1D# MW-12
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
35.41455 N-80.80797
6. Is (are) the well(s): @Permanent or ❑Temporary
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you cart
submit one fain.
7. Is this a repair to an existing wen: ❑Yea or BNo
(irks is a repair, fdl out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
9. Total well depth below land surface: 40.94 (it,)
For multiple wells list all depths if different (example- 3 00and 2(100')
10. Static water level below top of casing: ° /A (ft.)
ijwafer level m above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
Auger
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: --_-- Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
fL
19 OUTER CASING for
w
maid -caned wefts ORLINVER ate lIcatde)
FROM
TO
t5tn tt t R
I3 n t( Y} MATERIAL
ft.
16. INNER
CASING OR TUBING
(geothermal closed4
TO
DIAMETER THICKNESS MATERIAL
0 ft.
20 ft.
2 to-
Sch 40
17. SCREEN
FROM TO
DIAMETER
SLOT SITE
THICKNE&S
MATERIAL
20 ft. 40 tr.
2 in.
.010
Sch 40
ft. iPit.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
17 ft.
Grout
Tremie
17 ft•
18 ft.
Bentonite
Pour
ft.
ft.
19. SAND/C=RAVEL
PACK
(If spplicablel
FROM
TO
MATERIAL
EMPLACEMENT METHOD
18 ft
40 ft.
#2 Sand
Pour
ft.
ft.
29 DRILLING
LOG {at tasit ad art it #S dteces r
t R8r st
TO
Dt C€;Rti tits €corer, hatd.,0m, soWrock qee ;rein act. etc.)
0 ft.
3 ft.
Dark Brown Clay
3 ft-
38 ft.
Light Brown Clay
it.
ft.
ft.
ft.
ft.
tz.
ft.
ft.
ft.
ft.
21. REMARKS
ev/5tUr)
22. Certification:
%mature of Certified Well Contractor
-9020 /0// /0)/
Date
By signing this form, 1 hereby certf that the welts) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 1n the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of welt
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of' this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Man Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

1, Well Contractor Information:
rt�
Is
Well Contractor Name
I
r
For Internal Use Only;
14. WATER ZONES
2021
1
1
1
a
me
1
Mr
1
NC Well Contractor Certification Number
c
Company Name
2. Well Construction Permit #:
List all applicable well construction permits /1 e VIC Count
y, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agriculiural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irritation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin. Coolin_ Return)
4, Date Well(s) Completed:1k60....4LWell ID#
5a. Well Location;
Factltty;OwnerName
DMunicipatPubtic
DResidentiat Water Supply (single)
DResidentiai Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStornnvater Drainage
DSubsidence Control
0Tracer
Other (ex lain under #21 Remarks)
Facility ID# (if applicable)
25)0
Parcel Identification No. (PiN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
�s y�312� N
6. Is(are) the well(s)
ri•
Permanent or Temporary
7. Is this a repair to an existing well: DYes
or EnNo
If this is a repair, fill out knotwr well construction information and explain the nature of the
repair tinder #21 remarks section or on the hack of this form,
S. For GeoprobetDPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed, indicate TOTAL NUMBER of welts
drilled:
9. Total well depth below land surface:
For mulnple wells list all depths ifdifferent (example- 3 ,200 2@)100
10. Static water level below top of casing:
if water level is above casing, use "r.•'
11. Borehole diameter:
12, Well construction method:
(i _e, auger,:otary, cable, direct push, etc.)^ --
FOR WATER SUPPLY WELLS ONLY:
13 a. Yield (gpm)
Method of test:
13 b, Disinfection type:
Amount:
w
(ft.)
(ft,)
FROM
FROM
unimmilTO
ft.
ft.
DESCRIPTION
1I
RA
SVILLE REGIONAL OFFI
OR LINER r' ucablc
-numeDiAit9
16. INNER CASING:'oR TUBING ° • eothermal closed-leo ,
BM
TO DLUVXETER THICKNESS
MATERIAL
11111111111 4/0
15':OUTLRCASINGfor ma18•cased well
TO
ft.i
17; SCREEN
FROM TO
fL
GROUT
FROM
`1 R.
ft,
TO
ft.
13 ft.
wIlL'EffniZENI
11111111111
ft.
19. SAND/GRAVEL ' PACK
FROi4
20.. s RILLING LOG
FROM rn
22
21. RE
ft,
fL
rt.
f
attach
ft.
6ft.
If
llcable
t 'I
MATERIAL
p
THICKNESS MIATERLIL
v•-
EMPLACEMENT METHOD & AAIOtiN
P- red
fri
EMPLACEMENT METHOD
fc
additional sheets.if necessa'.
DESCRIPTION color bardneis snit/rock .e •rain size etr,)
et 5ii�
ft. ft. t _
ft. ft.
22, Certification:
Signature of Certified Well Contractor
Date
By the
with signing
NCAC 02C , 0100 ar 15,4 NCACt0 2C 0 00IWell Consmuction Standards
nsoucted and that
ia
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or wei;
construction details. You may also attach additional pages if necessary
SUBMITTAL INSTRUCTIONS
24a, For Wad: Submit this form within 30 days of completion of well
construction All to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. or Iniectl_`n wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water SuDniv & Infection Wells:
the address(es) above, also submit one copyIn addition to sending the farm to
completion of well construction to the county health of sdepartment of the fonn within 30 dcounty
ays of
where constructed.
2v2v

Tint Form
•
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: y�
-JCtN1e /by/j die
Well Contractor Name I I'
NI0V 0 4 ?On
NC Well Contractor Certification Number
Cascade Drilling, LP
For Internal Use Only:
14' YI!A7',Ek ZONES
FROM
TO
DESCRIPTION
4156 s
15;.OUTER CASING (for,multr cased: wells) O1 L1t R(if'ap btaWe)
THICKNESS MATERIAL
ft.
ft.
Company Name I'.I-:OIOI:!/VI
I Ii;
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (IIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
�i Industrial/Commercial
Irrigation
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Recovery
Injection Well:
I Aquifer Recharge
iAquifer Storage and Recovery
�i Aquifer Test
Experimental Technology
(It Geothermal (Closed Loop)
!Geothermal (Heating/Cooling Return)
1
11
4. Date Well(s) Completed: 9
DGroundwater Remediation
DSalinity Barrier
DStormwater Drainage
0ISubsidence Control
Di Tracer
Other (explain underf#21 Remarks)J
Well ID# /7 1V �/1/
5a. Well%%Location: CO/Or0t a'/ P4 e
Facilliity/OwnerNa/me Facility ID# if applicable)
/iordi Uh11j'— (o %eosc :l f�C
Physipal Address,dr/City, and Zip
}ge, Il/t°r1 44, e�9 C
County /
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s)'Permanent or oTemporary
7. Is this a repair to an existing well: DYes or xi No
If this is a repair,1111 out known well construction information and explain the nature of the
repair under #21 remarks section or on the hack of this, form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: •
For multiple wells list all depths ifdifferent (example- 30' and 2(100')
9. Total well depth below land surface:
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
c('pti/C,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FROM
ft.
ft.
TO
ft.
ft.
DIAMETER
in.
16t-IN1VER CASING AIt 9 UBING (peothermal'Clo"sad loop)'':`
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
/ r ft.
/ ft.
184GROUL
in.
let in.
/c/ Z)
t O
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
V ft.
ft.
ft.
ft.
c%G'rk.71
ft.
ft.
19:54ND(GRAV .rPA'C
If Applresble)
FROM
TO
cj ft.
ft.
ft.
ft.
MA ERIAL
EMPLACEMENT METHOD
r/e1,,M/(eat
:20ARii'13NCOIibCI:?(91tac6::additio�el'.sli'eefs ifidecesssfyj;5r,':�'•
FROM
ft.
TO
ft.
DESCRIPTION (color, hominess, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
OCT 2620
20
21, REMARKS
Irfiatrv,a��ei
[)vi'
22. Certificatio i :
Signatur : ' " i ell Contractor
Date
By signing this ,form, 1 hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county

I. Well Contractor information:
Ke12 i t ei4, F-Q
Welt Contractor Name
NC Well Contractor Certification Number
P•rty .n W* 1
Company Name
2. Well Construction Permit #:
l.ist all applicable well construction permits (i.e. (11(', County, State, Variance, etc.)
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑Geothenal (lleating/Cooling Supply)
❑industrial/Commercial
❑ Irrigation
Non-Water`,o��Supply Well:
I]dMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells> 100,000 GPD
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifcr'I'est
❑iixperimental 'technology
❑Geothermal (Closed Loop)
❑Geothermal (tleating/Cooling Return)
❑Groundwater Remediation
❑Salinity 13arrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: 2 77 2.1Weil 11)# P1tiv t4-P
5a. Well Location:
Ca001:411 P,'pet; A4.t ovine.
Facility/Owner Name
Facility !Oft (if applicable)
"11 iA I.csS vAc..
Physical Address, City. and Zip l\opyate_rbs; »t
Mee,14t bt4 ��tia►~a-m-1
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it'well field, one lat/long is sufficient)
3s,91263 N - $o18055-7
6. is(are) the well(s): ❑Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or I'1No
(I this is a repair, fill out known well construction in/inmarion and eXplant the nature ajthe
repair mulct' ,r?1 remarks section or on the hack of thi.s./mm.
8. For Geoprobe/DP'I' or Closed -Loop Geothermal Wells having the same
construction, only 1 G\iV-1 is needed. indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: (ft.)
pia• multiple wells list oN depths ifdiflerent (example. 4010' and 2V 100')
10. Static water level below top of casing: (ft.)
lfwater level is above easing. use "
11. Borehole diameter:tQ,5 Co.2.. (in.) (viz,yt -Sf( 4(--
12. Well construction method: WDDUUosv irwn 011.90r7 /VW fOf4h,
(i.e. auger, rotary, cable, direct push, eta)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
14. WATER ZONES
FROM
T()
DESCRIPTION
61 3 ft'
7a.3 ft'
,1� . 40,G.4 �-
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR 1,1NER (if ap
licnble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ryry..
0' tJ't.
S(, Oft.
¢ in'
SC,yt. 40
SG,►.. 4-0 Roc,
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAME;EE:R
THICKNESS
MATERIALA
©s O ft.
/ Q ft.
r0
? L• U.
ede �! , 4'0
�r 1'i , -Ar c+ f �"
ft.
ft.
in.
17. SCREEN
FROM
TO
1 IAMETER
8LOI' SIZE
THICKNESS
MATERiAI.
643 ft.
74-.2ft,
Jft.
2 in.
©t 0 (
✓4r14, t0
SC t 40 Rd
ft.
in.
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT ME ll OD & AMOUNT
i7 , 19 ft.
t,/�
St, Oft.
c k
-1- Vd.lu t
0 ft.
60 Orr•
Qo.4444. cerk
•q* +i.e�°w‘. t
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
'I'0
MATERIAL
EMPLACEMENT Mk"1110D
att.
%1• ! ft.
Qlril)P.x'"? H
s •, 4- r.%
fr °ut0,n +L.
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
'1'O
DESCRIPTION (color, hardness, soil/rock tope, Brain size. etc.)
ft.
ft.
See- q ttt= l..0,9
ft,
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
21. REMARKS
Signature of Certified Well Contractor
By signing thalami. / hereby certify Char the we/(s) was (tare) c,msrructell in accordance with
iS t ,V('rl(' 02(' .0100 or iSI N('AC 02(' ,0200 Well C'on.strIwf,ou.l'tandarcle and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24, SiIBMIT"TAI, INSTRUCTIONS
Submit this GW-t within 30 days of well completion per the following:
24a. For All Wells: Original tbnn to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Infection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 10(1,000 GPI): Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh. NC 27699-1611
13b, Disinfection type: Amount:
Form OW -I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6-2018

Thomas Whitehead
Well Contractor Name
2907-A
114. WATER ZONES
moat TO __..
fL
ft.
ft. ft.
DESSCBIPTI
12. Well construction method:
(i.c. auger. rotary, cable, direct push, etc.)
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i'.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Comnercial
°Irrigation
Non -Water Supply Well:
@Monitoring
Injecfron Well:
°Municipal/Pubtic
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 9/2/20 Well DV MW-15
❑Groundwater Rcmediation
°Salinity Barrier
❑Stormwater Drainage
°Subsidence Control
°Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility 1D# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610450.293 N 1461470.456
6. Is (are) the well(s): GIPermanent or °Temporary
7. Is this a repair to an existing well: °Yea or INo
If this is a repair, fill nut known well construction information and explain the nature oldie
repair tinder #21 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: "" (ft)
For multiple wells list all depths if different (example- 3@200'and 2(0100')
34.79 10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 „ (in,)
Auger
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
13b. Disinfection type: Amount:
15. OUTER CASING (for maid -cased we OI
t"ROM '€`Ci DIAMETER
ft. It In.
16. INNER CASING OR TUBING t
FROM TO _ eotdermal erased t
DIAMETER THICKNESS MATERIAL
+3 ft. 24 n 2 in. PVC
Sch 40
ft.
17.SCREEN
FROM TO
24 ft• 39
18. GROUT
FROM
ft.
DTAMIsTRR
2 In.
SLOT SIZE F TMCKNESS
.010 Sch 40
ft.
MATERIAL
PVC
0 ft.
ft.
TO
3
ft.
21 It.
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
Bentonite
Pour
ft.
ft.
19. SANDJGRAVEL PACK ap qMe ,
FROM TO MATERIAL
21
ft.
ft.
39
5 Red Brown Clayey Silt
ft.
ft.
#2 Sand
EMPLACEMENT METHOD
Pour
2,9. DRILLING LOG (attach additional sheets if lemur/
ur /
FR.o i TO ti['..' :)4Irrt r# ( ilt
0 ft. 5 tt
ft. 39 1*,
ft. ft.
ft. _...._ ft.
ft. ft.
I. ft.
ft. tt.
21. REMARKS
Red Brown Silty Clay
IA
tie)
22. Certification:
Oft
Si natur of Certified Well Contractor
Date
By signing this form, 1 hereby certtfr that the well(s) was (were) constructed in accordance
with 13A NCAC 02C .0100 or 13A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. for All Wells Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources —

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: j %/�
1'1e.S /, '/1 Vk`
Well Contractor Name
J NOV 0 4 2020
NC Well Contractor Certification Number
Cascade Drilling, LP we E;O
Company Name MOORESVILLE RF(Of' AI.OI Fl(;:
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (/IC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
DGeothermal (Heating/Cooling Supply)
D.l Industrial/Commercial
(Irrigation
Non -Water Supply Well:
onitoring
Municipal/Public
Di Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
Dl Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
DlOther (explain under 421 Remarks)
4. Date Well(s) Completed: ?I) Well ID# r 7/14-
5a. Well Locatio . (�11 t
J C /a/01i1?e
Facility/Owner Name Facility ID# if applicable)
/Legs //(01/ v �s% (0/1)Ced
Physical Address, City,//and Zip
Jd c'/r",l tau✓ �, �J
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s)fPermanent or DDTemporary
7. Is this a repair to an existing well: DYes or SI No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
For Internal Use Only:
475637
14::WATE1tZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
13.OUTERCASIIS'G(ftii�mitln.ca9ed:'wells)OR.tIN�R(ifa'p hc8blejr >.
THICKNESS MATERIAL
FROM
ft.
TO
ft.
in.
16':JNNERCASXIVG1Drt'1'11:)3IlVG:(kerithermat:otosed loop};.':
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
'<47E:SCitRI:Nre:!r; zt
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
// ft.
t'16 /ft.
in.
if in.
JO/ Z1
t: it YO
11 c/c'
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
rt.
ft.
ft.
C act
ft.
ft.
14.SANp(GRi1'YEL PAtX';`(if SppltEeble}' , ;:
FROM
9 ft.
ft.
TO
tit, ft.
ft.
M TERIAL
/0?5a�c�
EMPLACEMENT METHOD
20 DIt3LI:fN(iLO.(# (attaili:addlhoaal`.eLeefs tfiieeeifiiei
FROM
ft.
TO
ft.
DESCRIPTION (color, hardness, soil/rock type, groin size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
� 202d
Cl ,\k.
ft.
21;REM'ARKS :'t
ft.
22. Certificatio
Signatur
ell Con actor
'2 0t
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed In accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
DIAMETER

