WM0301152_GW-1 records_20220801

This limn can he used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well ContractorNanre
2907-A
NC Well Contractor Certification Number
S&ME Inc
14. WATER ZONES
FROM TO DESCRIPTION
ft.
ft.
ft.
15. OUTER CASING (for multi -cased welts} OR LINER lif a
FROM
ft.
cable
DIAMETER THICKNESS MATIMIAL
ae.
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)
OlndustriallCommereial
°irritation
Non -Water Supply Well:
RI Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Mtmicipai/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
COStonnwater Drainage
CISubsidence Control
°Tracer
°Geothermal (Heating/Cooling Return) °Other (explain under #21 Remarkst
4. Date Well(s) Completed: 9/1 5/20 Wep ID# M W-48
Se. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
1 511 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! Held, one lat/long is sufficient)
610606.396N 1461638.047 E
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one fatxt.
6. Is (are) the well(s): CdPermanent or DTemporary
7.1s this a repair to an existing well: DYes or ENo
flints 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: 4" (ft.)
For multiple wells list all depths if different (example-3twi00'and 2Q100')
10. Static water level below top of casing: NIA (ft.)
1f water level is above casing, use "+"
11. Borehole diameter: 10 (In.)
Auger
12. Well construction aaethod:
(i.e. auger, rotary, cable, duvet push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Form G W-1
Method of test:
Amount:
16. INNER CASING OR TUBING (geothermal erased -loot)
FROM TO DIAMETER THICKNESS
+3 ft.
11
ft.
4
IL
Sch 40
MATERIAL
PVC
ft.
ft.
17. SCREEN
FROM @ To
11 a 46 ft.
ft. ft.
IL GROUT
4
DIAMETER_
a
in.
in.
SLOT SITE
.010
TMCKNESS
Sch 40
MATERIAL
PVC
FROM
0 ft.
TO
6
ft.
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
Tremie
6
tt.
8 ft.
Bentonite
Pour
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
8 ft 46 ft. #2 Sand
ft.
EMPLACEMENT METHOD
Pour
0. D
dt
0
40
10
ft. 40
ft 46
ft.
ft.
SCRIP
color, hardn
soiVroek ty. Praia size. etc.)
Gray brown Silt
Gray Silty Sand
ft.
ft.
-- _ ft.
n
R.
21. REMARKS
R.; ,
22. Certrlication:
Signature of Certified Well Contractor
1C/,
Date
By signing this intro, I hereby certify that she welks) was (were) constructed in accordance
with ISA NCAC 02C.0100 or I5A NC/IC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram sr 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.
SUBMTTrAL INSTUCTIONS
24a For U We : 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.
North Carolina Department of Environment and Natural Resources —Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
J 1"(45 bin// Jr��
Well Contractor Name
J Yi} NOV 0 4 2070
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name MOORESVILLE REGIONAL ()Friel-
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
on -Water Supply Well:
Monitoring
Municipal/Public
®'Residential Water Supply (single)
Residential Water Supply (shared)
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Recovery
0Groundwater Remediation
0Sal inity Barrier
DStormwater Drainage
['Subsidence Control
0Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: ?1 /4f11) Well ID# /f'/ /1/-9 9
5a. Well Location:
Cdoi1J, a/ PJ 9 e
Facility/Owner Name/Fa_ciility ID/I If applicable)
/'//'ox i/ ,ijzvr I)y/4-- (oi,'ce?l(.:I" Id/`(1'�id/
Physipal Address, City,//and Zip
,, ec rle t Diu/tni
County Parcel Identification No. (PIN)
60.
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)fVfPermanent or OTemporary
7. Is this a repair to an existing well: QYes or DNo
I%this is a repair, fill out known well construction information and explain the nature (lithe
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:
Ss�
9. Total well depth below land surface: (ft.)
For multiple wells list all depths t/d(erent (example- 3@200' and 2@l00)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
tint.Fpr r)
nternal Use Only:
`�-14:'VF'ATRIfZONP.S`•;';i:i:ai,: �:::.
FROM
TO
DESCRIPTION
ft.
ft.
FROM
ft.
ft.
15,•:OUltI eASING:(for;`multu.casea wells) OICLWERVII u ltealil4
FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
16 i:NN 14:0A$)NG` 3R TV141NG:(geot1iermal oloYCd IoetlI'. y.
TO
ft.
ft.
DIAMETER
in.
THICKNESS
MATERIAL
ft.
°1TG�scIl�Etv;;=�;
ft.
in.
FROM
0
ft.
TO
ft.
DIAMETER
y ft.
67 ft
in.
f in.
SLOT SIZE
THICKNESS
MATERIAL
it)/Z�
FROM
O ft.
ft.
TO
-7 ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
//e/4/7) 4W
ft.
ft.
19 $ANA/GRAVE):,PACKfitapphcgble)
FROM
ft.
ft.
TO
9 ft.
ft.
MATERIAL
EMPLACEMENT METHOD
11
/ /empli N't"
20:Dit11LING.`LbG,(AiJBC$:aiidfhonalklieet9i(tiecessary) .=; .
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
FROM
ft.
TO
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
RPa"
ft.
ft.
OCI 6 nza
j Crt ; IGI,"Sr'i1i1C, �f11't
ft.
VREIVIARltS -,;.
ft.
22. Certificafio :
Signatur
611 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 /5A 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
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Company Name Ii/I )ORrSVILLE REGIONAL OFFICE
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (I1C, County, Slate, Variance, etc)
yy L` LL 1.. ViV �J 11(U1.11(JN RECORD (GW-1)
1. Well Contractor Information:
Well Contractor Name ltiifiCLIIfIl;)jhf(,OEhl1-T/f" 10 91
,/ Z? lS', , NI p
NC Well Contractor Certification Number Q V 0 4 2020
Cascade Drilling, LP
WO! 40U
3. Well Use (check well use):
Water Supply Well:
WATERZONES ',
FROM I TO
ft.
ft.
DESCRIPTION
ft. ft.
15':OUTER.CAs1NG (for`'nudtt case4'welis):Ofl LINER ifap lieahle)
FROM TO DIAMETER THICKNESS MATERIAL
fti
ft. in.
16. INNER CASING OR°TVUINGr(geathermi I ctosed loop)',
FROM TO I DIAMETER 1 THICKNESS
ft. 1 ft. I in.
MATERIAL
Agricultural
1 Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
RI
°Municipal/Public
°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)
Groundwater Remediation
°Salinity Barrier
°IStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9 t /k4 t O Well ID# /t' A 'CD
5a. Well Locationn: t
.,..,) Cc/ow, a /flo e
Facility/Owner Name Facility ID# if applicable)
/y/O '', r'.s' Olt — 6/Jam/ ge
Physipal Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
N W
6. Is(are) the well(s) jL i ermanent or DTemporary
7. Is this a repair to an existing well: °Yes or _°J 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: J (ft.)
For multiple wells list all depths ifd different (example- 3@200' and 2@l00')
10. Static water level below top of casing: (ft.)
1f water level is above casing, use "+"
(in.) t.
11. Borehole diameter:
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW-1
0 ft.
ft.
17'SCREEN; ::;;;
FROM TO (DIAMETER SLOT SIZE 1 THICKNESS
in.
ft.
in.
{ ft 1 3 ft
FROM 1 TO
a ft.
ft.
ft.
ft.
MATERIAL
MATERIAL �EMPLACEMENT METHOD& AMOUNT
7 4-4L, I Jiy7eiell 7 r ret<K
ft.
ft.