I. VI, erg t.,ontracror lnlorm:r[toc
Vev/v ti L✓lnl 4-Q-
Well Contractor Name
NC Well Contractor Certification Number
Pei VOi "-3r /0 '(-F
Company Natne
2. Well Construction Permit #:
l3st all npplicuh/('well construction permits (i.e. (/I(', ('otcnly.:State, Garia,tce, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
❑Geothermal (Heating Cooling Supply)
❑industrial/Commercial
❑[rrigation
❑Municipal/Public
URcsidential Water Supply (single)
❑Residential Water Supply (shared)
❑Welts - 100,000 GPD
No -Water Supply Well:
�1'Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Cixperimcntal Technology
❑Geothermal (Closed Loop)
❑Geothermal (I leating/Cooling Return)
❑Groundwater Remcdiation
❑Salinity 13arrier
OStormwater Drainage
❑Subsidence Control
❑'('racer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: bJ►II'121 Well ii # tVCVV "') 1)
5a. Well Location: '`
Co10h\Cot` 179eV•a. 14 IA YSV�%tom
Facility/Owner Name Facility Mil- (if applicable)
�� tiro ,Av3-t.
Physical Address, City. and Zip T.)Aktr':&A\ Comity J 1
Parcel Identification No. (PIN)
Sb. 1,atitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/tong is sufficient)
N-So\go761
6. Is(are) the well(s): ❑Permanent or ❑'temporary
W
7. Is this a repair to an existing well: :Yes or CnNo
If this is a repair,,/ill out know„ well construction n f,rwauou and erplam the nature ol'the
repair under =21 remarks secuna nt nn the hock o/'this finm.
8. For Geoprohe/DP"I' or Closed -Loop Geothermal Wells having the same
construction, only 1 (iW-I is needed. Indicate'I'OTAI, NUMI3ER of wells
drilled: 1
9. Total well depth below land surface:
I nr multiple wells list all depths fd(Iferent (example- .1GQ200' and ?!ii?l00')
iSO�
10. Static water level below top of casing:
If water level is above casing, ,,xa "' ,
11, Borehole diameter: (! •
(ft.)
(ft)
12. Well construction method: PsoI(01v S4'x s a<{-tA eir.
(i.e auger. rotary, cable, direct push. etc.) Qs. tp+-OLV-r
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13h. Disinfection type:
Method of test:
Amount:
14. WATER ZONES
PII051
'1'o
DESCRIPI'R)N
It 0 ft,
130 ft.
Q v." -Votc-}M,t,42.,,-
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap
licable)
FROM
TO
DIAMETER
'THICKNESS
MATERIAL
60.
7 Qt.
4,. i» •
scr►. 40
Sc II. eto 9 de
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
ft
in,
0 , 0 ft.
j I O,Ort.
.Z in.
SG IA .'Fo
Pt/ 4---
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIALTERIAL
ft.
110
130 ft.
in.
AD a
r.{rJ�'y ,
.-L1,,eo A
ft. ft.
in.
I8. GRd11T
IROM
'to
MATERIAL
EMPLACEMENT METHOD & AMOUNT
CrO ft.
%-G ft.
16 h
D ,oft.
13 O ft'
p + sn,_ i
t- -0r' 112--14'‘ Le---
ft. ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
Edll'I A('Ex1ENl' SIE;r[IOD
t.
I, v4 ft,
CivCneb.jS sail to
Srp,,. We. t
+-kette : e
ft,
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. San loess, soil/rock tpl)e. ¢,:•tin site. etc,)
ft.
ft.
Sae 00-44t i-d- Lc:
ft,
ft.
fi
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification
Signature of (Willie Well Contractor
Date�
By signing this Jam, 1 hcrehv certif.), that the well(t) was (Were) constructed in aeca'dm,ce with
/54 MA(' 02(' .0/00 nr 154 :Y(',1(' 02(' .0200 Well ( onutruelom Mandards and that a copy
, f this ,•,cord has ham, provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks I3ox). You may also attach additional pages if necessary.
24. SUBMITTAL. INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original limn to Division of Water Resources (DWR),
Intbnnation Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IBC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCIIA
Permit Program, 1611 MSC'. Raleigh, NC 27699-1611
Form (i\V-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6-2018

Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. tlIC, County, State, Variance, etc)
3, Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Well
WELL CONSTRUCTION RECORD (GW-1)
1, Well Contractor Information:
6ane—!y Xv,er Mtirinc3
IZ
Contractor Name ✓
4138`1i9
NC Well Contractor Certification Numher
um Ike,- Hi Il n UJr-L." 4,11c ! 1
QMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
�Stormwater Drainage
Subsidence Control
Geothermal (Closed Loop) E3Tracer
Geothermal (Heating/Cooling / Return) Other (explain under #21 Remarks)
4, Date Well(s) Completed: //2 I2j.720 Well ID# / nu— `2
5a. Well Location:
9a/,,11a� Pee Iine
Facility/Owner Name Facility ID# (if applicable)
i3?2E 1f�.n7Grsvll�� Con GC',c/Rd, ,40f'ti
Physical Address, City, and Zip 25'o '&
meckle,,h 4rc C7192i2t2
County Parcel Identification No. (PIN)
5b. Latitude and longitude to degrees/minutes/seconds or decimal degrees:
i w
t f well field, one Iat1 ong is sufficient)
3S,411332/ N
6. Is(are) the well(s)
�i
(90.80?2 2?
Permanent or DTemporary
W
7. Is this a repair to an existing well: DYes or MNo
If is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form,
8, For GeoproberDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: Si)9. Total well depth below land surface: S
For multiple wells list all depths if different (example- 3@200' and 1@100')
10. Static water level below top of casing:
If water level is above casing, use " s
6 (in.)
11, Borehole diameter:
12, Well construction method: 50/1i1.:.
(i.e. auger, rotary, cable, direct push, etc.)
(ft,)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b, Disinfection type: Amount:
For Internal Use Only:
14. WATERZONES
DESCRIPTION
PECEIVEDttPNGDEQ N11
SFP 2 0.?011
MOORESVILLE REGIONAL'OFFICE
15:OUTER CASING' for.mnlB.cased wells OR LINER 1Ta..Ilcabio
DIAMETER
THICKNESS
f6;IN1HEI.CASING'ORTUBING eothermalclosed-leo.
FROM TO �C:R�nreaa;�
ft. 10 ft, ln. *s:�s=cumal
.4 yU
ft. ft. In,
17. SCREEN
ft, ft,
18, GROUT
FROM TO
6. ft.
•
ft,
ft.
DIAMETER
SLo r SIZE
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
EMPLACEMENT METHOD
8 1t, S© rt. tt -ern d/
ft, ft, �4rt �w%�/i"hf-afe
MATERIAL
MATERIAL
THICKNESS
MATERLAL
EMPLACEMENT METHOD & AMOUNT
20.1SItarANG LOG'(attacb addittanaI sheets If necessary)
FROM TO DESCRIPTION (color, hardness, salyrock type, grain
£6el 5; hilt C
I2* (ft,
20 ft.
22, SIt,
ft,
r7, ft.
22 ( ft,
i1 ft.
21. REMARKS
ft.
Ize, etc.
22. Certification:
Signature of Certified \'/ell Contractor
Date
v2D
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or ISA NCAC 02C .0200 Weli Construction Standards and that a
copy of this record has been provtded to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
const uction to the following;
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Supply ;Cc Inlection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

1. Well Contractor Information:
Thomas Whitehead
14. WATER ZONES
FROM
TO
DESCRIPTION
We1I Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
ft.
ft.
15. OUTER CASING
ft.
FROM TO
ft. ft.
for multi -cased wefts) OR LINER (if npplicoblet
DIAMETER THICKNESS MATERIAL
la.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. Counry, State, Variance, Injection, ere.)
3. Well Use (check well use):
Water Supply Well:
DAgricuitural
°Geothermal (Heating/Cooling Supply)
D.Tndustria1/Commercial
❑irrigation
DMunicipaUPublic
DResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
®Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
ClExperimental Technology
DRecovery
°Groundwater Remedietion
DSalinity Barrier
OStolmwater Drainage
❑Subsidence Control
°Geothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 9/2/20 Well ID# MW-18
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDtt (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, sad Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
610817.943 N 14621 5.479
W
6. Is (are) the well(s): rdPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or €'1No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
12. Wen construction method:
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths ifdii different (example- 3a^(200' and 2@l01Y)
10. Static water level below top of casing: 39.78
(ft.)
Ifwater level is above casing, use "+"
45
11. Borehole diameter: 8
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13h. Disinfection type: Amount:
} ay. Logo. it a.eWai.NV Vic a UDI5 ., {gefnnermal ctosen-It)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+3
ft.
30
ft.
2
in.
Sch 40
PVC
ft.
ft.
in.
L FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
30
ft. ! 45
ft.
2
In.
.010
Sch 40
PVC
ft.
ft:
id.
FROM
0
D.
ft.
MATERIAL EMPLACEMENT METHOD & AMOUNT
3 ft. Grout Tremie
27
ft.
Bentonite
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
127 ft. 45 ft. #2 Sand
- ft n.
Pour
EMPLACEMENT METHOD
Pour
20. DRILLING LOG (attach additional sheets if aecentnrs`t
("Ravi TO DESCRIPTION (color, aardos-,, soil/rock nos. groin fine ebr t
0 ft. 6 ft. Red Brown Silty Clay
6
15
ft.
It.
ft.
ft.
15 ft.
Red Brown Clayey Silt
45
ft.
Gray Silty Sand
ft.
ft.
ft.
ft.
21. REMARKS
tZe.v;< 0n
22. Certif ration:
6,1 t
S attire ofCertified Well Contractor
j ^^;
Date
By signing this form, 1 hereby certijy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C..0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
constriction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information:142
Tit L/j r tiA or?
Well Contractor Name
NC Well Contractor Certification Number
c
Company Name
2, Well Construction Permit #;
List all applicable well construction permits (i.e, UiC, County, State:
3. Well Use (check well use):
ya6
111
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
IndustriaUCommercial
Irri_ation
Non -Water Supply Well:
1
is
1
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin•ICoolint Return)
4. Date Well(s) Completed:
5a
Well Location:
Facility;OwnerName
Physical Address, City, and Zip
County
Parcel Identification No. (PIT()
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well.fietd, one latilong is sufficient)
N
Variance, etc)
°MunicipalPublic
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
°Groundwater Remediation
Salinity Barrier
DStonnwater Drainage
°Subsidence Control
°Tracer
Other (ex lain under #2 t Remarks)
1/1&2� WeIJ ID# i • I. "1
Facility tD# (if applicable)
I Uri' e l' ircui
2 o9'
For muleplewells list all depths ifdifferent ,/example-3® 36
00' (ft.)
10. Static water level below top of casing: �-
If water level is above casing, use '4- -
11. Borehole diameter: c9
(in.)
12, Well construction method:
O.e. auger, rotary, cable, dvoct push, etc.;
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gprn) Method of test:
I3b. Disinfection type;
Amount:
6. Is(are) the well(s) .1'Permanent or °"temporary
7. Is this a repair to an existing well: °Yes or No
if this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:__
9. Total well depth below land surface:
(ft.)
FROM TO
ft,
© ft. 6 ft.
19. SAND/GRAVEL PACK if a . Ucable
EMPLACEMENT NIET7IOD
6 •
ft.
20. DRILLING LOG attach additional sheets If necessa
FROM TO DESCRIPTION color hardness soli/rock t ,e •raln size, etc:
S 74-y C .
S
0 ft,
ft.
rt.
ft.
ft,
ft,
2.0 ft,
21.RENIARKS
22, Certification:
For Internal Use Only:
14, WATER ZONES
ft,
ft,
TO DESCRIPTION
(RECEIVED/NCDEQ/D
15;`OUTRRCASING°formal ,-cased`weih 0
FROM TO t Uceblc
ina�onIAMeTEe
16.num
INNER CASINGOR TUBING- thernal close
FROM To
DIAMETER
ft,
ft.
ft.
17. SCREEN
FROM
ft.
in.
MATERIAL
MATERIAL
...L,,j sLO THICKNESS
fr. 1111111®
18:;GROUT "`
FROM
TO
MATERIAL
v,.
Ei11PLACEMENT METHOD & ArsIOUNi
ft.
ft.
ft.
ft,
ft.
s1
tllfh
i
Date
By signing this form, I hereby certify that the well(s) was (were) constructed to accordance
with ISA NC4C 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that :z
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or weii
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For A11 Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699.1636
24c, For Water Su ply & Inlecti on Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days ofcompletion of well construction to the county health department of the county
where constructed,
Signature of Certified Well Contractor
FFICE