14:SAND/GAZiV:ELPACT (if>ippliciible)
FROM/ I TO z ft,
L MATERIAL
/ ft. I s-J I # S�✓r
ft. 1 ft.
20tDR1LLIN(a:LOG (ettao
FROM TO
ft. ft.
EMPLACEMENT METHOD
717 t°/1i1GC%'
>eddtttohel`.flheeftl �fiecessary) . <- • ,�r:
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
1 REMA1U s /
,, )roe L �tri
1rf3IMa MN es3Ci'f n
22. Certificatio :
Signatur . ' ' :' tell Contactor
7/6'dig
By signing this form, I hereby certify that the well(,) 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 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 Sunnly & 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.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

1. Well Contractor Information:
roes /Mil
NC Well Contractor Certification Number
Cascade Drilling, LP
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
I1Irrigation
n-Water Supply Well:
it onitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
QExperimental Technology
DGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Well Contractor Name NECF.„/M(NICDEW,001,1-',1"
FROMTO
NOV 0 4 2020
MiOORESVILLWQI ?OS
E REGIONAI Oi :
�rci
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
(Other (explain under #21 Remarks)
4. Date Well(s) Completed: ,,, / /i5 I L/ Well ID# / f ! //I/ 5(
5a. Well Locatio
r� f
Coloilk a
Facility/Owner Name Facility ID# if applicable)
/y /eg liod�fe/s v,/l — CO,JCcmi i2c/
Physiwal Address, City, and Zip
JleC
County
Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
6. Is(are) the well(s)
itZ41
ermanent or OTemporary
14. WATER ZONES
ft. ft.
DESCRIPTION
ft.
ft.
15. OUTER CASING (for; multi -cased wells) OR LiNER (if ap
FROM TO i DIAMETER l THICKNESS
ft. ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM I TO I DIAMETER 1 THICKNESS
ft. ft.
m.
ficable)
MATERIAL
MATERIAL
ft.
17. SCREEN
FROM
ft.
In
p ft.
TO
ft.
DIAMETER
In.
SLOT SIZE
THICKNESS
MATERIAL
fi
IS. GROUT
/0/a
0
ptic
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
%/ ft.
�: (,-'lt f:
G°/77/'?/r/
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM TO
MATERIAL
EMPLACEMENT METHOD
13 ft. Llsft.
.) S end
jy,0,71,,oi,ea/
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
TO
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
ft.
OCT 2 6 2020
Irfori" oV(v.i Prn';es]strin Unit
Ssction
22. Certification :
W
7. Is this a repair to an existing well: rYes or ONo
J/ this is a repair, fill out known well construction information and explain Me 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: (ft.)
For multiple wells list all depths different (example- 3@200' and 2@100')
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)
13b. Disinfection type:
Method of test:
Amount:
Signatur r rs e 1 Conactor
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 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 constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
RECEIVED/NCDEQ/DWR
1. Well Contractor Information:
Well
e ...
Aanc's' Xat/ er HalrIr�q/pa
Contractor Name ��..//
NC Well Contractor Certification Number
(.tia/ker 1-1,'11 CI a/(alrmei1 a l
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (de. UIC, County, State, Variance, etc)
3, Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply WeU:
Monitoring ORecovery
Infection 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 (explain under #21 Remarks)
4, Date Well(s) Completed: 9/2.1/V20 Well ID# tY(.1!',a2
5a. Well Location:
Col0,116 Pi,pc is'i
Facility/Owner Name Facility ID# (if applicable)
el-erSil1 1/e " tur%COrc /cedi Minlerltsl lie
Physical Address, City, and Zip z sole
rneckIe iaiirL Oi9L/OII02
County Parcel identification No. (PEN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
.3 5, II/ 4/2 N c9c), 6'e) 21
6.Is(are)the well(s)JPermanent or ©ITemporary
7. Is this a repair to an existing well: Dyes or 3No
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 i GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9, Total well depth below land surface:
For multiple wells list all depths ifdifferent (example- 3t'22200' and 2@1') 00
'T 10, Static water level below top of casing: 2
If water level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method: Seri l (.2
(i.cauger, rotary, cable, direct push, etc.)
32.
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b, Disinfection type: Amount:
) i'1 I1
14. WATER ZONES vim.+ u v �....,
FROM
TO
DESCRIPTION
ft.
ft.
WQROS
ft.
ft.
MOORESVILLE REGIONAL Uf rlU
IS. OUTER CASING (for multi -cased wells) OR LINER (If ap Ilcobl)
FROM
TO '
DIAMETER
THICKNESS
MATERIAL -
ft,
ft.
In,
16.INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
1-3 ft.
2 ft.
iG,
jJ in.
t
$ /r1 v)
p VC
ft.
ft.
In.
17: SCREEN
FROM
TO
DIAMETER
SLOT SiZE
THICKNESS
MATERIAL
22. ft.
s2 rt.
L/ In.
, 0 / 0
.7 cf'L 40
P IiL
ft.
ft.
In.
18..GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
/ ft.
z ft,
Pe f/c45
Poured ` /1 - %iuc 4 '-
V ft.
/O ft.
{ CS
CC men*
t .'mMle /b- e. 4
ft,
ft,
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
20 ft.
S2- ft,
If 54,4i
A2,,f eii(/r+l rqid._
ft.
ft,
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO DESCRIPTION (color, hardness, solUrack type, grain size, etc.)
n ft.
2. 5 ft
sl /f( C%,�
2.6 ft.
20 ft.
,^v t.4..h t.IGV 1�20
ft.
3 ,? -t.612atqf�flY
1 ft.
3-1
6t* ry -S li-
3), c� ft,
ft.
11.
/
ft,
ft.
ft,
ft.
i
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
l0/13 /2oou
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 foot 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: 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 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:
KCIOCl S' Xczftier
Well Contractor Name
NC Well Contractor Certification Number �
tV a (1Ci r l�/ I I £2v/ awl e 1.1;
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)
Indus tria VCommerctal
}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:
5a. Well Location:
L.onrei% Pi/3ctae
Facility/Owner Name
Ffu 01+erSU1 vvi
Physical Address, City, and Zip
rn C ck/et') tlrL
County
DMunicipaluPublic
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
Subsidence Control
Tracer
Other (explain under (#21 Remarks)
e ) Well ID# /%%,U " �J
Facility ION (if applicable)
COrt:� /2 /'ifrri
�/94/0/02
Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one latllong is sufficient)
? CIS// N a'OS'72 /
W
6. Is(are) the well(s)g)Permanent or [Temporary
7. Is this a repair to an existing well: DYes or Fallo
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: ,�hy
9, Total well depth below land surface: •/J (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100`)
10. Static water level below top of casing: (ft,)
If water level is above casing, use "+"
11. Borehole diameter: is (in.)
12. Well construction method: 3'0t1 / l,;
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
RECEIVED/NCDFQJDWR
SEP202021
'14. IVATER ZONES
FROM
ft.
TO
ft:
DESCRIPTION WQROS
MOORESVILLE REGIUI AL OFFIE
ft.
ft.
15. OUTER CASING (for mull -cased wells) OR LINER (if ap llcable)
THICKNESS MATERIAL
FROM
FROM TO
ft.
DIAMETER
ft. In.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
*3 rt.
ft.
17. SCREEN
FROM
Ito ft,
TO
Y u ft.
ft.
i in.
In.