1. Well Contractor Information:
Thomas Whitehead
14. WATER ZONES
DESCRIPTION
12. Well construction method:
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
FROM TO
ft.
ft.
,t.
It
15. OUTER CASING (for multi -cooed wells) OR LINER ti 31r1r lcahie)
FROM To nIAMF,TFtt ? TIIrCIE
ft.
ft.
in.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
16. INNER CASING OR TUBING (othennal closed-ioo
MATERIAL
FROM
TO
DIAMETER
TRICKNEBS
MATERIAL 1
1 +3
ft
33
at
2
ln . Sch 40
PVC
ft.
rt.
In. 1._________,
Water Supply Well:
DAgricuitural
DGeothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
Dilrigotion
DMunicipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
RMonitoring I:Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
ClExperimental Teclmology
DGeothermal (Closed Loop)
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
❑ Subsidence Control
❑Tracer
DGeothermal (Heating/Cooling Return) ❑other (explain under 1/21 Remarks)
4. Date Weil(s) Completed: 9/3/20 Well no MW-2Q
5a. Well Location:
Colonial Pipeline
Facility/Owner Namc Facility 1D# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
610895.751 N 1462288.912
6. Is (are) the welds): OPerntanent or oTemporary
W
7. Is this a repair to an existing well: [Wes or BNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3(u200' and 2@100')
48
18. Static water level below top of casing:
limier level is above casing use "+"
8
42.25
11. Borehole diameter: (in.)
Auger
(i.c. auger, rotary, cable, direct push, etc.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) — Method of test: _........................_... ...____ _._.
13b. Disinfection type: Amount:
7.
FROM 1 TO
33 ft, 48
ft.
DIAMETER
ft.
2
in.
SLOT SITE i TRICKNERS [ MATERIAL_
.010 Sch 40 PVC
18. GROUT
i FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
3
rw
Grout
Tremie
3
0.
31
ft.
Bentonite
Pour
ft.
ft.
19. SAND /GRAN EL PACK (Ff applicable)
FROM TO MATERIAL
31 ft 48 ft. #2 Sand
ft. ft.
EMPLACEMENT METHOD
Pour
0 ft.
9 ft.
[13
G LOG (attach additional beets if neees,ary)
.l.
9
13
ft.
ft.
C It3N (enbm hardness. son/rock t.pr, craw site. ate.)
Brown Silty Clay
Red Brown Clayey Silt
ft.
20
It.
Gray Silty Sand
120 ft
48
ft.
Gray Clayey Silt
ft.
ft.
ft.
R.
21. REMARKS
evl5d c27
22. Certification:
-/ 14/A(—
Signature of Certified Well Contractor
Datc
By signing this form, 1 hereby certifj. that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ropy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For Aft Welk: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
flFCEIVEDZ1CDEQ/DWR
I, Well Contractor Information; �.
(rano Xavier Ir=n jc la✓1
Well Contractor Name
(1385A
NC Well Contractor Certification Number -}�
UJa //ref f-TL'n Udr,dt`1,JC'1 1:4 I
Company Name
2, Well Construction Permit B:
List all applicable well construction permits (i.e, UIC,, County, State, Yariance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industri a t/Commercial
Irrigation
SEP 2 0 202
14. WATERZONES
FROM TO
ft.
DESCRIPTION
WQRos ±
MOORESVII..LE REGIONAL OFFICE
ft.
ft.
15.OUTER CASING for multi -cased well OR LINER If imam,
111111111111.11111111
1.6, INNER CASING:OR TUBING + . cothemial closed -too
r DIAMETER
-k y&
FROM
-f.
Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
QSalinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7/3/2020 Well lid trnw 2/
5a, Well Location:
Co/1 ;l.t/ R,,r line
Facility/Owner Name
13926 l #'i ersttIlie
Physical Address, City, and Zip
Facility ID# (ifapplicable)
CLn ti, ci Rel, l�t.•i ,
reckltn hlt.4 CJIg2l212
County Parcel identification No. (PEN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
{tf w,li.ne,d, one lat/long is eufTmtent)
3..5 y12831 N <90,90 2o5-6
6, Is(are) the well(s)
Permanent or DTemporary
W
7. Is this a repair to an existing well: Dyes or ,iNo
if this is a repair, fill out knawa well construction information and explain the nature of the
repmr under #21 remarks section or on the back of this form.
8. Far Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-i is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: �Q (ft.)
For multiple wells list all depths ifdifferent (example. 34 200`and 4'100)
10. Static water level below top of casing: (ft.)
water level is above casing, use
•
11 . Borehole diameter: (in.)
12. Well construction method: -S0f1i .j
(i.e, auger, rotary, cable, direct push, etc.)
I FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
f
13 b, Disinfection type: Amount:
EMPLACEMENT METHOD
111111111
20. 13RILLINGLOG attach additional sbeets if necessa
DESCRIPTION color herdneu solUreck .e •rain size etc
FROM _ TO
12,
ft.
ft,
17, SCREEN
FROM
DIAMETER
ft.
TO
1
ft.
ft.
llcabli
In
MATERIAL
MATERIAL
Put:
TO
DIAMETER SLOT SIZE THICKNESS
IS. GROUT
IIMMIIIMIRE1110111111111
hL1TERIAI.
ft IMEMenal
ft, ft,
19. SAND/GRAVEL PACK if applicable)
FROM MATERIAL.
ft,
ft,
ft.
ft.
2
SC>
ft,
ft,
ft.
ft, ft,
ft. ft.
S
110.1.1.01 544
ft.
ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
P r J -�
TO
.S1) ft.
21. REMARKS'
ft.
f,
Date
By signing this form, 1 hereby certifj that the well(s) was (were) constnrcted in accordance
with I SA NGAC 02C .0100 or ISA NCAC 02C .0100 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or weii
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of mail
construction to the following;
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constnsctert
22, Certification:
Signature o� Well Contractor

Well Contractor Information:
Thomas Whitehead
4. WATER ZONES
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Weil Construction Permit #:
List all applicable well permits (Le. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Weli:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
. imitation
Non -Water Supply Well:
@Monitoring
injection Well:
4. Date Well(s) Completed: 9/3/20 Well ID# MW-22
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Teat
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return) ❑Otter (explain under #2I Remarks)
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Facility ID# (if applicable)
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
610918.335 N
'1462111,418
6. Is (are) the well(s): @Permanent or OTemporary
7. Is this a repair to an existing well: °Yes or PINo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2I remarks section or on the back of this form.
1
8. Number of wens constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3®200' and 2@I ANY)
10. Static water level below top of casing: 34.80'8 (1L)
If water level is above casing, use "+-"
OM
TO
DESCRIPTION
ft.
ft.
ft.
S. OUTER CASING (for mufti -cased weals) OR LINER Of applieab1)
ROM TO DIAMETER TRiCKNLSS MATERIAL,
ft. ft. In.
Ili. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER r T1UCK1iESS MATERIAL
+3 ft 19 ft. 2 Ia l Sch 40 PVC
ft. ft. In. (1
17. SCREEN
❑Municipal/Pubiic
❑Residential Water Supply (single)
°Residential Water Supply (shared)
❑Rceovcry
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
34
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) .._.. _._......_................
13h. Disinfection type:
Method of test:
Amount: _._.
19
OM TO
t.
ft.
34 ft.
8. GROUT
FROM
0
3
DIAMETER
2
n.
rn.
SLOT Cr7B f THICKNESS
MATERIAL
.010 Sch 40 j PVC
ft.
ft.
ft.
3
7 ft.
ft.
:MATERIAL ENPLACEMEKI• METHOD & AMOUNT
Grout Tremie
Bentonite I Pour
19. SAND/GRAVEL PAC
FROM TO
17 ft. 34
ft.
ft.
ft.
(
eppfcable)
ATERIAL
#2 Sand
20. DRILLING LOG (attach additional sheets If
FROM 1 TO
0 rt. l6 ft.
ft. 114 11
14 ft. 134
ft. l tit.
ft
PLACEMENT METHOD
Pour
DESCRIPTION (calar, baranes,, wa/rock t
Brown Silty Clay
Red Brown Clayey Silt
Brown Silty Sand
ft. ft
21. REMARKS
22. Certification:
ture of Certified Well Contractor Date
By signing this form. I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 24)13

Thomas Whitehead
Well Contractor Name
2907-A
14. WATER ZONES
FROM
TO
DESCRIPTION
R.
ft.
ft
NC Well Contractor Certification Number
S&ME Inc
15. OUTER CASING (tor multi -cased wens
FROM TO DIAMETER
OR LINER (if applicable)
THICKNESS' MATERIAL
ft. ft. in.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
❑lnigation
Non -Water Supply Well:
°Monitoring
DMtmicipaliPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
DRecovery
Injection Well:
°Aquifer Recharge
DAquifer Storage and Recovery
°Aquifer Test
OExperimental Technology
❑Geothermal (Closed Loop)
°Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Return) °Other (ex lain under #21 Remarks)
4. Date Well(s) Completed: 9/3/20 Well mot MW-22R
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude hi degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
610918.335 N 1462111.418
6. Is (are) the well(s): Ir7Permanent or ❑Temporary
16. INNER CASING OR TUBING cothermal closedd
iFROM
TO
DIAMETER
THICKNESS
MATERIAL
i
+3 ft•
19 ft•
2 Im
Sch 40
-PVC
ft,
17. SCREEI
FROM
119 ft•
ft.
18. GROUT
TO
34 ft.
ft.
DIAMETER
2
In.
SLOT SIZE
.010
THICKNESS 1 MATERIAL
Sch 40 PVC
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT j
0
ft.
3
ft.
Grout
1 Tremie
3
ft•
i7
ft•
Bentonite
i Pour
ft•
ft.
1 q
119. SAND/GRAVEL PACK .Of aiceitcable)
FROM TO iNA I'ERIAr.
117 ft. 34 ft•
#2 Sand
EMPLACEMENT METHOD
Pour
ft.
ft.
20. DRILLING LOG tatty
FROM TO
0 ft• 6
6
ft.
14
ft.
ft.
acdditiunatxlareit(fee ecsanv
*sa, soiVrac . h pe. grato sloe, etc.
Brown Silty Clay
Red Brown Clayey Silt
1
ft.
ft.
34 ft.
ft.
ft.
ft.
ft.
tt.
Brown Silty Sand
ft.
21. REMARKS
22. Certification:
W Si,
7. Is this a repair to an existing well: °Yes or i )No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 34
For multiple was list all depths if different (example- Stu; 00' and 2®100')
10. Static water level below top of casing: 34.88
limier level is above casing use "+"
11. Borehole diameter: 8 (in.)
Auger
12. Well construction method:
(ft.)
(i.e. auger, rotary. cable, direct push, Mc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _,....,,..
Method of lest:
13b. Disinfection type: Amount:
ure te
o€Ccrtified Well Contactor
Date
fly signing this form, I hereby cent& that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the welt owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Inlection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this from within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su Iv & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: /
(rtinc/ j. XII)1G�r Warr nt lt�ml
Well Contractor Name
{ 3 V F ! 1
NC Well Contractor Certification Number
LUa I ker 111,`
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
.Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
EDRecovery
Groundwater Remediation
Salinity Barrier
oStormwater Drainage
Subsidence Control
DTracer'
rillOther (explain under #21 Remarks)
4. Date Wells) Completed:'?/3/2v2u
5a. Well Location:
Crt/ndli' t! Ape line
Facility/Owner Name
/3 ?2 6, 1 ,,7 arc ci //e
Physical Address, City, and Zip
rn klen Ai r jr
County
Well ED# f}1W 23
Facility WD# (if applicable)
• Concvra/2 � 1�4.,,dv,W
28028
0/7212/2_
Parcel Identification No. (PEN)
5b. Latitude and longitude In degrees/minutes/seconds or deetmal degrees:
(if well field, one laiJlong is sufficient)
.33 '/12 7 21.. N 'oo 6o 92 ,c5
W
6. Is(are) the well(s)ElPermanent or OTemporary
7. Is thls a repair to an existing well: DYes or ,lNo
If this Is a repair, fill out known well construction n fermation and explain the nature of the
repair under On remarks section or on the back of this form.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
Far multiple wells list all depths if different (example- 3Qa 200' and 2@l00')
10. Static water level below top of casing:
lfwater level is above casing, use
11. Borehole diameter: (.T (in.)
12. Well construction method: ,.Soul(•;
(i.e. auger, rotary, cable, direct push, etc.)
411,
(ft,)
(ft.)•
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gprn)
13 b, Disinfection type:
Method of test:
Amount:
*3 ft,
ft,
For Internal Use Only:
SEP 2 O'2t
14. WATER'ZONES
FROM
ft,
ft,
TO
ff.
ft.
WQRUb
DESCRrPTi fJ-(ESVILLE BEGIONAEOFFtCr
.15 OTJTER CASINdL(forain [ ,cased ivells):OR LTNF,R (If ap llceblb)
FROM TO DIAMETER THICKNESS J MATERIAL
In.
ft.
ft.
. i6JaINER CASENG;'OR TUDiNG?(Qcotheimal.closed..laup)
FROM TO DIAMETER THICKNESS
17� SCREEN
FROM
1`ft,
ft,
ft.
ft,
I,/ In.
in,
Sell v0
MATERIAL
Pvc:
TO
18•'.GRO.UT'
FROM
ft,
DIAMETER
t/..• In.
in,
SLOT SIZE
THICKNESS
s'ch fa
MATERIAL
Pv�:
1
ti ft.
o ft.
ft,
TO
1. ft.
ft.
ft,
MATERIAL
1110'S
CC. C.#11-
EMPLACEMENT METHOD & AMOUNT
PC) tired I / h'ut:,1ca:
T"rnm e/3-89 s
19.. SAND/GRAVEL ' PACK at applicable)
FROM TO MATERIAL, EMPLACEMENT METHOD
13 it' VC"' '%r2 Suirld 12 4rec' / (/Ihra1 e.
ft. ft.
•20. DRILISINGtOG`(4tach;addidonal'sheetsdf hecosaiy.)
FROM DESCRIPTION (calar, hardness, salt/rock type, grain lze, etc,)
(/aV
Cray 5r1/-
0 ft.
20 ft.
ft.
ft.
ft.
ft,
21; REMATt1{'S
TO
217 ft,
ft,
ft.
ft,
ft,
22, Certification:
1
Signature of Certified Well Contractor
10l/3/2)20
Date
By signing this form, 1 hereby cerljy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fora: within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells; In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed,

Thomas Whitehead
Well Contractor Name
2907 A
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
f.
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Constriction Permit #:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
15. OIJTER CASING fformid-cased welly)ORLINER licable)
FROM TO DIAMETER `Ctttt KNE.ss MATERIAL
ft.
ft.
la..
16.1NtER CASING OR TUBJNG geothermal closed -loop
FROM TO DIAMETER TffiCKNESS
MATERIAL
+3
It.
ft.
15
ft.
2
hL
Sch 40
PVC
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
❑brig ttion
Non -Water Supply Well:
®Monitoring
❑Mtmicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/21 /20 Wen 1D# MW-23R
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
13900 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01921204
County
Panel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610088.879 N 1461555.526
6. Is (are) the well(s): I3Permanent or ❑Temporary
7. Is this a repair to an existing welt: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair tinder #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -wager supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 45 (ft.)
For multiple wells list all depths if different (example- 3 � 00' and 2Qa 10ty)
10. Static water level below top of casing: NIA (ft.)
Ifwater level is above casing, izse "+"
11. Borehole diameter: 8
12. Well construction method:
Auger
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:._.
13b. Dtstnfectlon type: Amount:
17. SCREEN
FROM 1 To
15 IL 45
DIAMETER
hi.
suer SIZE
.010
TRTCKNESS i MATERIAL
ft. ft.
Sch 40
PVC
8. GROUT
TO
6
ft.
13 ft.
MATERIAL EMPLACEMENT METHOD & AMOUNT
Grout
Bentonite
Tremie
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable) ..
FROM TO MATERIAL
13 ft. 45 ft: #2 Sand
EMPLACEMENT METHOD
Pour
9*
0
35
LI.
ft.
ft.
ft.
t; Lt3G {attach ad )ttmeal sheets lltxeceeservi
TO DE54`ItIPitOttgcolor, hardness,wWrocki.ee,J,rtan lice,etc.
35 1. Gray Silt and Clay
45 f. Grayish Brown Silty Sand
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
21. REMARKS
ft.
r
.e, a)5 i vrt
22. Certification:
Signature of Certified Well Contractor
.912 126- )U
Date
�64a1
By signing this farm, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For Alt Weld Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
14. WATER ZONES
FROM TO
ft.
DESCRIPTION
ft.
ft.
8, Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
sttbntit one farm.
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lim all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
FROM
+3 ft.
15. OUTER CASING (for mull! -eased wellOR LINER ' 1 a . b1c
€ftt 4t TO DIAMETER TIOCKNE
ft. tn.
16. INNER CASING OR TUBING (geothermal closed -I
TO DIAMETER THICKNESS MATERIAL
ft.
39 ft• 2
ft,
ra.
Sch 40
PVC
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
©Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
ORecovery
❑Groundwater Remediation
❑Salinity Banter
❑Stonnwater Drainage
°Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under 821 Remarks)
4. Date Well(s) Completed: 9/4/20 Well ID# MW-24
5a. Well Location:
Colonial Pipeline
Facility/OwnerNemo Facility 1D# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/Iong is sufficient)
610605.100 N 146 116.596
6. Is (are) the weB(s): raPermanent or 17Temporary
7. Is this a repair to an existing well: OYes or PJNo
If this is a repair, fill ant known well construction information and explain Me nature of the
repair under #21 remarks section or an the back of this form.
1
9. Total well depth below land surface: 54
Far multiple wells list all depths if different (example- 3(200' and 2Qa 10IY)
14. Static water level below top of casing: 46669
If water level is above casing, use "+"
11. Borehole diameter: 8
12. Well construction method:
(In.)
Auger
(ft.)
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: _�...___...__._........_ Amount:
FROM
39 ft.
TO _...
54
DrAMETER
7 ,..._._ In.
SLOT MU THICKNESS
.010 Sch 40
MATERIAL
PVC
ft.
ft.
18. GROUT
FROM
0 ft.
TO
3
_MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
3
ft.
37 ft.
Bentonite
Pour
ft.
rt.
19. SAND/GRAVEL PACKIf applicable)
FROM TO MATERIAL
37
ft.
54 ft.
ft.
#2 Sand
EMPLACEMENT memoir
Pour
20 DRILLING LOG tattach additional
EROS( TO AG ~urrTt
0 ft.
9
eels Unman
(color. hard he s, seilheck h
Red Brown Silty Clay
in size, etc.)
ft.
!20 ft.
20
ft.
25 ft.
Red Brown Clayey Silt
Brown Silty Sand
25 ft.
134 ft-
34
ft.
Brown Sandy Silt
ft.
Brown to Gray Silty Sand
ft.
ft.
21. REMARKS
ei' Yon
22. Certification:
Signature of Certified WO, Contractor Date
By signing this form, 1 hereby ceri Mat the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Weston Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699.1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
c...,., reir .
•

1. Weil Contractor !Mr/nation:
Thomas Whitehead
Well Contractor Name
2907-A
f 14. WATER ZONES
FROM TO
ft. ft.
DESCRIPTION
ft.
ft.
❑Mumcipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
9/4/20
12. Weil construction method:
NC Well Contractor Certification Number
S&ME Inc
Company Name
15.OUTER CASING for meld -eased weds) OR LINER of a
FROM TO DIAMETER THICKNESS
ft.
in.
1 16 IN ER CASING OR TUBING geothermal closed -loop)
---..
FROM TO DIAMETER THICKNESS MATERIAL _.-
ablea
MATERIAL
ft.
2. Well Construction Permit #: +3 ft.
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑agricultural
CGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
dirt' ation
Non -Water Supply Well:
EMonitoring
lilt
eaten Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return) LJOther (explain under #21 Remarks)
❑Recovery
4. Date Well(s) Completed:
5a. Well Location:
Colonial Pipeline
❑Groundwater Remediation
©Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
Well ID#
MW-25
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
610724.207 N 1462220.540
6. Is (are) the wll(s): 2Perntanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or EINo
If this is a repair, fill out known well construction information and explain the nature of the
repair tinder #21 remarks section or on the back of this form.
1
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one flout
9. Total well depth below land surface: 57 _(ft.)
For multiple wells list all depths if different (example- 3 200' and 2®100'
10. Static water level below top of casing: 43` 52 (ft.)
If writer level is above casing, use "+ "
11. Borehole diameter: 8 (in.)
Auger
(i.e. auger, rotary, cable, direct push, cu:.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) __ Method of test:
13b. Disinfection type:._.
Amount:
ft.
17. SCREEN
28 ft. 2 I0' Sch 40 PVC
I FROM 1 TO
128 ft• 157
ft.
DIAMETER
2
SLOT SIZE
THICKNESS
E MATERIAL i
PVC
in.
.010
Sch 40
ft i
in.
18. GROUT
FROM
ft •
TO
3
rt
MATERIAL
EMPLAC'_1 M *THOD & A,'MOUNTI
I0
Grout
Tremie
3
ft.
25
ft.
Bentonite
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
METHOD_
25
25
it 57 ft.
ft.
#2 Sand
Pour
20. DRILLING LOG attach additional sheets if necesssr )
FROM . TO ))ESC IFITON (color, hardness, Rail/rock hpc. j;rein s e!r, de.?
0 ft. 3 ft.
3
`10
ft.
►t.
ft.
10
57
ft.
ft.
ft.
ft.
Red Brown Silty Clay
Red Brown Clayey Silt
Brown to Gray Silty Sand
ft.
ft. ft
21. REMARKS
leUi'Sidn
22. Certification:
Stir icassc: of Certified Well Contractor
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A rVCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. for All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form C. W.1
Nn,th ('.amtitta rinnwmn,-nt of nnvimnmrnt and Nahnxil Rrmnimcec — r)ivicirm of Water Rmrnrmec R..warA A„e,.et 11111

1, Well Contractor Information:
frail et S Wavier Nacrt
Well Contractor Name
14: WATER 20NT5
FItOM TO
ESCRIPTION
/3 62
Company Name
2. Well Construction Permit #:
List all applicable well construction penults (Ie. UIC, County, State, Parlance, etc.)
3. Well Use (check well use):
NC Well Contractor Certification Number
Loa /kee Hill Ed..tt :re (Uri C /114
Water Supply Well:
Agicuifurai
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
9MunicipaVPublic
©II Residential Water Supply (single)
ItResidential Water Supply (shared)
Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
0Bxperimentai Technology
, Geothemial (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
Salinity Barrier
QStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: //I/9/2o2o Well ID#
5a, Well Location:
Co%ttla/ flee lime
Facility/Owner Name
Facility ID# (if applicable)
Plan er; jriIle M',larS v
Physical Address, City, and Zip 2.109
109 85'
(n e e k lest l�ur f!
County
y
Farcei Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell:field, one fat/leng is sufficient)
b /o 936. cj,? N
6, Is(are) the well(s)
it / 2tg'i. yo`1
Permanent or OTemporary
7, Is this a repair to an existing well: Yes orof No
Ifthts•-is a repair, nil out ;dwn well construction information explain the nature of the
repair under ti2i remarks section aeon ttiabacit thitrfonn,
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I QW,I is needed. Indicate TOTAL NUMBER of wells
dsSlied:
1
9, Total well depth below land surface:
For mulliple wells list all depths tfdifferent (example- 3Qo 200`and g41001
10, Static water level below top of easing:
if water level is above casing, use "+"
11. Borehole diameter: (in,)
12, Well construction method: 'Soule
(i.e. auger, rotary, cable, direct push, etc.)
l%.(-
(ft.)
(ft.). -
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
13b, Disinfection type:
Method of test:
Amount;
ft,
ft.
ft'
ft.
WQROS
MOORESVILLE REStIONAL OFFICF
15 {UTTER CASING (torannlf .c,, ud wolf `•:OR LTNItxt(If applicable)
FROM T rn DIAMETER THICKNESS MATERIMATERIAL1"' 3 ft, ell, tit, LI le. ! SJ j L/O 6
IN, NER,comt0r'yii'1U7311y($l at7thorigat boxed-lon
FROM ro! • ITIAMR1h'R TilICK,NES.
ft, ft. In,
FROM TO
o ft,
ft,
L1 jL
ft.
SLOT SIZE I THICKNESS
A'rtuIuAL
ft~e,(f
Eh!PLACEiMIENT METHOD &. AMOUNT
rir>iel,c I r J5
ft, ft.
IA;S s/SIC VELPACK (if app)ieRbh7);
I MATErtL1L
ft,
20.-DRU 1'4 LO(:'{offset ndditional siteat<y.ffnecesiary.l.
FROM TO ft, ft, tSESCnIPTtO,N tsak(t,r, hart fleas, ;;unfrock tree, 4r•,n ,itc g
ft, ft. 1N O �rq' 1'3 / ki, On
22. Certification:
Signature t Certified We11 Contruciar
l 2/2/2v 20
Date
By signing this,1rnt I hereby certify that the wells) was (were) constructed in accartionet
with .154 NCAC 02C 0100 or /5.a NCAC 02C 0200 Weil Construction Standards and duo w
copy of tins record has bean provided is the well owner.
23, Slte diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699.1636
24e, For Water Supply & infection Wells: In addition to sending the form to
the address(es) above, also submit one. copy of this form within 30 days of
completion of welt construction to the county health department of the county
where constructed.
Form GWI
North Carolina Department of Environmental Duality - Division of Water Resnurr.,..s

WELL CUNS"1'RUC'1'IUN RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
For Internal Use ONLY:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable wellpemtits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrijation
Non -Water Supply Well:
CelMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
ORecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
OExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
9/4/20 MW-26
Well ID#
Facility ID# (if applicable)
Physical Address, City, and Zip
Mecklenburg
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
610924.172 N 1462017.515
6. Is (are) the well(s): G3Permanent or ['Temporary
7. Is this a repair to an existing well: DYes or 1No
If this is a repair, jilt our known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 37 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2(4;100')
10. Static water level below top of casing: 33.25 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
14. WATER ZONES
FROM I... TO DESCRIPTION
ft
ft.
ft.
i
15. OUTER CASING for mull -cased wells) OR LINER (if a lleabie
f t. f%
i DIAMETER
,
.
in
THICKNESS MATERIAL
_ ._.
16. INNER CASING OR TUBING
(geothermal closed -loop
FROM TO
DIAMETER THICKNESS i�MATERIAL
+3 ft.
22 ft.
2 to
Sch 40
PVC
ft,
ft
j in.
17. SCREEN
FROM 1
TO DIAMETER
SLOT SIZE 4 THICKNESS
MATERIAL
22 ft
ft.
37 ft. 2
ft.
In.
in.
.010
Sch 40
PVC
18. GROUT
FROM
TO
MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft.
3 rr
3 ft.
20 ft
Grout Tremie
Bentonite Pour
ft.
19. SAND/GRAVEL PACK
if a 3 fcable
FROM
20 it,
TO
37 ft.
MATERIAL
EMPLACEMENT METHOD
Pour
#2 Sand
ft.
ft.
20. DRILLING
FROM „„�,,,
0 ft•
LOGsattach
TO
additional sheets if necessary)
DESCRIPTION(color, hardnrss, sollfrock type, grain stn. etc)
13 ft.
Red Brown Silty Clay
13 ft
20 ft.
20 fL
37 ft.
Red Brown Clayey Silt
Gray Silty Sand
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft
21. Rtr MARKS
22. Certification:
Signature of Certified Well Contractor Date
By signing this form. 1 hereby certifi that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mal Service Center, Raleigh, NC 27699-1636
24c. For Water Sul lv & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

1. Well Contractor Information:
Thomas Whitehead
4. WATFR ZONE
TO
DESCRIFf1ON
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the sante construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example-- 3(ai200' and 2(0(Y) 10
10. Static water level below top of casing: 33.25
If water level is above casing, use "+"
Well Contractor Nome
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance. Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Olndustrial/Commercial
dlrrigation
OMtmicipaUPublic
OResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
EMonitoring
Injection Weil:
OAquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
OExperimental Technology
❑Geotherrnal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
dRecovery
❑Groundwater Remediation
DSalinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
C Other (explain urtSit,'r rill Remarks)
4. Date Well(s) Completed: 9/4120 Well ID# MW-26R
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (ifappticabic)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 019401 02
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610924.172 N 1462017.515
6. Is (are) the weU(s): Permanent or DTemporary
7. Is this a repair to an existing well: OYes or ®No
If this is a repair, fill out known well construction infrrrmalion and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
37
11, Borehole diameter: 8 (in.)
12. Well construction method: Auger
(ft.)
(ft.)
(Lc. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
ft.
ft.
ft.
ft.
15. OUTER CASING (for araltfcased wefts) OR LINER (if applies )
FROM TO DIAMETER 1 '1111(.'K'4 S MATERIAL
ft. ft. 116
16, INNER CASING OR TUBING (xeotbermal closed-1
FROM
TO
DIAMETER
THICKNESS
MATERIAL
t3 ft,
22
ft,
2
la. i
Sch 40
PVC
ft
ft.
in.
t
d
FROM
22 ft•
TO
37 ft,
DIAMETER
2 In.
SLAT SIZE 1 THICKNESS
.010 i Sch 40
MATERIAL
PVC
ft.
18. GROUT
ft,
Ia.
FROM
0
ft,
ft.
ft.
TO
3
ft.
20 fL
i
MATERIAL , EMPLACEMENT METHOD & AMOUNT
Grout ITrernie i
Bentonite I Pour
19. SAND/GRAVEL PACK (R applicable)
FROM TO MATEWAr.
EMPLACEMENT METHOD
20 ft. 37 ft. #2 Sand
Pour
ft.
20. DRILLING LOG attach addltiamd sheets if tf,
FROM TO
0 ft: 13 ft
13 ft, 20
20
ft.
ft.
ft.
ft.
37
ft.
ft.
ft.
(color, hardness. soil nick t, rsla sFce, etc.
Red Brown Silty Clay
Red Brown Clayey Silt
Gray Silty Sand
ft.
ft.
(t ft.
21. REMARKS
22. Certification:
loin t 6
Signature of Certified Well Contractor pate
By signing this form, I hereby certi161 that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0700 or 75A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this forth within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Weals ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Namo
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
° irrigation
Non -Water Supply Well:
El Monitoring
njectioa Weil:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
DGeothennat (Closed Loop)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
0Stormwater Drainage
°Subsidence Control
°Tracer
❑Geothermal (Heal inr.='(ogling Return) ❑Other (ex under #2 1 Remarks)
4. Date Well(s) Completed: 9/5/20 Well 10# MW-27
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility 1D# (if applicable)
14 511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
01940102
County Parcel Identification No, (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one 1st/long is sufficient)
610986.312 N 1462085.698
6. is (are) the well(s): ®Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or EJNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 300' and 2@100')
33.27
42
(ft.)
10. Static water Level below top of casing: (ft.)
If water level is above casing, use "-t•"
11. Borehole diameter: 8 (in.)
12. Well construction method:
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
t4. WATER ZONES
FROM
TO
b€SCRIP7ION
ft.
ft.
ft.
A.w.
--
tt.
ft.
15. OUTER CASING (for mold -cased wells) OR LINER (1f applicable)
FROM TO DEAMETEI& THICKNESS
MATERIAL
ft.
It.
in.
16. INNER CASING OR TUBING (geothermal closed -
FROM TO DIAMETER 1 THICKNESS MATERIAL
+3 ft.
27
ft.
2 to. i. Sch 40 PVC
ft.
ft.
la.
17. SCREEN
FROM
27
ft.
TO
42
ft.
ft.
DIAMETER
2 in.
SLOT SITE : THICKNESS ; MATERIAL
.010 Sch 40 PVC
18. GROUT
FROM
0 ft.
ft.
TO
6 ft.
25 ft.
ft.
MATERIAL EMPLACEMENT METHOD & AMOUNT
Grout
Bentonite
19. SAND/GRAVEL PACK Of applicable)
FROM . TO MATERIAL
25
ft.
ft.
42
Tremie
Pour
ft.
#2 Sand
20. DRILLING LOG iattarh addltiow
FROM TO BEES' RWr ri
0 ft. 11 ft.
11 ft- 14
ft.
vex, soil/rock type, etaia eFsti etc.)
Red Brown Clayey Silt
Gray Brown Sandy Silty Clay
14 ft 42
ft.
ft. ft.
ft.
Gray Sandy Silt
ft.
ft. ft.
ft. m
21. REMARKS
22. Cert fuation:
.R'
of Certified Well Contractor
ia»0,
Date
By signing this form, 1 hereby certify that the well(s) was (were) co,istructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Weil Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the fotm to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health departutent of the county where
constructed.

I. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (1,,e, County, Sta
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑IndustriaVCommercial
❑Irrigation
Non -Water Supply Well:
IBMonitoring
Injection Weil:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
te, Variance, Infection, etc.)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks
4. Date Well(s) Con►pleted: 9/6/20 Well ID# MW-28
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Physical Address, City, and Zip
Mecklenburg
County
Facility ID# (if applicable)
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
610218.934 N 1461369.873
W
6. Is (are) the well(s): EPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑ Yes or LINo
If this is a repair, fill out known well construction information and explain the nature of the
repair under i121 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 40 (ft.)
For multiple wells list all depths ifdifferent (example- 3©200' and 2(100)
10. Static water level below top of casing: 2 9.3 7 (ft.)
IJwnter level is above casing, use "+"
11. Borehole diameter: 8 (In.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
•
Auger
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:.,
Method of test:
Amount:
0 ft.
3
1_ 14. WATER ZONES
FROM _ i TO :j.,_DEscRIPTION
ft. 1 i
ft. • ft.
•
15. OUTER CASING (for multi -cased wets) OR LINER it f plicable)
FROM 4 TO i DIAMETER THICKNESS "T MATERIAL
ft. ( rt. I in,
16. INNER CASING OR TUBING fgeothermal closed -loop)
FROM TO DIAMETERj THICKNESS j MATERIAL
+3 ft. 25 ft.2in ( Sch 40
ft.
17. SCREEN
ft.
TO DIAMETER
40 ft 2 in.
ft. ft. in.
18. GROUT
M1tATERIAI E
FROM TO _ MENT METHOD & AMOUNT ft-. 16 fEMPLACE
L ! Grout Tremie
ft. 23 ft-�.__....._..,.�..
Bentonite Pour
tr. ._n:
SLOT SIZE
.010
19. SAND/GRAVE[, PACK of applicable)
FROM TO MATERIAL-
23
ft,
40
ft.
ft.
EMPLACEMENT METHOD
#2 Sand Pour
20. DRILLING LOG (attach additional sheets If necet
FROM TO sa- I DESCRIPTION (color( hardness„ selFracktlpe, rain size, etc.
30 ft. = Red Brown Clayey to Sandy Silt
ft.
ft.
40
Gray Silty Sand
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
Date
By signing this form, 1 hereby cert( that the wells) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 1 SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
., mC5i/ Jie
Well Contractor Name
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name
NOV 0 4 2020
2. Well Construction Permit #: �p� r��`
List all applicable well construction permits (it (ji t, qo SIa 1,1,17 RI.,(lohce, etc)
3. Well Use (check well use):"t )rdf;i
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
1:Industrial/Commercial
Irrigation
Non -Water Supply Well:
®°r onitoring
Injection Well:
1(1
lif
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Municipal/Public
Dl Residential Water Supply (single)
DIResidential Water Supply (shared)
Recovery
°Groundwater Remediation
Salinity Barrier
.OI Stormwater Drainage
°Subsidence Control
0Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: / / G i) tJ Well ID#
5a. Well Location:
cc(Q/IJtt!/ P4'e
Facility/Owner Name FaciilityID# if applicable)
/WM i l/t /3 li,//,& l- / ©,JCcl
Physical Address, City, and Zip
�/MeCe n to/1, CJ
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
W
6. Is(are) the well(s)Permanent or EllTemporary
7. Is this a repair to an existing well: Di Yes or * No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2/ remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: ' D
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Print Form
For Internal Use Only:
`•14.WATERZONES
FROM
ft.
TO
ft.
DESCRIPTION
ft.
ft.
15;;OUTER CASING (for;militt eased wells) Olt't heable)<
tiff -
THICKNESS 11 MATERIAL
FROM
ft.
11
In
%1.6 jlVNl''R'C"ASXN.G'iOlt'.Tf3$ING''(ketifhermaC!cliised'itioji'
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
171.SCREEN ;
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
1 cl ft.
5-0 ft.
in.
it in.
r0/ Z1
rot
10
PVC
FROM
ft.
ft.
TO
6 ft.
ft.
MATERIAL
/int71
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
19.SAND/GRAYEI PAc1'(ifNppbcable)
FROM
ft.
ft.
TO
TO
cb ft.
ft.
MATERIAL
EMPLACEMENT METHOD
20.DRIX;I.IN(i`;tiO.G(attatti;atldfhonal'shcefs�t'.iecessary)-is--'.
FROM
ft.
TO
ft.
DIAMETER
DESCRIPTION (color, hardness, soil/rock type, grain size, etc,)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
1 .REIVIA,RKS
ft.
ft.
O C T 2 6 2020
Y.
D`aP, Ss‘o
el Ugh
22. Certificatio :
Signatur ellCon actor
Date
By signing this, form, 1 hereby certify that the well(r) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the tortn to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

nomas Whitehead
Well Contractor Name
1llESCRll'17ON
4. Date Well(s) Completed: 9/7/20 Well JD# MW-30
5a. Well Location:
Colonial Pipeline
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permiLe (i.e County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
° Industrial/Commercial
Olrti'atimn
Non -Water Supply Well:
©Monitoring
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
°Geothermal(Ctosed Loop)
OMuaicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
❑Salinity Barrier
°Stormwater Drainage
❑Subsidence Control
°Tracer
❑Geothenmal (Heating/Cooling Return: °Other (explain under #21 Remarks)
Facility/Owner Name Facility 1D# (if applicable)
14511 Huntersvill - ncord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610799.782 N 1461554.298
W
6. Is (are) the webs): taPermaneut or ❑Temporary
7. Is this a repair to an existing well: °Yes or MNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, youcan
submit one form.
9. Total well depth below land surface: 35 (ft)
For multiple wells list all depths ifd Brent (example-33(i3200'annd 2 100')
10. Static water level below top of easing: 30.59 (ft.)
1f water level is above caving, use "+"
11. Borehole diameter: 8
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
Auger
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnt) _ ......_..._. Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
rgfEi
it.
rt,
ft.
+3
j 15. OUTER CASING (for multi -cased Wells)
__..�,._ ..
Wells)ORLINER_i to
FROM TO DMAMPTEtt `iittrar i S
ft. ft.in.
16. INNER CASING OR TUBING " (geotdermal ctesetas
ed
i FROM TO DIAMETER i Tg1CgNs ss
2 la Sch 40
20
ft.
ft.
r 17. SCREEN
E FROM
20 tr.
TO
35 fa
ft. l ff.
18. GROUT
FROM
0 it.
i 3 11.
DIAMETER
2 in.
SW
.010
in.
AL
MATERIAL
PVC
TRRCKNFSS
Sch 40
MATERIAL
PVC
TO
3
18 ft.
• ft.
_ MATERIAL
Grout
Bentonite
19. SAND/GRAVEL PACK Of too owe)
FROM MATERIAL,
18 "t 35 IL #2 Sand
R. fr
EMPLACEMENT METHOD & AMOUNT
Tremie
Pour
20. DRILLING LOG
ft.
ft
EMPLACEMENT METHOD
Pour
roc r€ u;evsa['1
pr fits [color berdnes enpUrockis 5einy;m.
, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
lee�i_�l'en
22. Certlt ration:
gaaturc of Certified Well Contractor
) /1 /r)
...._....__......_..
Date
By signing this firm, hereby certify that the welt(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Cansattetion Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. Far All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Weld ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources -Division of Water

rrELL ' U1NSTRUCTION RECORD
1, Well Contractor Information: t/
'fa ' /. . P C7a e 1 4 a`7t!
Well Contractor Name
NC Well Contractor Certification Number
WCY1/rcr 1'T1/1 LnUip,?ilent: *4
Company Name
GW-1
2, Well Construction Permit #:
List all applicable well construction permits (l,e. UiC, County, Stale, Variance, etc,)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply WeU:
Monitoring
Injection Well:
DMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Aquifer Recharge D Groundwater Remediation
Aquifer Storage and Recovery pSalinity Barrier
Aquifer Test DStomrwater Drainage
Experimental Technology 0Subsidence Control
Geothermal (Closed Loop) Tracer
Geothermal (Heatin. Coolin: Return) JJ' Other (ex lain under #21 Remarks
4. Date Well(s) Completed: 7 ! 2/202(J Well LD# Ma, ' f
So. Well Location:
Pee Ili e
Facility/Owner Name
Physical Address, City, and Zip
County
Parcel identification No. (PEN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weil field, one Iatl ong is sufficient)
��•'y/24� '`� N
6. Is(are) the well(s)EtPermanent or DTemporary
7. Is this a repair to an existing well: DYes or EjNo
If this Is a repair, fill out known well construction information and explain the nature of the
repair under 821 remarks section or on the back of this form,
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: /
9. Total well depth below land surface:
1
Facility Mil (if applicable) JJ
Ur /C s T
2 'O'7e
For multiple wells list all depths ifdifferent (example. 3 200 an
Q100')
10. Static water level below top of casing: 3
If water level is above casing, use "+
11. Borehole diameter: C3
(in.)
12. Well construction method:
(i.e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY;
13 a, Yield (gpm)
Method of test:
13 b, Disinfection type: Amount:
(ft,)
(ft.)'
For Internal Use Only:
14. WATER'.ZONES
FROM TO
ft.
15;tQUTOR'CASIN
FROM TO DIAMETER THICKNESS
ft. ft. in.
iC,INNERCGASING'OR TUBING (gcotbeimalclosed=loop)
DESCRIPTION
RECEIVED/NCDEQ/DWFI
SEP 2 0 ZO
FROM
1"3 ft,
TO
ft,
SCREEN
FROM
ft.
ft
TO
/ ft,
ft,
ft.
ft.
_18AGRD..UT
FROM TO
!4 ft' 12, ft,
DIAMETER
y In,
DIAMETER
In.
In,
In.
WQRnS
LE REGIONAL (JFFI
MATERIAL
THICKNESS 1 MATERIAL
Sc 4 y0
SLOT SIZE
FUc
THICKNESS
MATERIAL
MATERIAL EMPLACEMENTiI ETHOD & AMOUNT
alraglaral
19,:SAND/GRAVEL'PACK li:a..Bc'able
FROM TO sy ,
•'����ThfETHOD ...__
ft.1
1111111
attachadditlonaIstieets IG aecessa
DESCRIPTION calor hardness, solllrock typel1rain_slze, etc.
���•�,���..►� rdwnL�Slt
20.
FROM
TO
`DING.L0G
rt
ft.
v ft. Lf ft.
ft. ft.
ft.
11. REMARKS
I M /lt
rOwil sc !
POW vt /
w/M SOH
9
0/10124)2v
Signature of Certified Well Contractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15.4 NCAC 02C,0100 or iSA NCAC 02C,0200 Well Construction Standards and that a
copy of this record has been provided to the well owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary,
SUBMITTAL INSTRUCTIONS
24a, For All Webs: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of weil
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
1

YY L' ILL 1..1J1131 RV411V1\ 1RL'. ,.l.r Rlir
This tium eon be used for single or multiple wells
Fur Internal Use ONLY;
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Welt Construction Permit#:
List all applicable we// permits (i,r. County, SIMt, t errinnce, Infection, etc:)
3. Weir Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (tleating/Cooling Supply)
D h,dustrial/Commercial
Olrrigation
Non -Water Supply Well:
@Monitoring
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
° Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loup)
❑Geothermal (Heatingg/Cootine, Return)
°Groundwater Rernediation
❑Salinity Barrier
OStortnwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 5-10-21
5a. Well Location:
Colonial Pipeline Company
Facility/(honer Name
Well ID# MW-31D
Facility I DII (if applicable)
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
4660193695/1921204
Paicel Identification No, (PIN)
511. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/Iona is sufficient)
35.412004 N-80.807398
w
6. Is (are) the well(s): @Permanent or fTemporary
7. is this a repair to an existing well: °Yes or R1No
IJ this is a repair, fit/ ant knouvr well contraction in/imrnralion and explain the nature (Oho
repair under -21 remarks section or on the hark q/ this firm,
0. Number of wells constructed: 1
For multiple in/nelinn or man -water supply wells ONLY with the cane construction, rant can
wthntlt one farm.
9. Total well depth below land surface: 70 (ft)
l.nr multiple wells list al/ depths il'tftlfereni (example- 40ofI' and 2@i00')
10. Static water level below top of casing: 59 (ft.)
11lvoter level is above easing, use "
1 I. Borehole diameter: 2 (in.)
12. Well construction method: 6 5/8 HSA @ 2" spoons and 4" and 6" Air Hammer
(i.e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY' WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
hletbod of test:
Amount:
a WATER 7d)NE4
FROM
TO
DFSCR1P71ON
59 ft,
70 ft.
Wet
ft.
ft.
iS, GIMER CA
wells) O* LINER (tf gppatalite)
FROM
TO
DMAMF;rgk
IIlit'KNESS
MATERIAL
ft,
It.
in.
16.1NNER
CASING OR TUBING
(itentitermal dosed-taapl
FROM
TO
DIAMCTrR
THICKNESS
M;%Trim %t.
0 ft.
55 it
2 in,
sch40
pvc
- ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLU I' SIZE
't'tflt'KNFS.S
MATERIAL
55 ft.
70 ft.
2 in.
.010
sch40
pvc
ft,
ft.
In.
1S. (;ROUT
room
TO
,NATERI:tL
F.MI'1 1C'fa<EN'I Nicrit0li& %MOt NT.
0 rt.
48 ft.
Portland Cem
Tremie
46 ft,
51 ft.
Bentonite Chit
Tremie
ft,
ft.
19, SAND!t4Rr[VFL.'PACK
(ifappttadlile)
FROM
TO
MATERIAL
k.MPI.AC:EMENT METHOD
51 ft.
70 ft,
#1 Sand
Tremie
ft.
ft.
29 DRILI,11901O
(time
ltttddistaanI4taws trnceusaary)
FROM
TO
DF_t+CRPPriON (rater, hatdn.*.la Ilt. cIt tvPn;.ai`atu yrsr,ere.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
tt.
ft.
ft.
ft.
ft.
H.
ft.
21.REM ::U1KS
2X2Pad
8" Flush Cover
22. Certification: //JJ Imo`" �, �+J`j��
�c"mwr"�........._...
Signature ol'Certitied Well Contractor
Date
Hy signing this fnna, I hereby certify that the well(s) was (irerel Lonstructed bt accordance
with 1 SA N('A(.' 021' ,0100 or 15.4 RAC 02(' .11300 Well Construction Standards and that a
copy glans record has been pririded to the well ouvwt•.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTIONS
248. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply Sc Injection Wells:
Also submit one copy of this form within 3U days of completion of
welt construction to the county health department of the county where
constructed.
Form CiW-1
Nnttit Carolina Department of Environment and Natural Resources — Division of Water Resources Revised august 2013