THICKNESS
Sc% �v
MATERIAL
p �c
TO
6,0 ft.
ft, ft,
18. GROUT
DIAMETER
In,
In.
SLOT SIZE
00/0
THICKNESS
Sch.Yv
MATERIAL
FROM/TO 1 MATERIAL j EMPLACEMENT7METHODD & AMOUNT
3� ft' 3� ft, ! t'' //CTS n f 1 -
Poured t. ie^
34 ft. ; Cemerr '
O ft.
ft,
ft.
19. SAND/GRAVEL PACK (if applicable)
TO
3eft,
ft,
Oft.
ft.
MATERIAL
EMPLACEMENT METHOD
Au«d /visit fe.
20. DRILLING LOG (attach additional sheets if necessary)
TO DESCRIPTION (color,/hardness, sa(Vrocktype, grain size, etc.)
A/0 50/
FROM
ft.
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature Pied Well
Contractor
104y/2020
Date
By signing this form, ! hereby certify that the we11(s) was (were) constructed in accordance
with 15,4 ,VCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Construction Standards and that n
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 Mall 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 & 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.

4, Date Well(s) Completed: y/2R/
5a. Well Location:
Colon,e 1 Pt3c/ioc'
Facility/Owner Name
f �c� rl+erSU# i/e - ton
Physical Address, City, and Zip
rnecklt:.�Jairrt
Count
y
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: L�
rlC�raIC, S' Xavier parr/hq ra
Well Contractor Name ✓✓
NC Well Contractor Certification Number
/I .
1 a/K;er Win £ijilir>,r7rMe!'j k /
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industi al/Conunercial
Irrigation
Non -Water Supply Well:
Ivtonitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
i Geothermal (Heating/Cooling Return)
For Internal Use Only:
14. WATER ZONES
FROM
TO
RECE►V =
SE? 2 0202.1
DESCRIPTION
ft.
ft.
ft.
ft,
CMOs
P 1O()RFSVII LE REGIONAL OFFICE
15. OUTER CASING (for multi -clued wells) 0R LINER (if ap llcoble)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft, In.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
ft.
TO
ft,
i in.
In,
THICKNESS
MATERIAL
P �c
DMunicipal/Public
DResidential Water Supply (single)
DResidentia! Water Supply (shared)
DReeovery
Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
2v2 ?
Well ID# ,5/A1
Facility ID# (if applicable)
Cord ke./ Nuei7LerSvi 1/e
2.bI'C�•�t`�
OiC141n162
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Of well field, one let/long is sufficient)
W .C21.N 6'o, 9PIl ? 9
6. Is(are) the well(s)Permanent or DTemporary
7, Is this a repair to an existing well: DYes or ONo
Ifthis is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or or 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: 1
9. Total well depth below land surface:
Far multiple wells list all depths if different (example- 3(J200' and 2@I00')
10, Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method: Son / C
(i.e. auger, rotary, cable, direct push, etc.)
tv
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
17; SCREEN
FROM
TO
ft.
ft.
ft. ft.
18. GROUT
FROM
DIAMETER
zi in,
In.
SLOT SIZE
•D/o
THICKNESS
S A qv
MATERIAL
I� UC
1 ft.
Q ft.
ft.
TO
a ft.
11 ft.
ft,
MATERIAL
Pe //. LS
Ce me
19.'SAND/GRAVEL PACK'(if applicable)
FROM TO
.3 ft,
ft.
vft.
ft,
MATERIAL
Sigid
EMPLACEMENT METHOD & AMOUNT
Poured / (- �t✓� �tf
EMPLACEMENT METHOD
Paure
20, DRILLING LOG (attach additional sheets If necessary)
FROM DESCRIPTION (color, hardness, solVrock type, grain size, etc.)
8rO s, /,W tom%
UY ft.^ rrT /5't win 4/1
/ vc i s
�lV ft. pl 5 PItJ(y s (T
U rt,
Se yr ft,
'/t) R,
ft.
TO
14 ft,
60ft,
ft.
ft,
ft.
ft,
21, REMARKS
ft.
22. Certification:
Signature of Certified Well Contractor WJ I V/2220
Date
By signing this form, 1 hereby certify that due well(s) was (were) constructed in accardunce
with 1 SA NCAC 02C.0100 ar 1 SA NCAC 02C .0200 Well Consnrtction 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 Mall Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the farm 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 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
1. Well Contractor Information;
GW-1
For Internal se Only:
VED/NCD Q/DWR
Well Contractor Name
NC Well Coon -actor Certification Number
/
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):
err
•
1
1
Water Supply Well;
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Cornmerciai
Irri anon
Non -Water Supply Well:
•
i
mo
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: hg/4 nv Well ID#
5a. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
County
rt:.
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
Other (ex lain under #21 Remarks)
/Facility ID11 (if applicable)
e'. 'Orel /
s p
2-6(%', V
v1�1 MIDI �2
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lauIong is sufficient)
r'
N
6. is(are) the well(s)fJpermanent or OTemporary
7. Is this a repair to an existing well; °Yes or
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, 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: k
For multiple wells list all depths if different (example- 3@200' and 2@a /00y (ft.)
10. Static water level below top of casing:
/f water level is above casing, use " ' ' (ft.)
11. Borehole diameter: L
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:
14. WATER ZONES
rscum TO
111111.11111
15, OUTER CASING for multi -cased wells OR LINER
FROM DIAMETER
In.
SEP 2 0 2021
ft.
ft,
DESCRIPTION
MOORESVIL.L
If a •llcable
�-�16. DINER CASING OR TUBING : eothermel closed•leo
FROM DIAMETER
43 ft.
F
TO
MATERIAL
111111111111111111.1111111��
17. SCREEN
FROM TO DIAMETER SLOT SIZEIMI TTH11CCKj ESs MATERIAL,
�/r fL rI1'�a�i%iar
r
EMPLACEMENT METHOD & AMOUNT'
r �
19. SAND/GRAVEL PACK If a •Ileable
M
FRO
lt fit EMPLACEh1ENT METHODrV ral�
ff,MISCA '
20, DRILLING LOG attach addldonal sheets if necessa
xenui m� INDESCRIPTION colas hardness, solUrock
ft.
TO
�/
21 REMARKS
22. Certification:
s
TO '
ft.
ft.
Li In.
S/
,, 5
THICKNESS
Date
By signing this form, 1 hereby cert fy that the well(s) was (were) constructed in accordance
with 15,1 NCAC 02C .0100 or 154 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 Mall Service Center, Raleigh, NC 27699-1617
24b. or In'ection Well 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, F r Water Su 1 & In ection 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.
rain size, etc.)
Signature of Certified Well Connector

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
KC, ►C, C/S'
Well Contractor Name
�99
HHQrr/j70 /1
NC Well Contractor CertificationNumber .�.
ker I-/1I! £ijtlllvr'}t/I?C1i /G/
Company Name
2. Well Construction Permit #:
List al! 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:
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Monitoring DRecovery
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
DTracer
Other (explain under #21 Remarks
4. Date Well(s) Completed: 9/20/124.0 Well rD# mu/ •' +`6
5a. Well Location:
C)/o,, t / I C
Facility/Owner Name Facility ID# (if applicable)
Het efferSU, I/� ' Cc'V Ord r . NtirlierSts, //e
Physical Address, City, and Zip 41-690,2p
mecklerfla.lrt: 0/9'10102 V
County Parcel Identification No. (PW)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iati ong is sufficient)
. 5. 4114' 62 N iV 'O£ 7( Z
6. Is(are) the wells) JPermanent or E3Temporary
7. Is this a repair to an existing well: DYes or gi3No
If this is a repair, fill ma known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: '
W
9. Total well depth below land surface: e t/ (ft.)
For multiple wells list all depths ifdifferent (example- 3@200' and 2@a 100`)
10. Static water level below top of casing: (ft.)
((water level is above casing, use ".."