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
14. WATER ZONES
FROM TO
DESCRIPTION
ft.
12. Well construction method:
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e County, State, Variance, injection, ere.)
3. Well Use (check well use):
ft.
ft.
15. OUTER CASING (for mvlti-easedwells) OR LINER Of applicable)
FROM TO n1AMt114TIItCKNEss tit:VURIA
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal efoaed-loop
FROM TO DIAMETER THICKNESS
+3 ft. 10 ft 2 I° Sch 40
MATERIAL
PVC
ft.
17.SCREEN
ft.
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
DlndustriaUComrnereial
Olrrigation
DMunicipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
C7Mouitoring °Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (HeatingfCooling Return)
❑Groundwater Remedietion
❑Salinity Barrier
DStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4..Date Well(s) Completed: 9/6/20 Well ID# MW-32
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is suflicient)
611207.899 N 1461763.847
6. Is (are) the well(s): 2I.Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or ENo
1f this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 25
For multiple wells list all depths if different (example- 3(t 200' and 2Qa 100')
10. Static water level below top of casing: 16.19
If water level is above casing, use "+"
11. Borehole diameter: 8 (m.)
Auger
(ft)
(it)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: --- __...._ Amount:
FROM TO
10 ft• 25
ft.
ft.
DIAMETER
In.
SLOT SIZE
.010
THICKNESS MATERIAL
Sch 40 PVC
ft.
18. GROUT
FROM
0 ft.
TO
6
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
ft.
8
ft.
Bentonite
Pour
R.
ft.
19. SAND/GItAVEL PACK (If apglleable)
PROM TO MATERIAL
EMPLACEMENT METHOD
8
ft.
25
ft.
ft.
#2 Sand
Pour
0 ft•
8
ft.
TO
8
10
ft.
ft.
dctltlanai sbrrta if aaeyl
RIP t ttr (color. hardness. soil/mak i.pt, Asia stxa etc.1
Brown Clayey Silt
Gray Sandy Clay
10
ft.
13
ft.
13
25
ft.
Gray Silty Sand
ft.
Gray Brown Silty Sand
ft.
ft.
ft.
ft.
21. REMARKS
22. Certtr)yation:
Signature of Certified Well Contractor
By signing this farm, 1 hereby cent& that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0I00 or 1SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been pmvided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of we11
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (Le. County, Slate, Variance, injection, etc)
3. Well Use (check well use):
Water Supply Well:
DAgticulturat
DGeothermal (Heating/Cooling Supply)
❑IndustrialiCommercial
Oltriotion
Non -Water Supply Well:
®Monitoring
GMtmicipal/Public
1JResidential Water Supply (single)
DResidential Water Supply (shared)
GRecovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
OAquifer Test
DExperimental Technology
DGeothennal (Closed Loop)
❑Geothermal (H€astingl.'cnriirat Return
4. Date Well(s) Completed:
Sa. Well Location:
Colonial Pipeline
GGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
OSubsidence Control
DTracer
DOther (_ plain under #21 Remarks)
9/6/20 welllD# MW-33
FacilityiOwncr Nanic Facility 1DN (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or deetmal degrees:
(if well field, one latiiong is sufficient)
611254 11N 146 1864.564
6. Is (are) the well(s): @Permanent or ❑Temporary
7. Is this a repair to an existing well: OYes or ITNo
If this is a repair, jilt out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:.,
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one fans.
9. Total well depth below land surface:25
(ft.)
For multiple wefts list all depths ifdifferent (example- 31200' and 2(70100)
10. Static water level below top of casing: 13.2 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
Auger
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM TO ,_mm
R. $ H.
15. OUTER CASING (for multi -eased wells
e FROM TO ! DIAMETER
16. INNER CASING OR TUBING (geothermal Nosed -too
FROM
TO
DIAMETER
1, THICKNESS
MATERIAL
+3
ft'
10
ft.
ft.
2
in' 1 Sch 40
PVC
In.j7
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:.,,., .., ___ Amount:
17. SCREEN
FROM E To DIAMETER
10 ft' , 25 ft- 2 in
ft. ft. is
18. GROUT
sun SIZE ! THICKNESS
MATERIAL
.010 Sch 40
PVC
, FROM
0
ft.
TO
MATERIAL
. _EMPLACEMENT METHOD & AMOUNT '
Tremie
6
t9i.
Grout
t3
ft.
8
ft•
Bentonite
Pour
fl.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM ; TO MATERIAL
8
ft.
ft.
25 It. #2 Sand
ft.
EMPLACEMENT METHOA
Pour
0
8
ft.
rt.
.6
15
25
ft.
ft.
ft.
ft.
ft.
rains Fie, etc.
Brown Clayey Silt
Gray Sandy Clay
Gray Brown Silty Sand
Gray Sandy Silt
ft.
21. REMARKS
ft.
22. Ce 'cation:
Signature of Certified Well Contractor
Date
8y signing this form, 1 hereby certify that the well(s) wus (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All L2'eUs: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit.
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Infection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

I. welt contractor information:
Thomas Whitehead
Well Contractor Name
2907-A
ItWATER ZONES
mutt TO DFSCR1p71Us.m.
ft. ft.
ft.
ft.
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Constrnctlon Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
IS. OUTER CASING (for rnalf-cased welts) OR LINER if applicable)
DI4Ik.TE:Ri
rt.
ft.
ht.
MATERIAL
MANNER CASING OR TUBING eother7mtal closed -loop
FROM To " DIAMETER THICKNESS
+3 ft.
5
ft.
2
to
Sch 40
MATERIAL
PVC
ft.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothemral (Heating/Cooling Supply)
° Industrial/Commercial
❑irrigation
Non -Water Supply Well:
®Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
CExperimental Technology
❑Geothermal (Closed Loop)
❑Municipa /Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating;Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/6/20 Well ID# MW-34
Sa. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
611273.038 r, 1461934.811
6. Is (are) the welds): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction MP -motion and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 20
For multiple wells list all depths if different (example- 34`200' ((ann�d 2®100')
10. Static water level below top of casing: 1 0"89
If water level is above casing use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
()
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method dint:
13b. Disinfection type: Amount:
( FROM TO
5 ft. 20 tI.
ft. ft.
DIAMETER
2 Ia.
ia.
MATERIAL
Grout
18. GROUT
i FROM
i 0 ft.
TO
3
13 ft. 4
ft.
ft. ft.
SLOT SIZE THICKNESS
.010 Sch 40
MATERIAL
PVC
1 EMPLACEMENT METHOD & AMOUNT
Tremie
Bentonite ' Pour
19. SAND/GRAVEL PACK
FROM TO
4
ft.
20
ft.
a Cable
MATERIAL
#2 Sand
ft.
EMPLACEMENT METHOD
Pour
20. BILK I i NC LO( (attach additional sheets if
TWA TO
0 ft. 3 ft.
color« hardness, soil/rock tape. Irma size etc.
Brown Clayey Silt
3 ft. 8
ft.
Gray Sandy Silty Clay
8 ft. 10.5 ft.
510.5 20
ft.
ft.
ft.
ft.
ft.
Gray Sandy Clayey Silt
Gray Silty Sand
ft.
m_ 21. REMARKS
22. Cetttfkation:
i6tic2
argnaturc ,.ertificd Well Contractor Date
By .signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NC/IC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following.
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Auger
Form G W-

01940102
6. Is (are) the weit(s): ®Permanent or °Temporary
7. Is this a repair to an exisdng well: DYes or EJNo
flats is a repair, fill out known well construction information and explain the nature ofthe
repair under #2I remarks section or an the back of this form.
1
37
For multiple wells list all depths tj'dierent (example- 3tc00' and 2()I00')
°Groundwater Remediation
°Salinity Ranier
DStormwater Drainage
°Subsidence Control
DTracer
% {j DOther (explain under #21 Remarks)
(�
4. Date Well(s) Completed; `�/ /20 Well 113#MW-355
14. WATER ZONES
Mat TU
1)EACRIp1gpN
ft. ft.
ft.
0.
• 115. TITER CASING) r multi cased Ae a t}LINER Or a
DIAMETER , 111ICENES
ft.
R.
16. INNER CASING OR TUBIPIG
FROM
17. SCREEN
1& GROUT
Bentonite
In.
ft. ft.
19. SAND/GRAVEL PACK if a € ' R iicahle
13 .. M ft., 37 fr. #2 Sand
20,D'
Q�FROM
iG
11 a.
ft.
somas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Pernttt #:
List all applicable well permits (i.e. County, State,
3. Well Use (check well use):
Variance, Injection, etc.) .
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
Dhrimition
°Municipallpublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
®Monitoring DRecovery
Injection Well:
°Aquifer Recharge
DAquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
❑ Geothermal (Heatin Cooling Return
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
3b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latrlong is sufficient)
611009.321 N 1461705.220
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construceo submit one fann. n you can
9. Total well depth below land surface
{it.}
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Vicki (gpm)
13b..Disinfection type:
10. Static water level below top of casing: 26078
If water level is above casing, use "+ (ft.)
11. Borehole diameter: 8 (in.)
Auger
Method of test:
Amount:
wed
tA�_ L----�
MATERIAL —
PVC
MATERIAL
PVC
EMPLACEMENT METHOD & AMOUNT
Tremie
Pour
EMPLACEMENT METHOD
Pour
G LOG attach addttanalxfleets f
ttr,<wt" ti+'S`t4)=ti Door. hardnesx soiltrock te.: ruin siie, etc.
Red Brown to Gray Clayey Silt
Gray Sandy Silt
22. Cettjl#lcation:
Signature of Certified Well Contractor
Data'
Ity signing this firm, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 154 TIC/IC 02C .0200 Well Construction Standards and that a
copy of this record has been pmvuded to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. for Ail Wetla: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699..1617
24b. For Infection Wells ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Super& lfJection Wellg:
Also submit one copy of this form within 30 days of completion of'
well construction to the county health deportment of the county where
constructed.
Form G W-1
North Carolina Dcpattment of Enviro .nt and N,.h,r.l Q-.. .

1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lthl all applicable well permits (i.e. Crnmiy, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricuitural
OGeothermal (Heating/Cooling Supply)
Dindustrial/Commercial
Elimination
Non -Water Supply Well:
taMonitoring
Injection ell:
°Aquifer Recharge
°Aquifer Storage and Recovery
:Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal ilico tin Cooling Return)
OMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
°Salinity Bather
OStormwater Drainage
0 Subsidence Control
°Tracer
ClOther ( lain under #21 Remarks)
4. Date Well(s) Completed: 9/8/20 Well TD# MW-36
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility lDtt (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
610925.672 N 1461745.145
6. Is (are) the weifts): 53Permanent or 0Temporary
7. Is this a repair to an existing well: 0Yes or No
If this is a repair, fill out known well construction information and explain the nature alike
repair under 021 remarks section or on the back of this form.
& Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one foim.
1.
9. Total well depth below land surface: 42
(ft.)
For multiple wells list all depths if different (example- 3@,200 and 2(3100')
10. Static water level below top of casing: 28.62
If water level is above casing, use "+"
11. Borehole diameter: 8
004
Auger
12. Well construction method:
(i.c. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (pm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
_
ft.
ft.
ft.
ft.
rn j
15. OUTER CASING (for multi -eased wefts) OR LINER fir oppikaario
FROM
TO
mAsterest
THICKNESS
VI 4,TERIAI.,
ft.
ft.
in.
MANNER
CASING OR TUBING
jgeothermal
elosed4o9rn
FROM
TO
DIAMETER
TITICICNESS
' MATERIAL
+3 ft.
27 ft.
2 in.
Sch 40
PVC
ft.
ft.
11.SCREEN
FROM
TO
DIAMETER
SLOT SITE
THICKNESS ' MATERIAL
27 ft•
42 ft-
2 in.
.010
Sch 40 1 PVC
ft.
01.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
6 ft.
Grout
Tremie
6 ft.
25 ft•
Bentonite
Pour
ft.
ft.
19. &AND/GRAVEL PACK
Of usenet(*)
FROM
TO
stArEntAL
EMPLACEMENT METHOD
25 ft•
42 ft.
#2 Sand
Pour
ft.
ft.
.
20. DRILLING
'Rom
LOG (attach
addlfional sheet if amass '
To
f»WRJt FIUN (color, II ordot k pt. in krt., v.)
0 ft.
27 rt.
Red Brown to Gray Clayey to Sandy Silt
27 fe•
42 ft-
Gray Silty Sand
ft.
ft.
r--- ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
21. REALARICS
R8.t/j5ioYy
22. Certification:
S.gnature of Certified Well Contractor
tOffi (a /
Date
By ,signing this firm, I hereby coll.* that the well(s) was (were) constructed in accordance
with 1.5A NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Constriction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

Well Contractor Name
ft:
DESCR
CEIVED/NCDEQ/DWR I
ilT'ION
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit if:
List all applicable well constrrtction permits (l,e, UIC, County, S;ate, Parlance, etc.)
3. Well Use (check well use):
Water supply Weii;
JAgidcul urat OMunicipai/Public
EN Geothermal (Heating/Cooling Supply) C3Residential Water Supply (single)
hidusttial/Contmereial DResidential Water Supply (shared)
Irri anon
Non -Water Supply Wet1:
Monitoring
Injection Well;
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothemaal (Heating/Cooling Return'
Recover/
Groundwater Remediation
Salinity Barrier
QStormwater Drainage
Subsidence Control
Tracer'
Other (ex lain under #21
4. Date Well(s) Completed: / iz0 Z . Well ID# ►Y1 fA/'• 3(on
5a, Well Location;
Facility/Owner Name
Physical Address, City,
County
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if we11.field, one lat/long is sufficient)
6, Is(are) the well(s)Permanent or orremporary
7. Is this a repair to an existing well: D'Yes or
iNo
If (ha4a repair, fill out known well construction information sn explain the nature of the
rapr.rr under 021 remarks section or on the back of'this firrm,
8. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW.1 is needed. Indicate TOTAL NUMBER of wells
drilled; I
A
Facility 1DN (if applicable)
narks)
le
9, Total well depth below land surface:
For multiple wells ifs/ all depths ((different (example- 3(cy200' and 2 u'1 t1Q`j
10. Static water level below top of casing:
I(water level is above casfreg, usesx (ft,)
r r,
11. Borehole diameter: F (in.)
12, Well construction method:
(i,o, auger, rotary, cable, direct push, -----.--_�._
p , etc.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b, Disinfection type: Amount;
Form GW.1
North Carolina Department of Envirorunenta
ft.
ft,
35, O3Yi'ER CAS1Nt(fer,tltul(t casod� ltsl R, WNW if u
FROM TO DIAMETER
fi3erinsplaIlgt
ft. go ft, Li In, ck
tiq i GASi}<r_E It'1'I1B INN' cot arival.cluse =loo
FROM TO D MA:'
TKR In, _THICKNESS
ft,
ft
ft.
ft.
ft.
ft.
ft.
GROM
FROM T'0.
D ft. v0 ft'
ft. ft.
ft,
ft.
EL PA
ft,
ft,
I n.
DIAMETER SLOT.SIZE THICKNESS
In,
Pve.
MATERIAL
In,
EMPLACEMENT METHOD 3 AMOUNT
Pietnsiz, I • ,3 $
204 IIslaINC 1 tit;'- ntlrich adtiltit ial sfieetslf vecessgr,
FROM TO DFSCnrP'rION c 4ur hardoass, Witted( type,
0 rt. '7D rt, Rlv
LACs01ENT MI3THUi
22, Certification:
12 /7/202v
Date
By signing this Ann, I hereby certifit that the well0:i was (were) consieneted in accordance
with 15.4 NCAC Q2C .0/00 or ISA NC.4C 02C .0200 Well Cansbwcitan Standards and Harr rr
copy of this record has been provided to the well owner.
23, Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL TNSTIttI TIONS
24a. For All Wells: Submit this form within 30 days of completion of well
constriction to the following:
Division of Water Resources, Information Processing Unit,
1617Mail Service Center, Raleigh, NC 27699-1617
24b, For In !Winn Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following;
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e, Cor Water finnply Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed,
I Duality - Division of Water RaRrt rrrc
Signature of Cenified Well t.Qnl(aatoT
ICE