11. Borehole diameter: g (in.)
12. Well construction method: SO/1 / C
(isauger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
RECEIVED/NCDEQ/DWF
SEP 2 0 2021
14. WATER ZONES
FROM
ft.
TO
ft,
DESCRIPTION
WnaQS E
rt.
ft,
15. OUTER CASING (for multi -cased wells) OR LINER (if all [(cable)
FROM TO DIAMETER THICKNESS MATERIAL
ft, ft, in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER THICKNESS
"f^ ft. %f') ft. L/ in.
ft.
17. SCREEN
FROM
fL
In.
S AYo
MATERIAL
VC
to
ft.
ft.
18. GROUT
FROM
TO
ytJ ft.
ft.
DIAMETER
In,
l a.
SLOT SIZE
'0/O
THICKNESS
MATERIAL
SC1i Kt? (%c.
ft.
rt.
ft.
TO
ft.
ft.
rt.
MATERIAL
Pe
Cemen7(-
19. SAND/GRAVEL PACK (If applicable)
FROM TO MATERIAL
ft, Y0 ft.
ft.
ft
EMPLACEMENT METHOD & AMOUNT
ruvrec/
ltI'f7M,e
,gVL �a
`Pg2 /
EMPLACEMENT METHOD
Pored/olycifa
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soltfrock type, grain size, eta.)
ery '4 Sr fly a
e7 rt. /U ft. 1fj h f > S', /7/' /;4e S4,�n.>/
i!� ft. 12 ft. grrt am Clayey Si hi-
1 2. 23 -Ca4A'i. S, /f''
b ft,
ft,
ft.
ft,
21. REMARKS
ft,
ft.
ft.
s /4
!O / 2o2G
Signature of Certified Well Contractor Date
By signing this form, I hereby certifj that the weli(s) was (were) constructed in accordance
with 15.4 NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Consruction Standards and that
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 Mall Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: hi addition to sending the fonn 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 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: �v/-�
knettlij ruuG1
L-J

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
County
Physical Address, City, end Zip
e[kIer)by
y
(a, c, s' kci.,, er Hain 10r2
Well Contractor Name �L//
'13 62g,c
NC Well Contractor Certification Number
(Va 1k;er l-r 11 Fri u/'`or),naell
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
DGeothermal (Heating/Cooling Supply)
L_:l fndustriaL/Commercial
Irrigation
Non -Water Supply Well:
tigMonitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
i Geothermal (Heating/Cooling Return)
DMunicipavPublic
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
DSalinity Barrier
0Stormwater Drainage
DSubsidence Control
Tracer
Other (explain under 1121 Remarks)
4. Date Well(s) Completed: /19/1%
5a. Well Location:
C0/un,/I/ Pupc c
Facility/Owner Name
Well ID# 1V1Gut",j%
Facility m# (if applicable)
NuiikersU1 /le -Concord /,miers//e
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one Iatilong is sufficient)
3S, /4/66 N pd. ?0.5t724
6. Is(are) the well(s)1DPermanent or DTemporary
7, Is this a repair to an existing well: DYes or EINo
If this is a repair, fill out known well construction information and explain the nature gfthe
repair under #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-I is needed. Indicate TOTAL NUMBER of wells
drilled: %
9, Total well depth below land surface: _ 7 (ft.)
Far multiple %veils list all depths ifdifferent (example- 3@200' and 2@100`)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method: / I,;
(Lcauger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
14. WATER ZONES
FROM
ft.
ft.
TO
ft.
ft.
DESCRIPTION
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM TO NIA -FERIAE
ft,
ft,
DIAMETER
In.
THLCKj'ESs
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER
f-3 ft. 0 ft.
ft. ft.
17. SCREEN
FROM
1) ft.
ft.
18..GROUT
FROM
TO
4/5 ft,
TO
ft.
Li in.
ln,
THICKNESS
ScJ) 4►v
--OFFICE
MATERIAL
PJ�
ft,
ft.
ft.
Pe / S
Cc men*
19,'SAND/GRAVEL PACK (If applicable)
FROM TO MATERIAL
g ft. Y' ft �2 r9/
J �!
ft, ft.
DIAMETER SLOT SIZE
ZJ to.
lo.
•U/a
THICKNESS
.5-et) Lio
MATERIAL
MATERIAL. EMPLACEMENT METHOD� & AMOUNT_
&,pee:/ ?,L,
lffmMie f 2-
EMPLACEMENT METHOD
20. DRILLING LOG (attach additional sheets if necessary)
FROM DESCRIPTION (color, hardness, soiVrnck type, grain size, etc))
eroid.31 Si Mei G%
G,, 54,41 'Si
0 ft.
3fL
10 ft.
ft,
ft.
ft.
ft.
TO
3 ft.
t L it,
f1.5.- ft.
21. REMARKS
ft.
fL
ft,
ft.
� 10//l ZvGv
Signature of Certified Well Contractor Date
By signing this form, I hereby cernfy that the well(s) was (were) constructed in accordance
with 1 SA ,NCAC 02C .0100 or 1 SA ANCAC 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 & 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,

WELL CONSTRUCTION. RECORD (GW-1)
1, Well Contractor Information:
ran 6 S )(a trl'c r llgrrtri }' o
Well Contractor Name ✓
4'3891
NC Well Contractor Certification Number
Ufa/ker. Hi/1 Ell titre /Iffieh�q�
Company Name
2. Well Construction Permit Th
List all applicable well construction penults (t e, WC County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well;
Agricul ura1
Geothermal (Heating/Cooling Supply)
Indusiria l/Cominercial
hrit;ttitn
Non -Water Supply Well:
Monitoring
injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
For Interual Use Only:
RECEIVED/NCDEQ/DWR
SEP2 O'2021
RZO
IWM
ft,
ft,
TO l fhSCflfl'l'loN
ft.
WOROS
- CAOOFiESVtttE 1 FCrteNAL OF
i5 Q1JT 1R. GASINt:?(fer.mnitl-triad tr6lis) t?1t LANE ( (1t aap ltcablb)
3%110M TO DIAMETER 1 l}UCKNEgipj,SS MATERIAL
F ft. I it/
ft f./ in, j Sc J Io U,
•18ENNEI CASINGOR UBING(gelitliermat elnied400p);
FROM to DIAMETER THICKNESS 1 MATERIAL
ft, ft. In.
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
E)Recovery
Groundwater Remediatiou
Salinity Barrier
Stormwater Drainage
OI Subsidence Control
Dl Tracer
Other (explain under Y21 Remarks)
4, Date Well(s) Completed; l / /q ZOZO Well ID# trey.. jp% p
5a. Well Location;
Co%n is / Ape line
Facility/Owner Name 1
Physical Address, City, and Zip
11'1eckfetaAury
County
Facility IDff (if applicable)
(1111e
29a9e
Farce! Identification No. (PLN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well,fieid, ore lat/long is sufficient)
6!t2.-r0 6S N !V6/5'6.116'9
6, Is(are) the well(s)Permanent or DTemporary
7. Is this a repair to an existing well: cjYes or No
If Mi. la a repair, fill out known well consultation i, jar otatton ant explain the nature of the
repair under 01 rarnarks seethe) ar vrr the back of`ihi's forru,
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:
For multiple wells list all depths 1f dtlerent (example- .4@200' and 2@i00')
10, Static water level below top of casing;
Ijwarer levet t' above Vwsfug, use "F
ely
11. Borehole diameter: {T (in.)
12. Well construction method; 'S /l/C
(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;
Form QW.I
ft.