1. Well Contractor Information:
8. Number of wens constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
Thomas Whitehead
Well Contractor Name
2907-A
Well Contractor Certification Number
S&ME inc
FROM
ft.
TO
It.
_
_DESCRIPTION
ft.
ft.
15. OUTER CASING (for ma
FROM
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (cheek well use):
TO
DIA
ft. ft. In.
16. INNER CASING OR TUBING (geatheruu
ER (ifapp !cable)
tNf_SS MA1l:RlAt.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
1 +3
ft-
20
ft.
2
i'L
Sch 40
PVC
i
.
1L
in.
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
°irrigation
OMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
QMtmitoring °Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Groundwater Remedietion
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
❑Geothermal (HeatinWCooling Return) °Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/8/20 Well ID# MW-37
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaUlong is sufficient)
610847.989 N 1461775.311
6. Is (are) the wen(s): t7Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or ®No
If this is a repair, fill out known well construction information and explain the nature of the
repair tinder #21 remarks section or on the back of this form.
1
9. Total well depth below land surface:
For multiple wells list all depths ifdiferent (example- 3(i200' and 2@100')
35
10. Static water level below top of casing: 269 "
Limiter level is above casing, use "+"
11. Borehole diameter: 8 (In.)
12. Well construction method: Auger
(i.c, auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) __
Method of test:
13b. Disinfection type: Amount:
FROM i TO
20 11-135
ft.
ft. E ft.
DIAMETER
2
la
In.
SLOT SIZE
.010
THICKNESS MATERIAL
Sch 40 j PVC
l
18. GROUT
FROM
0
i6
rt.
ft.
ft.
'1'O
6 rt.
18 ft.
MATERIAL jEMPLACEMENT METHOD & AMOUNT
Grout I Tremie
Bentonite I Pour
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
EMPLACEMENT METHOD
18
ft.
ft.
35 ft-
ft.
#2 Sand
Pour
20. DRILLING LOG (attach additional sheets if necessary)
i'ROM TO DESCRIPTION (color, bantacsa, soiltrock typo, grain si c. etc.)
0 ft. 35 ft. Red Brown to Gray Clayey to Sandy Silt
It.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
1L
rt.
ft.
21. REMARKS
•
22. Certification:
Tait 6/0 /
gnature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of' this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
$41e5 141i/ Jk,
RECEIVI=OINCOE~I+ll ;i.nilh
Well Contractor Name
j)'A? /
NC Well Contractor Certification Number
Cascade Drilling, LP
NOV 0 4 2020
Company Name
2. Well Construction Permit #:
O
MOORESVIE..LE REGIONAL 01:1_r,:;
List all applicable well construction permits (i.e. WC, County, Stale, Variance, etc)
3. Well Use (check well use):
For Internal Use Only:
b 14i WATER ZONES:c
TO
FROM
5
DESCRIPTION
ft.
ft.
ft.
ft.
5;:2)UTER.GASiNG (for;`,multt cased. ells) 01t L IfQE1{ (if a'p lteatile);
THICKNESS MATERIAL
14 XNIVEIi CASMOORIV.HING (600ierrtiti raLiel tiiiii
FROM
ft.
FROM
TO
TO
ft.
DIAMETER
DIAMETER
in
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
on -Water Supply Well:
Aft
onitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Municipal/Public
Di Residential Water Supply (single)
Residential Water Supply (shared)
EiRecovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
0ISubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: / /r) ( Well ID# /1/211 _.
5a. Well.Location: I t
C. / 4.'t / r1 e
Facility/Owner Name Facility ID# if applicable)
/! il/ 0g '�R 1� 4)- (or"cC3d"t:.:l Rd
Physical Address, City, and Zip
/ :fr c (/r"ot CJll rt�, 6
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is(are) the well(s)jr VPermanent or OTemporary
7. Is this a repair to an existing well: DYes or * No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths ijdifferent (example- 3@200' and 2@I00')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)ceffitifi/
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
X L+ ft.
ft.
in.
dif in.
/
ft.
ft.
TO
a ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
7t7 e, l r,,
ft.
ft.
19 '$AN:D/GRAN L PACl :(if applicijble)
FROM
1 T ft.
ft.
TO
S--0 ft.
ft.
MATERIAL
EMPLACEMENT METHOD
201R17LINO'GU.FI (st(ach:eddihbpelsheet� tGiuecessery):.
FROM
ft.
TO
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21.'REIIIARKS , .
OCT 2 6 na
unit
p�,v6
22. Certificatio :
r"
Signatu
ell Contactor
9, 0.10
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
1

;�✓ tt7YY-1
For Internal Use Only;
WR
1. Well Contractor Information;
'J2t c/.
Well Contractor Name
NC Well Contractor Certification Number
1
3. Well Use (check well use):
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
Water Supply Well:
Agriculiurel
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irri ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin.'Coolin• Return)
4, Date Well(s) Completed:
5a. Well Location:
Pityiy/OwnerNary
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
°Groundwater Remediation
°Salinity Barrier
r3Stornrwater Drainage
°Subsidence Control
°Tracer'
Other (explain under #21 Remarks)
-[a11 2 ) Well ID# i�i (,(f • q
r y r
Physical Address, City, and Zip
County
Facility ID# (if applicable)
e 71.ecv,
2e078
Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees,'minutes/seconds or decimal degrees:
(if weii.field, one lot/long is sufficient)
4//339y N
6, Is(are) the wells)
e0, 642579c
Permanent or °Temporary
W
7. Is this a repair to an existing well: °Yes or
If this is a repair, fill out known well construction it formatimt and explain the nature of the
repair under till retnarkr section or on the back ojthts faun.
8, For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:__
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3 2 (ft,)
[a) 00' and 1(a 100�
16. Static water level below top of casing: ,3,
If water level is above casing, use "' MO'
11. Borehole diameter: t7
(in.)
12. Well construction method:
(i.e:. auger, rotary, cable, direct push, elc.)
FOR WATER SUPPLY WELLS ONLY:
13 a. Yield (gprn) Method of test:
13 b. Disinfoctton type:
Amount:
14. WAT)R'2ONES
FROM Tn
DESCRIPTION
0 '20
21
ESVILLE REGIONA
15;OIITFR'CASING'foc:oaniNkasedwells ORt Unit
FROM ilia
ft,
.1CINNEItCpS P t�a
TUBING'
cofharan.
ahclosadlooFROM TO
17; SCREEN
18,GROx)T
SAND/GRA
lcabli
SLOT SIZE
THICKNESS
f'a
MATERIAL
EMPLACEMENT METHOD & AMOUNT
EMPLACEMENT METHOD
20.; i RILED/GT.0G attach nddlttoripl sheets if hccesaa FROM TO DESCRIPTION color hardness roWzock pe main size, etc
MNI
.'t !^D 111
C/a
S
22, Certification:
Signature of Certified Web Contractor
Date
g this fora', I
by certifit
the
By h 15AnNCAC 02C .0100eor 1 SA NCAC102C .0200)Well Construction Standad rds and thatwa
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional web site details or well
construction details. You may also attach additional pages if necessary.
S `11. AL IN TRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b, 'or In eccton Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-I636
24c. For Water Su 1 & In colon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of web construction to the county health department of the county
where constructed,
FFICE

W L' LL L UPl51 KUl; I IUfl KJ11 I:UKU
This form can be used for single or multiple wells
1. Well Contractor Information:
For Internal Use ONLY:
Thomas Whitehead
Well Contractor Name
2907-A
.....______-.
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (Le. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating)Cooling Supply)
❑ Industria/Commmercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
IBMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks}
9/9/20 MW-40
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
IS "lC,,j 14, l^t (av'cc' '.cut
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610244.764 N 1461670.079
6. Is (are) the well(s): 22/Permanent or ❑Temporary
W
7. Is this a repair to an existing well: DYes or BNo
If this is a repair, Jill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
1
12. Well construction method:
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3Q200' and 2@100')
37
(ft.)
10. Static water level below top of casing: 33.25 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: ......................................._........._.. Amount:......
14. WATER ZONES
FROM 4 TO
DESCRIPTION
ft. ft
ft.
ft.
15. OUTER CASING (for multi -cased wets) OR LINER (If applicable)
FROM
TO 1 DIAMETER ( THICKNESS
MATERIAL
ft.
ft. i fa
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM I TO I DIAMETER I THICKNESS
MATERIAL -.-
+3 ft• 27 ft• 2 is ` Sch 40
PVC
ft. 1 ft. 3n
17. SCREEN
FROM TO I DIAMETER SLOT SIZE
THICKNESS MATERIAL
27 ft• 137 it
' 2 in' .010
Sch 40
PVC
ft. ft.
. in
1& GROUT
FROM
TO I MATERIAL I EMPLACEMENT METHOD & AMOUNT
0 ft.
6 ft. j Grout ` Tremie
6 ft.
ft.
25 ft• I Bentonite I Pour
ft. I
f
19. SAND/GRAVEL PACK if a ilcable)
FROM TO MATERIAL
EMPLACEMENT METHOD
25 ft. 37 ft. I #2 Sand
Pour
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardaessosoH/rock alpr, In size etc.
0 ft.
37 ft
Red Brown to Gray Clayey Silt
ft.
ft.
ft.
It.
fr.
ft
ft.
ft.
ft.
fr.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
2t'J4)
Date
By signing this form. I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to Me well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

I. well (,onrracror Itnlormauoa:
Thomas Whitehead
Well Contractor Name
2907-A
14. WATER ZONES
FROM TO
ft.
DESCRIPTION
ft.
ft.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form
NC Well
Contractor Certification Number
S&ME Inc
15. OUTER CASING (tor multi -cased wells) OR LINERjlf appUcable)
F tt)4T TO DIAMETER 'tNlcKNF:ss MATERIAL
ft.
ft.
Ia.
Company Namo
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM TO DIAMETER 1 Turclawss
+3 ft. 50 ft. 2 in" Sch 40
ft. ft. In. 1
i
17. SCREEN
MATERIAL
PVC
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lnd u strial/C ommercial
1Jrrigation
CDMunicipat/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
(Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Experimental Technology C]Subsidence Control
° Geothermal (Closed Loop) °Tracer
❑Geothermal (Heating,/Cooling Return) ❑Other (explain undcr.42I Remarks)
4. Date Well(s) Completed: 9/9/20 Well ID# MW-4 1
5a. Well Location:
Colonial Pipeline
Facility!Owner Name Facility ID# (if applicable)
14.511 Huntersville-Concord Rd
Physicecklal Addreaens, City,
bandurg Zip
M
01940102
County Pared Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610493.441 N 1462185.803
6. Is (are) the weil(s): ®Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
if this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form,
1
9. Total well depth below land surface: 5
For multiple wells list all depths if different (example- 3@200' and 2@10 0')
10. Static water level below top of casing: 53.40
If water level is above caring, use "+"
11. Borehole diameter: 8 (in.)
12. Wee construction method:
Auger
(ft.)
(ft.)
(Le. auger, notary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FROM To DIAMETER
50 ft. 65 ft. 2 In.
SLOT 51ZE THICKNESS
.010 Sch 40
MATERIAL
PVC
ft. ft.
18. GROUT
FROM
0 ft.
ft.
TO
3
ft.
48 ft.
MATERIAL I EMPLACEMENT METHOD & AMOUNT
Grout Tremie
Bentonite j Pour
ft.
ft.
14. SAND/GRAVEL PACK if a Icarus
FROM TO MATERIAL
148
rt.
ft.
65
ft.
ft.
#2 Sand
EMPLACEMENT METHOD
Pour
20. DRILLING LOG tattach additional sheets If meessaryt
room - TO Dt;.4L:'EtP'rtON {eeloshatdnes4, eoWrock life, gran itze, eic.
rt, 65 ft. Red Brown to Gray Clayey Silt
ft.
ft.
ft.
ft.
rt.
fL
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Rev; S; on
22. Ceriili atlon:
Signature of Ccrtifici Wcll Contractor
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0700 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & In, ection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form G W-1
Nnrth t'amlinn
•

For Internal Use Only:
t-F('l-IVFI)/N(7
SEP202021
14. WATER ZONES
Company Nome
2, Well Construction Permit #:
List all applicable well consnucnon permits (.e. UIC, County, State, Variance, etc.)
3, Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
)Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4, Date Well(s) Completed; 7 h/! 2020 Well ID# Ma/
5a. Well Location;
((e)itit3iCl Ape LJne
Facility/Owner Name
..uL % %./1NO1'AUL11UIN ((.TW-1)
1, Well Contractor Information:
I'ranC/S, v,er Warri,�i"ia6
Well Contractor Name
'18(1
NC Well Contractor Certification Number
WOI %/Cd( ` i/
FROM
ft,
TO
ft,
DESCRIPTION WQHOS
MOORESVILLE REGIONAL OF
DMunicipal/Public
DResideutial Water Supply (single)
IDResidential Water Supply (shared)
Recovery
0Groundwater Remediation
DSalinity Barrier
DStornlwater Drainage
Subsidence Control
Tracer.
rolOther (explain under #21 Remarks)
Facility tD# (if applicable)
/3?126 114i,h'/j- ui //r • C ,icvrd I-4,446164.
Physical Address, City, and Zip 2,807e
Theck/en t)urg �
County 0/72121
Parcel Identification No. (PIN)
5b. Latitude and longitude to degrees/minutes/seconds or decimal degrees:
(if wellfield, one lat/long is sufficient)
`f/3/26 N 0.. (9OS2 %';
6. Is(are) the weU(s)CPermanent or DTemporary
7, Is thls a repair to an existing well: DYes or ,3No
If this is a repair, Jill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form,
8. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface; .5?
For multiple wells list all depths if different (example. 3 tI 200' and 2@100`)
10. Static water level below top of casing;
If water level is above casing, use
11. Borehole diameter: (in,)
12. Well construction method; SW/C.;
(i.e. auger, rotary, cable, direct push, etc.)
444
33
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13 a, Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft,
ft,
1S;:pUTFiRCASINC`(for:nulkesedwclls),DRLINE (if ap'kohl 6)
FROM TO THICKNESS
DIAMETER
ft. ft.
In.
16:INNER, CASING 'ORTUBING'(geothermal-closed-coop)
FROM TO DIAMETER THICKNESS
/ti ft,
ft.
17; SCREEN
FROM
/ ft.
ft,
18,.GROTJT
FROM
j ft,
ft.
/ In.
In.
MATERIAL
Sc k y0
MATERIAL
P
TO
S17 ft,
ft,
DIAMETER
f.! In,
/ In.
SLOT SIZE
' O I
THICKNESS
Sch i/a
MA1'ERLAL
Pv4:
-9 ft,
ri ft,
ft.
TO
9 ft,
ft,
ft,
MATERIAL
R iIas
Ce.m. an',"
19..SAIND/GRAVEL'PACK (if applicable)
TO
FROM
7 ft,
ft.
SI ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUN'l�
Trt"a11fi;d /3 - el.95
P`2
EMPLACEMENT METHOD
20.,IIR1 I)ING.:LOG'(pttach additional sheets if necessary)
FROM TO DESCRIPTION color, hardness soil/rock
type, gr
raain
/size, ace./
Or."'
%K�✓ ft, DAL Sr eiiej4 5 / 1 del
)t, 17<c fL Gran t9tva,n s !& C74(
r7,,�,J
(ft. 30 ft, �j //?� {y 5(
3I (y G`��r
ft. /
ft.
ft.
ft,
2T: REMARkS •
ft,
ft,
22, Certification:
W (geOtatl XeefUL /7
Signature of Certified Well Contractor
i01/40 / 202(.?
Date
By signing this form, I hereby certib that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 !Yell Construction Standards and that a
ropy of this record has been provided to the well owner•.
23, Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Inlecton Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
ICE

�..-,.,.✓...., tVYY 1)
1. Well Contractor Information:
Konca 'tau/ er t arringir7
Well Contractor Name ��//
IFor Internal Use Only:
14. WATER ZONES
FROM I TO
RECEIVED/NCD
5 .r
2021
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
°Aquifer Recharge
W
3
Far multiple wells list all depths if different (example.�(ft,)
Q200'aannd„@100')
10. Static water level below top of casing:
Ifwarer level is above casing, use "+" (ft.)
11. Borehole diameter: (in.)
12. Well construction method:
e auger, rotary, cable, direct push, etc.)
NC SVetl Contractor Certification Number
(Val k.er 1I ,En ay rorwrierl'h
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i. e UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural °Municipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial [Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
DAquifer Storage and Recovery °Salinity Barrier
Aquifer Test DStormwater Drainage
Experimental Technology °Subsidence Control
Geothermal (Closed Loop) °Tracer
Geothermal (Heating/Cooling Return) f Other (explain under #21 Remarks)
4. Date Well(s) Completed: gbe9/ 2Q Well ID# t:(/— ,a
5a. Well Location: Cc)/oFrn/
l t t_eye
acili
F tyt Owner Name
flu ri+ersu, Ile
Physical Address, City, and Zip
mecklcnbvf
County
Facility ID# (if applicable)
Concord lle
0194'O!&2.
Parcel Identification No. (PiN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lanlong is sufficient)
3 5. 4//39 Li' 2. N ea 84)69?/
6, Is(are) the well(s)MPermanent or D Temporary
7, Is this a repair to an existing well; ®yes or No
/f this is a repair, fill ow known well construction information and explain the nature of the
repair under #21 remarks section or an the back ofthis form.
9, For GeoprobeJDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 7 7
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft.
ft.
ft.
ft.
DESCRIPTION
WOROS
MO(riE ,ViLLE REGIONAL nFFIC,E
15, OUTER CASING (for molts -cased welts) OR LINER (If ap
FROM . ft. TO ' DIAMETER I THICKNESS
ft, tn.
16. INNER CASING OR TUBING(geothermal closed -loop)
FROM TO DIAMETER THICKNESS
ft. f 2, ft. i in.
ft.
17 SCREEN
FROM
f2
ft.
ft.
18. GROUT
PROM
ft.
In.
Sc.l1pov
Itcablc)
MATERIAL
MATERIAL
VC
TO
417 1t.
ft.
DIAMETER
ID,
In.
SLOT SIZE
•0/0
THICKNESS
SchYv
MATERIAL —
ft.
0 ft.
TO
/0
rt.
ft.
ft .l ft.
MATERIAL EMPLACEMENTME�T-HHOD & AMOUNT
NT
Poured 1-
CcThe nl- 77.1,11M/e
19. SAND/GRAVEL PACK (If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
20. DRILLING LOG
FROM
attach additional sheets If necessary)
DESCRIPTION color hardness, Sollirock
?�25�/2v2v
Date
By signing this form, I hereby certh that the we/l(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suv & Injection Wells: In addition to sending the formto
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
22. Certification:
Signature of Certified Well Contractor

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
•41e5 1Mil J.
For Internal Use Only:
r4. WATEk ZONES
5549
Well Contractor Name
NC Well Contractor Certification Number
Cascade Drilling, LP
NOV 0 4 2020
Company Name
2. Well Construction Permit #:
vy(.iHUS
MOORE'SVILLE REGIONAL OFFICE
List all applicable well construction permits (i.e. (/IC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
onitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
0Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
JOther (explain under #21 Remarks)
4. Date Well(s) Completed: / 'ffa 61 Well ID# /2/r V 7 9
5a. Well Location: I
Cao,v,a! 7 1 �»
Facility/Owner Name FaaciilityID# if applicable)
/y/OS 1/0thl'/° t) 4'-. (cid comi iqC
Physical Address, City, and Zip
, '%C (/rol u✓t�, ( '
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
,,,ma�yy
6. Is(are) the well(s)#' Permanent or Temporary
7. Is this a repair toiiann existing well: DI, Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' and 2@l00')
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
iS,:t)i)TER EASING (for'mulh.cased:wellsj Ok 1:INElt{ifap ltenble)r :' .
THICKNESS MATERIAL
#6i1N1VERCASXNGfT1tST.i1B1Nt;(denfhermafotosed Iaup)r':
FROM
ft.
FROM
TO
TO
ft.
DIAMETER
DIAMETER
in.
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
in.
/ 0, 't.
3 ft.
in.
/
5(. 4 / W
FROM
6 ft.
TO
/`5 ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
19-SANI3/GRpyEL PAC'1';(if tippl�ciible) > ':
FROM
g ft.
ft.
TO
3) Sft.
t
ft.
MATERIAL
EMPLACEMENT METHOD
20rDk1I)L1NG. LOGt (atteCti ktldthonal'.itheets �f: ieoedsary) FROM
ft.
TO
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
'11 1vrAngs
ft.
6 2020
r;rFst-,111
22. Certificatio s :
Signatur
ell Con actor Date
By signing this. form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
N Nt C"rnnno nprnart..,on FF .,.. n..-1:... :..: _: _.. _a nr_.__ n

WELL CONSTRUCTION RECORD (GW-1)
1, Welli�Contractor Information: y
l'ruliC/ i Xcxvier Warr+ng I64
Well Contractor Name ✓
413
NC Well Contractor Certification Number
Company Name
2, Well Construction Permit 11:
List all applicable well construction permits Be. U/C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Weil:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
wd
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer 'rest
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipalfPublic
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
oStormwater Drainage
Subsidence Control
DTracer'
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 74 di /2O2/ Well ID# f)IIL' 1/-3"P
5a, Well Location:
re)lam/v;a/ Prc if
Facility/owner Name Facility WY (if applicable)
/3 92 6 l ,,' rs v, Ile • con c vrd
Physical Address, City, and Zip
fre_ck/en &1i- t`J/g2/2l2
County .J Parcel Identification No, (PHI)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well
field
, d, one tat/long is sufficient)
,3S: W285: N SD. go,Sy 9c
6. Is(are) the well(s)
Permanent or DTemporary
W
7. Is thls a repair to an existing well: DYes or ,ON°
If this Is a repair, Jill out know,, well construction (»formation and explain the nature of the
repair under 1(21 remarks section or on the back of this farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /
9. Total well depth below land surface: re)
For multiple wells list ail depths if different (example- 3(200' and 2 100')
10, Static water level below top of casing:
/(water level is above casing, use " ('
11. Borehole diameter: C3 (in.)
12. Well construction method: SaAif.•;
(i.e. auger, rotary, cable, direct push, etc.)
..XJ
(ft,)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13 a. Yield (gpm)
13 b. Disinfection type:
Method of test:
Amount:
For Internal Use Only:
RECEIVED/NCDEQ/DWR
14. WATLR ZONES
FROM
ft.
ft.
fis
TO
ft.
ft.
DESCRIPTION S E P 2 0 L U L t
WORDS
15OUTBRca;'s1Nt;° for:intiib:caM O s pRL .LF RFC-1InNAL OFFICE
FM AS Tie of. go &ebb)
RO
DIAMETER THICKNESS MATERIAL
ft. ft. in.
163,NNEFiXASING:OR TUBINGt(geothermal closed=loop)
FROM TO DIAMETER THICKNESS
ft,
ft,
f7SCREEN"
FROM
TO
dd ft,
ft,
18 GRQ.UT
10
-'0 R.
ft,
ft.
ft.
L/ In,
i In.
DIAMETER
ty tn.
In.
FROM TO MATERtsr
e ft. Cl ft.
b ft.
ft,
ft,
ft,
S£ 4 yU
SLOT SIZE
aildis
(C,VL t vt /
19.:SANt)/GRAVEL'PACK (it applicable)
TO
FROM
ft,
ft.
.5e`oft.
ft,
MATERIAL
Sq tic/
v /0
MATERIAL
THICKNESS
Sch i#a
vt:
MA1'E}UAL
EMDUN
EMPLACEMENT MET} OD & AO'r
—POurrcr/ // /4LLT
l /Aill 11it /2-- 8,v _._
EMPLACEMENT METHOD
.lrr,recj /w6rrai
204FifliU1NG'.LOG<.(aYta'ehadifltionpl'sheets if betetsaiT)
FROM TO DESCRIPTION (color, hardness, soll/roek type, grain site, etc.)
0 ft, 12, fit,Rcei/f y fie;
/2,i ft. '2 J ft, QhlNS'G [j�(Jj! G[J4 5; /14
ft. 3 ( ft. ✓
7 l3ro 614 !f
[ j!yClaley
glati-Aerce/
Clayey st (�-
3 ft.
Y[ ft.
.S"i) ft,
ft.
2I; REMARkS"
ft.
22, Certification: 0161.224.0,
/�_ - 2-
Signature of Certified Well Contractor
10/,)/21)2a
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 01C .0100 or I SA NCAC 02C .0200 Well Consultation Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional web site details or web
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this form within 30 days of completion of web
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of web
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of web construction to the county health department of the county
where constructed,
•

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information:
TGt t:(j
Well Contractor Name
NC Well Contractor Certification Number
C ! C { rI
Company Name
2. Well Construction Permit #;
List all applicable veil constsrction permits (i.e. U1C, County, State, Variance, elc.)
3, Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irritation
Non -Water Supply WeU:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Coolin: Return
4. Date Well(s) Completed:
5a, Well Location:
�rt t!7t9t�a t/ Pin_, 1.'.
Facility/Owner Name
Physical Address, City, and Zip
County
Ih'2/24L2i2 Well ID#
DMunicipal/Pubiic
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer'
Other (ex lain under #21 Remarks)
Facility ply (if applicable)
R` , 'Arc
2802$
2121'
Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one las/long is sufficient)
• 9 22 N , BQ$? /,?
W
6. Is(are) the well(s) i'� Permanent or OTemporary
7. Is this a repair to an existing well: Dyes or KING
If this is a repair, fill out known well construction Information and plain the nature of the
repair under 021 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-i is needed. Indicate TOTAL NUMBER of wells
dri Iled:_ �_.._ ....._.._._
9. Total well depth below land surface: �(7
For mulup(e wells list all depths if different (example. 3(g200' and 2Q100')
10. Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter: 6 • (in.)
2. Well construction method: ��i7iL
i.e. auger, rotary, cable, direct push, etc,l — -----
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
Method of test:
13 b, Disinfection type:
Amount:
For Internal Use Only:
14. WATER`ZONF.S
FROM DESCRIPTION
ft,
ft.
TO
ft,
1iECEIVED/NCDEQ/DWR
SEP 2 0 2021
rtwfa!
15;.0 TLR'CA'SING'ftif:aiaiticasedWells ORLINER' �
FROM TO nreMn"ER
in.
cotbormalcclosed.loo.
ft, ft.
17. 5 GR$ElY
FROM TO DIAMETER SLOT SIZE TrifCKN;
1© ft.
ft,
18..GRpS1T
ft,
6. DINER
FROM
FROM
TO
DIAMETER
MATERIAL
=
1111111111AM
19..SAND/GRAVEL 'PACK !La
FROM
ft.
ft.
ft,
ft,
ft,
CASING:'OR TUBING
TO
ft,
Uceble
MATERIAL
•
EGION
Ucable
MATERIAL
MATERIAL
1QUL
MA"FERIAL
v••
EMPLACEMENT METHOD & AMOUNT
P
,71/11i -
♦
EMPLACEMENT M
AlMiger
20., I`ING;LOG<' attach :add! onaatsheetsffbecctsa
FROM T�t►I�° nESCRIPt. ION colo
2 AMU
d �.
1•
21. RE
ft,
ft.
ft.
ft, ft.
ft
ft,
ft,
ft,
22, Certification:
('t7„ 's1
I'a
Signature of Certified Well Contractor
Date
By signing this form, 1 hereby certify That the well(s) was (were) constructed in accordance
with iSA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft,) 24a, For All Wells: Submit this
construction to the following:
tow
THOD
hardness soil/rock ,e rain size, ere.)
`a
a e (
5L I
(ft,)'
lobby/2v
form within 30 days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Inlec_ tionWells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 clays of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Fragrant,
1636 Mall Service Center, Raleigh, NC 27699-1636
24e, For Water Su 1 & Iu colon Wells: hi addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
FICE

If water level is abavesi g, use
top of easing;
casing, rue "+„
•
11. Borehole diameter: (y ,
(in.)
12. Well construction method;
(Le, auger, rotary, cable, direct push, etc.}
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
3 b. Disinfection type;
Amount:
• V1Na 1 RUCTION RECORD
I. Well Contractor Information;
''Tfil oj.
Well Contractor Name
`!_38
NC Well Contractor Certification Number
Company Name
2, Well Construction Penult #:
List all applicable well construction permits (i.e. 01C, County, Slate, Variance, etc,)
GW-1
3. Well
Use (check well use):
Water Supply Well;
Agriculhual
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well;
;A. Monitoring
Injection Well:
Aquifer Recharge
'i Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin• Cooling Return)
4, Date Well(s) Completed;
5a. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Groundwater Remediation
°Salinity Barrier
DStomtwater Drainage
°Subsidence Control
°Tracer'
Other (ex lain under #21 Remarks)
Well 1D# (.(/
Facility MY (if applicab lei `"
, 74
28096)
County
Parcel identification No. (P[Nr))
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well
field, one IaUlong is sufficient)
6, Is(are) the well() s > Permanent or -�+°
;Temporary
7. Is this a repair to art
If this is a repair, ousting well: Yes or ,�
repair undrepair remark;section ell cons back of u h(sform.flan and No
on j explain the nature of the
8, For Geoprobe/DpT or Closed -Loop Geothermal Wells having the same
construction�, only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
driiled;
9• Total well depth below land surface: For multiple svells list all depths jd(D rent (example- TAL INSTRUCTION
P 3@200' and 2@a 100') (ff) 24a, For All Wells; 10. Static water level ---- Submit this
construction to the following:
W
14, WATER ZONES
DESCRIPTION
OUTNR'CA5 LTVG- Not u[, eased wells
FROM TO
OREIiVI�iR : if g; Likable
DIAMETER
lm
1111.111121
5;11VEK CilS17Y
FROM TO TUBING � 'cofjlordjakClosed,to„
ft. ft,
!n.
17. SCREEN
GCE
MATERIAL
MATERIAL
1/� DIAMETERR _ SLOT SIZE THICKNESS
111111111111111111111111111111111111111111
ro sia
imunom
ft f'
1111111111111111.1
19,;SAND/GRAYEL'PACK ISa,.6"
FROM T
h1A1'ERLAL
EMPLACEhrENTrMETHOD & AMOUNT
P. ise/
2O..D12rLD .Ve'LO� h:add(tionei sbeeta
FROy TO lfbecesaa
olar hardness saltIrock a rain
DESCRIPTION
(ft.)
2
t
c
Signature of Certified Well Contractor2.�`,
Date%® Gap
By signing this forum, / hereby cernjy chat the well(s) was &ere) constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standads and that a
copy of this record has been provided to the well owner,
23, Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMIT
S
21. REMARKS
22, Certification:
%_. ize, eta)
4, / i44 So /t
cr—
Sa, / Lc
form within 30 days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mali Service Center, Raleigh, NC 27699-1617
24b, For Infection Wetic:
above, also submit one co In addition to sending the form to the address in 24a
construction to the followingy of this form within 30 days of completion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
4c, For Water Su 1 & In action Wells;
be address(es) above, also submit arc co In addition to sending the form to
ompletio❑ of well construction to the county health of sde a,,,,,
n1 within 30 days of
here constructed,