17 SjatrEN
FROM TO
ft,
ft.
ft.
DIAMETER
in,
ft.
18.,CRRO1i1
FROM
C7 ft,
ft,
ft.
ft.
in.
SLOT SIZE
I I I ICKNESS
MA7'ERI,1,1.,
TO
f y ft,
ft.
ft.
MAMMAL
MAL
EMPLACEMENT METHOD & AMOUNT .t
Cmcy 7ift/Mit /2V-
i1, SAND/GlLAVEL PACK (lf appllaatile),
IrRUA9 TO •Yt, PERIAL
--
ft, ft,
ft.
ft,
MI'LtCEM1SNT M
—� sa y. 40, D1211 [ 1111 Flit ( ttocit additional sheets if necessary.)).
FROM TO DESCRIPTION t Aar tisrdro>s snWreckt o 3ala s4.0 etc.)
ft,cse r $14r-4 / I `�✓ 611'4 > ij
rill'`f , D+'QI"f*C_ft. ft,
ft, _ ft.
ft,
ft.
ft.
ft,
ft.
ft,
zt. ttt:n1ARKS -.'
ft,
22, Certification;
d n441r.43 .'tCtif![8i9 d
Signature of Certified Well Contractor
12/21/t,2o
Ue?
BF stgnfng this form, I hereby cat* that the wel((s) was (were) curt xy',-- v; �, accardarrce
with 1.54 bIC.4C 02C.0100 or 134 Nate 02C 1Ve11Construction Sfo,,/nds and ddtar a
ropy (Obis record has been provided la 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
constntclian to the following;
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 21699-1617
24b, leor lnlection 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, Fur Water Supply & Ioleciion 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.
North Carolina Department of Environmental Ouality - Division of Water Re.conrcr..e
"ICE

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information;
For Internal Use Only:
IIECEIVED/NCnFn/nWR
Kane/ s' kcw, e,- Harrnrg7 r2
Well Contractor Name �/
L-1.3 t5'c7 J7
NC Well Contractor Certification Number �.
t%a l ker /-/1 t l �n UI t^Jnd11 c i1 1 �*
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3, Well Use (cheek well use):
Water Supply Well:
Agricultural
�Geothermal (Heating/Cooling Supply)
IndustriaUCommercial
3Irrigation
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
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
DSubsidenee Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: /O/2120rp Well ID# IYIW-.Sg
5a. Well Location:
Colonic,/ Pt,pc/i'4t
Facility/Owner Name Facility m# (if applicable)
f-1l� eikeeSUl Ile • Concord kel 14.47erS vl e
Physical Address, City, and Zip 2,8v9p
PrCck1CflL.irt. C t f1
County vi 1 /oI b�.
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweelll field, once lat/longjis sufficient)
l
6. Is(are) the well(s)OPermanent or OTemporary
7, Is this a repair to an existing well: JYes or RiNo
If this is a repair, fill out known well construction iujormation and explain the nature of the
repair under #21 remarks section or on the back of this jorni,
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
dr lied: /
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: (ft.)
(limier level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method: ,spn /
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b, Disinfection type:
Method of test:
Amount:
SFP 2 0 2021
14. WATER ZONES
FROM
TO
DESCRIPTION WOROS
ft.
ft.
MOORESVILLE REGIONAL OFFI(
ft,
ft
15. OUTER CASING (for muttl-cased wells) OR LIVER (if ap lleoble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
ft.
In.
16.,INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
3 ft,
.
i 9,,5,-R
r! In.
` T
.sL�'1 jT'�i
pVC
ft, '
ft,
In,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
/9 ft,
i
i /t� ,7 .
In,
/
V
do/D
J e11 L/o
ve.,
ft.
ft.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD
l.� ft.
l ? ft'
Pe //c7l.5
& AMOUNT
&red ! 1 - a... f
r� ft.
V
/� ft,
l
c: t
CCIi'tell ! �r11IMl� /�
ft.
n,
19, SAND/GRAVEL PACK.(tf applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
L '� fL
L9, 5/'
/! JJJJ
'2 Sant
/�)vre'd /fibrci
ft,
ft,
, L /
20, DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type,grain size, etc.)
® ft.
Q ft,
(r7
/. t6rOs;✓/1 Clety
ft.
/ ft.
afi $a Mr / S'%fir,"
`i ft,
142 ft.
Grac „5'�t; ,jSj /f
(.12. ft
`
`l ft,
Grant ad / f4,,,rJ
tidy ft,
lg.4" ft.
61,4 5440y- s1 /f
fL
fL
ft,
ft.
21. REMARKS
22. Ctilication:
W
Signature of Certited Well Contractor
0/424)
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15,4 NCAC 02C .0100 or 15,4 NC,4C 02C .0200 Well Construction Standards and that n
copy plans 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 Alt 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 f'orrn 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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
SEP 2 0 2024
A/W./ 5' Xtcv/ er l7gt�1✓tq%�FJr1
Well Contractor Name
f3 lq
NC Well Contractor Certification Number
Walker f' 1// �hwt 00gi► er /G /
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:
10 Agricultural
Geothermal (Treating/Cooling Supply)
D Industria l/Commercial
r)Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
QExperimental Technology
DGeothetmat (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipaWPublic
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
}Groundwater Remediatian
Salinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: (O/. j'/`2. 20 Well ID# %%%u/
5a. Well Location:
C /Ondeil
Facility/Owner Name / Facility ID# (if applicable)
hu •1fLrSir1 Ile ' Concord i t / $ferStrl /fit:
Physical Address, City, and Zip et.),,
V
meckl�,Ji,irq viy?-1©162.
County Parcel identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one Iatlong is sufficient)
3.(4: �l 14/30 N Rya go 2. Yb�
6. Is(are) the well(s)JPermanent or DiTemporary
7, Is this a repair to an existing well: [JYes or @No
If this is a repair, fill out known well construction information and explain the native of the
repair under 421 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop. Geothermal Wells having the same
construction my 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface: (ft,)
For multiple wells list all depths if different (example- 3(a)200' and 2@100')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+ "j
11. Borehole diameter: lS (in.)
12. Well construction method: gpn /C
(i.e. auger, rotary, cable, direct push, etc.)
s'e)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b, Disinfection type:
Method of test:
Amount:
14, }PATER ZONES
FROM
ft.
TO
ft,
WOROS
MOORESVILLE RFf;lON/ I OFFICE,
DESCRIPTION
ft.
fL
15. OUTER CASING (for multi-casid wells) OR LINER (if apVeable)
FROM TO DIAMETER THICKNESS E MATERIAL
ft.
ft.
In.
16, INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
TO
20 et.
ft. ft.
17. SCREEN
FROM
2v ft,
ft.
In.
![ In.
THICKNESS
$"t./1 4/0
MATERIAL
P �c
18. GROUT
FROM
TO
SD 0.
ft.
DIAMETER
LJ In.
in.
SLOT SIZE THICKNESS
,0 Leo
MATERIAL
TO
1S 0.
yr ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
So IL Pe. //Ss Poured / 1 ` Rig 414
4
1/Y,MM1E'
ft.
tri t n T
19. SAND/GRAVEL PACK(U applicable)
FROM TO
1 9 ft,
ft,
ft.
ft.
MATERIAL
1°2 ...4
EMPLACEMENT METHOD
recil/i%r fia
20, DRILLING LOG (attach additional sheets If necessary
FROM TO DESCRIPTION (color, hardness, solUrock type, grain size, etc.)
//?� / %rvevil La /
f J f L ter/ eavt4, ��6^^ i Gy s f ib
3S ft. (`G7�1 Jsjdi 71 /
o ety Se)NJ
ft.
12 ft.
is ft.
as' ft,
ft.
12 ft,
SU fL
ft.
ft,
ft.
ft.
21. REMARKS
22. Certification:
Date
By signing this farm, 1 hereby cart{ 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 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 INSTRUCTIONS
24a. For All Wellg: 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 SuDDIv & Injection Wells: In addition to sending the fomn 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.
Signature of Certified Well Contractor

For internal Use Only,
rc.n .�lAl®
RECEIVED/NCDJ_
2 2021_
WELL CONSTRUCTION RECORD (CW-1)
1, Well Contractor Information:
fro/lei Xavier Re# &I/294 n
Well Contractor Name
NC Well Contractor Certification Number
Walker Hill En viroam en'41
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (t.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well;
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Com neretal
lrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
3 Aquifer Recharge
County
DMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
p . Recovery
Groundwater Remediatiou
Aquifer Storage and Recovery iSalinity Barrier
Aquifer Test DStormwater Drainage
DExperitnental Technology Subsidence Control
Geotherrual (Closed Loop) °Tracer
Geothenmal (Heating/Cooling Return) ij Other (explain under #21 Remarks)
4, Date Well(s) Completed: 11 /319020 Well ID# mw• sef 1
5a. Well Location:
COI 11AJ P(Je idle
Facility/Owner Name Facility
Han e 1(/i lc
Physical Address, City, and Zip
/nrckleniut j
ID# (if applicable)
�f} 11vn (c.rittt I
2 909
11oro2
Parcel Identification No, (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latltong is sufficient)
611)67Y.gen N 1t/64(4 ►.�Q
W
6. Is(are) the well(s) 'e Permanent or Temporary
7. Is this a repair to an existing well: QYes or g9No
If this is o repair, fill out known well construction information an explain the nature of the
repair raider 611 remarks section al' an the back of this limn,
8. For Geoprobe/DPT or Closed -Loop Geothermal VWteils having the same
construction, only 1 OW -I is needed, Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface: V
For multiple wells list all depths if different (example- 3®200' and 1@IQc')
i
(ft.)
10. Static water level below top of casing: (ft,)- -.
if water level is above casing, use
11. Borehole diameter: (iJ • (in.)
12. Well construction method: •.5011eC
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY;
13a, Yield (gpm)
13b, Disinfection type:
Method of test;
Amount;
Form GW-1
14. WATER ZONgS
NROM i TO
DESCRIPTION
fL
ft;
vvQnos
REGIONAL OFFI
ft,
ft,
MOOf1ESVILLF
1•Q 5.' UTf R'CASL'YC (for:mulf•ca.sed we11 )'OR LINER {lf applicable)
FROM TO
DIAMETER I THICKNESS MATERIAL
�' �ft. !!� ft'
6 in, SCi L/Q
.° VC
1_
:INNER CASING. 11. T'UTkIN
(ientltermal eltisee�tWoou)
FROM
TO
DIAMETER
THICKNESS 1 MATERIAL
ft.
ft.
In.
ft. ft.
In,
SSCItEEEN
l'R
DIAMETER
3LOrSIZE
THICKNESS
htA1'kttJAk,
In.
In.
18 GRU. T"
Fnfhvt TO
MA't'ERLSL.
ItMPLACEMENT M> TI OD & AaaouNr
r ft.2
o ft,
Al
�tr+�mir t.3
/3, - Q�i,
rc.
ft.
ft,
1A., AND lCrrtAYV., , f'ACI{,(lf
applicable)';
I^`ROM
TO
ietet'J'ErkTAL l EMPLACINENrMETHOD
ft.
ft,
ft.
20<ARILDINC
ItOG`(tittdch
additional -aheets•Iftteers%Rry)
FROM
TO
DESCRIFIION (color, bardnessovillreck t7dsergrsln site, elr.i
O ft'
ft'
20j
grotten St Hy Cfafl
2�iif�t.
7..5 rt,
F�n Cla c• cr ('
Sv
�l r
�(;j�
_ ft
//
T
/Jt� n S! ill
Lio�_.�_LtL
4 rt.
/ et. f�
I6Gl !1 / it Sa#11 (N'F4 iei%!,(6,.
(�
re. C ()IQ/•ii�'c.) u}'rae/
421.2
I4itiRKi` J
Scar -Pa e C9 5>'1I
22, Certification;
Signature ofCeliitied Well Contractor Date
By signing this Joan, F1rereby cent," that the well(s) Ira. (were) constructed in accordance
with 154 NC4C 02C .0100 or 1511 NCAC 02C .0200 Well Construction Standards and that a
copy alibis record has been provided to the well owner.
23. Site dlagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details, You may aiso attach additional pages if necessary,
SUBMITTAL INSTRUC'I'IONS
24a, For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
i219/2122,0
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 & 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
..anstlucted.
North Carolina Department of Environmental Quality • Division of Water Resnrrrrrc
e

WELL CONSTRUCTION RECORD GW_1
I. Well Contractor Information;
%d [/. . 1 War,
Well Contractor Name (�
NC Well Contractor Certification Number
1
c
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 WeU:
Agricultural DMunicipaVPublic
Geothermal (Heating/Cooling Supply) °Residential Water Supply (single)
Industrial/Commercial °Residential Water Supply I (shared)
anon
Non -Water Supply Well:
Monitoring
Infection Well;
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin: Coolin
Recovery
°Groundwater Remediatio❑
°.Salinity Barrier
DStormwater Drainage
°Subsidence Control
°Tracer'
Other (ex .lain under #21 Remarks)
4. Date Well(s) Completed' J/,)4/2i.). ) Well tD# itLYZ :12a
5a. Well Location:
c'cr/rii9/(►! ripe ll/!E'
Facility/Owner Name
Physical Address, City, and Zip
County
Facility ID# (if applicable)
'' /C 1
�Q'St/i
2 7e
212/'
Parcel identification No. (PiN)
513. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wellficld, one Iatliong is sufficient)
4l/2N
6. Is(are) the wel!(s)0Peratanent or QTemporary
7, Is this a repair to an existing well: Yes or ,�No
1f ibis is a repair, Jt11 out known well construction formation and explain the nature of the
repair under #21 remarks section or on the back of this fart.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only GW i is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: y
For multiple wells list all depths ifdifferent (example- 3t©a 200' and 2@100`)
10. Static water level below top of casing:
If water level is above casing, use "+.'•
11, Borehole diameter; O
(in.)
12, Well construction method;
(i.e. auger, rotary, cable, direct push, etc..)
FOR WATER SUPPLY WELLS ONLY;
13a, Yield (gpm)
13 b, Disinfection type:
Method of test:
Amount;
(ft.)
(ft,)'
For Internal Use Only:
14. 'WATER ZONES
TO
i5; QUTSR'CASIN
iipint! cased'ircus
RECEIVED/NCDEQ/DWR
THICKNESS
16l`.INNEIf;GtisTIVO2R TUBING% eothervial:clo
TO DIAMETER
ft.
ft.
17, SCREEN
18:GRQI/T
tJ ft, 2v ft,
ft, ft,
19.. S AND/GRAVEL"PAC K
FROM TO
20:!L1RILDING:.LOG
22, Certification:
MATERIAL
el 741
unable
MATERIAL
MATERIAL
THICKNESS
L, �a
MATERIAL
pv.•
EMPLACEMENT METHOD
& AMOUNT'
• 11.
EMPLACEMENT METHOD
attach:addldonal sbeetsdf neeesea'.
DESCRIPTION (color hardneu salUrack type rain size, e
isl
Signature of Certified Web Contractor
Date
By signing this forn, 1 hereby cert i that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or /SA NCAC 02C .0200 Well Construction n 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 IN TRUCTIONS
24a, 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; 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,
I636 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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
anci st katu, t uro1
Well Contractor Name
11-3 4Y7
NC Welt Contractor Certification Number
GSl ike r !t 7 / 14/,1 r01e r1
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (Le, UIC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Cornmeraial
irrigation
Non -Water Supply Well:
Ntonitoring
injection Weil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
E xperirnental Technology
Geothermal (Closed Loop)
Geothermal Weal i t)!.iCooling Return)
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
IQRecovery
Groundwater Remediation
Salinity Barrier
:Storrnwater Drainage
DSubsidence Control
DTracer
r'other (explain under 421 Remarks)
4. Date Well(s) Completed: I /i.‘/202Q Well ID#
5a. Well Location:'
Cs /i00l elf 1. 11 //t7.
Facility/Owner Name I Facility iD# (if applicable)
k /Airl/r:r.C(riire.
Physical Address, City, and Zip
County
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwetl field, one Iat/long is sufficient)
For Internal Use Only;
14. WATER'LONES
FROM I TO
ft.
DESCRIPTION
ft.
ft.
RECEIVED/NCDEQ/DWH
WQROS
MOORESVILLE REGIONAL
Parcel IdentiRoane n No. (PEN)
to IP-I.?, N 1 416 23//, S' 3 w
6. Is(are) the weil(s)MPermanent or OTemporary
7. is this a repair to an existing well: fJYes or Eallo
If this is a repair, jiil out known well construction information and explain the nature of the
repair rtnd I21 remarks secrian or on the hack 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:
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100')
10. Static water level below top of casing:
if water level is above casing, use "4
11. Borehole diameter: (in.)
12. Well construction method; .J e ,3 a C.
(i.e. wager, rotary, cable, direct push, etc.)
FROM If)
13ft.3
ft.
15. OUTER CASING (for mult#•crued wells
FROM TO DIAMETER
ft. ft.
in.
OR LINER
TIIICKNES
a. +i'cab!
MATERIAL
16. LNNER CASING; OR TURING (geothermal closed loop)
DIAMETER THICKNESS MATERIAL
MATE IAL
q in. •�G!'t T!� p I/ c
ft.
ft.
In,
17, SC
FROM
ft.
TO
18. GROUT
FROM To
33 ft...( 3
0 fit,
33
51:01, SIZE
0
`THICKNESS MATERLIL.
S ��s Yv ._.,
MA`iURIA, ISIPLICEM ENT ;METI OJI)& 1,I0V'.I
ft. + / cTS Pre ' ALA: 4474.
(ft.)
19. SAND/GRAVEL PACK (If applicable)
FROM
ft.
ft,
'1'0 MATERIAL,
to
ft.
ft.
1t 2 ,Sone
MPL,ICEMEN'r METHOD !
Pavre
20. DRILLING LOG attach additional sheets If necessary)
FROM
10
DF.SC;RIP710N (color, hardness; sult+rsck typc,.(rain si[r,etra
ft.
ft.
rli"
IOPDtv_.�t1
y
ft.
i
IL
�6Ili
le ♦ ,, S .114 Set tl /
fit.
D
ft.
it ' .5 S
ft.
a ..._
ft.
fit.
/
t.LL1I _.il /%t/ 4/4
T t f li Cray 1 }
6.-2 ft,
ft.
_/S( a
s L 1y { c0,14 rf Pe/ ( =�
ft,
ft.
21. REMARKS
22. Certification:
Signature of Ccrolled Well Contractor
12 L212pza
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1 SA 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, INSTRUCTIONS
24a. For All Wells: Submit this fonn 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
Z4b. ('or 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 Simply & 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,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:

►�'� c V(�i5'TR[jC'I`TOI�' RECORD GW-I
1. Well Contractor Information:
Well Contractor Name
Company Name
NC Well Contractor Certification Number
___Lizethcr_,E./LEn jacamattia4
2. Well Construction Permit #:
List all applicable well construction permits (l.e, UIC, County, State, Variance, etc,)
3. Well Use (check well use):
er Supply Well:
Agticul ural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
hTi,atio
Non -Water Supply Well:
Monitoring
njection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal Heatin_'Coolin Return)
1?'?cctuf�'
County Parcel Identification No, (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wetl.field, one lat/long is sufficient)
Facility ID# (if applicable)
�e/4_tr aid.af,f144
b 1oyY3. 1b'2
OMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer'
;Other (ex lain under #21 Remarks)
4, Date Well(s) Completed: Efrhs222 Well ID#
5a, Well Location:
Facility/Owner Name
Physical Address, City, and Zip
2.9096'
,(3211
`12L22 _
W
6, Is(are) the well(s) Permanent or ° Temporary
7, Is this a repair to an existing well: °Yes or
No
if rhls 1 r a repair, Jill out known well construction information ant explain the nature of the
repair under 112) remarks section or on the back of th,v jam,
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
dtiiled:
9, Total well depth below Iand surface: _
Far multiple wells list all deptI fd!,ffcrent (exa+nlzte-.3{ 2a7 1�1 pp�— (ft.)
10. Static water level below top of casing;
Ifwow level Isabove easing use ".}'• (ft,)'
1I, Borehole diameter: ' ' (in.)
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;
Form GWl
For Internal Use Only:
AT'z2
RECEIVED/NCDEQ/DWR
ft, fr NI�OI EST
WQROS
)5 OUTER CASING 14i l-ensatl wells OR 1:,INfttt to appllca¢Ic}
rnum ro art; rtErElt
I'tlicKNI ss I� viAATggRLl1,. -1-3 ft, e) ft, Li In, s Z vi v6
PRO�)i;,C �Ipltlht1S ( *call
DIAMETER THICKNESS 41ATRRIAL
11, In,
17: SCitls`EN
l�ttil+Vl 'ro
ft, ft.
DIAMETER SLOTsizE
In,
8i.Gl2t?L1'1'':
RUM TO... MAT I?RIAL
0
ft, ft.
ft, ft,
ft, ft,
19„SAI+ID/G1(AVKL P/ C
mum TO
ft,... ft.
ft, ft
o RIL[iiNCI t tiC<tst
rROI
ft,
ft. ft,
r
ft, ft,
22, Certification:
ilia :,11a�T�- attire:
THICKNESS
_MATutttal _...
PI ACEMI...NTMETHOn de AMOUNT
EMPLACEMENT;Hun
ieh=.adtfltiutia) atieets if necessary:}:
1DESCRIPTiOliconLilhanHness avillrork Hypo, grain rles,
gnature afCertified well C'atlit-actor ,
Nte
By signing this font, I hereby rertty that the wvil{`v war. (were) ceasuua•tr_ci in accorehmee
with 13.4 All2,4C 02C,0100 or 154 NC:fa 02C 0200 TT/ell Construction Standards and that a
copy of thts reco. d 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.
sum/En— AL INS`rRUCT'IONS
2411, ForAil 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 Inieetfon Wvlis: 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;
Divas
water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c, For Water Sunnly & Iniaction fur
the addresstes) above, also submit one copylofn dthisl�on rmo senhin the days to
of
completion of well construction to the county health dep,tr rent of' the county
where constructed,
North Carolina Department of Environmental Ouality • Division of Water Resnnrres

Facility m# (iieapplicable)
260'78
212/a
3. Well Use (check well use);
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
lndustri a l/Commcreial
lrri; ulion
Non -Water Supply Well;
Monitoring
Injection Well:
WI LL :S SAV...CTIUN RECtIRD GW-I.
1. Well Contractor Information;
'"CCU c l.i r
Welt Contractor Name
NC Well Contractor Certification Number
I car l
Company Name
2. Well Construction Permit #:
List all applicable well construction penults (l.e. ftlC, Couiry, Slate, Variance, etc,)
°Municipal/Public
(Residential Water Supply (single)
DResidential Water Supply (shared)
Rcrtwory
Aquiter Recharge Groundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier
Aquifer Test j^Storrnweter Drainage
°
perimental Technology Subsidence Control
Georbel-ma: (Closed Loop) OTracer.
Geothermal (Heating/Cooling, Return) Other (explain under #21 Remarks
4, Date Well(s) Completed: -/t%/ %7dzy Well UM `
5a, Well Location:
Facility/Owner Name
Physical Address, City, and Zip
ii
County
Parcel Identification No. (PIN)
For Intern& use
14 wn•Itt�r�'zovr�s _
ROM
ft.
5. OUT City(
OR9t;'Titrno
G ffoi.inirlii.cased Wells
DIAMSTBR
RECEIVED/NCDEO/DWR
VILLE REGIONAL OFICE
L NLh lfa ilceblo)
6 INNEIC ASING9R T1111INGteothermel closed:luop
totoM — 'r0 17IAml7I
IttfsKNliSS
f it t l lu. t 4 4,0
ft. ft, in 7
PIAN} TER
in,
18,.GRG. 2
FROM . .t.p
rt.
ft,
ft.
ft,
SLOT, S17 (
0 i0
MAl'ERIA I.
HATER/AL
Ttl ICKN{w'3
MA'rERIAL� t
MATERIAL FM7�,.•_I.At EM t.NTt1Ir tIIpp K. AMUU1v[
14, sA sogRANT PACK tt.ci r IsL c),
1(120141C""` Ir1
MhTC?RL
ft,
ft.
$tbIPLAE.vi4i};NChtf:Ttf(rp. _ I
�'r` �J rice_.
20: DRIG1;i'N(, LO( 'nftuiltpddtfipntil'sla ots tfnecegsar
7 UI$SCtt1t'TION (cola, I,u, dnmss sawrock I p e grain atze, etc 1 I
0 .% r j r p c 5irc j
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wetLGeld, one at/long is sufficient)
22, Certification;
W
6, Is(are) the well(s)MPermanent or Temporary ��
7, Is thls a repair to an existing well: Yes or
No
If this is a repair, fill out known wall construction frJor ma:ton and explain the nature of the
repair under 02i remarks section or on the be.-k glans- fin
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW1 is needed, Indicate TOTAL NUMBER of wells
dri i
9, Total well depth below land surface; „ , -
For multiple wells list all depths if different (example• g7Ft 0' and 2 rr 00 (ft.)
Ci �
10, Static water level below top of easing:
((water level is above casing, use "+," (ft.)
t.:.
11, Borehole diameter;
(in.)
12, Well construction method:
(t.e. auger, rotary, cable, direct push, etc.,) ya
A y
FOR WATER SUPPLY ti ELLS ONLY:
13a, Yield (gprn) Method of test:
13b, Disinfection type;
Amount:
nature of Certified Well Contractor
Date
lysigning Pais form, i hereby cerl(& that the well(s) was (were) constructed In accordance
with /Sri b/CAC 02C.0100 or i5A NCAC 02C.0200 Well Consmietion 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 INS`CRUCFONS
24a, i+or rill Wells: Submit this form within 30 days of completion of well
constntction to the folowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, r 1co n ital_t�Vt0llr; 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
oostmction to the following:
Division of Watcr Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Sua t1 & In cotton Wells: In addition to sending the form to
the address(es) above, also submit our. copy of this brut within 30 days of
completion of well construct o t to the county health depamnent of the county
where cansh'ucted.

ti•
1. Well Contractor Information:
For Internal Use Only:
RECEIVED/NCDEQID^
Well Contractor Name
NC Web Contractor Certification Number
Ut rf /II ?„ l
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricuthural
Geothermal (Heating/Cooling Supply)
9Industrial/Commercial
irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Lop)
Geothermal (hleating/Goolinr Return)
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
0 Recovery
Groundwater Remediation
°Salinity Barrier
JlSton twater Drainage
Subsidence Control
Tracer'
Other (e
lain under 1121 Remarks
4, Date Well(s) Completed: j_,_11 LZo20 Well MY(,(i_
5a. Well Location:
CO/d/?i'a Plelf3e
Facility/Owner Name
County� lC'fcn Lcrrj_
Parcel identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
‘092Ia. 0 L// N
6, Is(are) the well(s)
Permanent or °Temporary
T 1vA 7k 7h7 S
_FROM TO DESCRIPTION
ft,
ft,
ft, ft.
WQROS
MOORESVIAE-14E640fdAL OFFIC
73, 011T412. CAS fNC `fpr,n1DI(i•onsotl'Wefts Olt LINER If a )
FROM '3 0 DIAMETER THICKNESS
1, It.li s-a ft,
rib I.'1,ti' R CASIN ORIVIIING (geotla'ortnat sinned loa
mom ro r nienncre' THICKNESS I MATERIAL
ft.
ft,
h" ,Sf REEK t'
FROM TO pG1I1E'i'SR Jl,Pr-SlZEC Y"HiC'IftV&S
ft, ft, In,
ft.
ft.
1n,
llcapla
MATEtiIAL
ft. ft
FROM
a ft.
ft,
ft,
TO
ft
ft.
In,
Gemenf"
t%G
M'i7TR' EM_ .i'LA'CEMENTMETIIt)n&.M10UN1'
I9, S 1NDJGI
FROM
ft,
ft
ft.
PACrK (if applionbio _"_
MATERIAL
ft,
ft,
EMPLACEMENT
'2U:,DRfr.LINGC OC:Vitt-la ncitiltionni sheetslf ueiessAr.y.}: —' — j
FROM TO _ DTP7tnr E',r nst, fell/reek ryas, grahtSlre eta}
0 ft. L/ 8 ft, jilio_siff{f{��jll
cj8 ft. S8 0""rr; 2�°`,""�-� "�j'
ft, ft, _ l
ft,
ft.
ft.
ft.
2I. kilts I KS
.,,d t! iek ee
22, Certification:
W r
7. Is this a repair to an existing well: Yes or pl No
1f th! h` a repair; Jill out known welt construction it farmatkrn One explain the nature of the
repair under #)/ remarks' section or on the back of ibis fern.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I OW -I is needed, Indicate TOTAL NUMBER of wells
drilled:_ (.....
9, Total well depth below land surface:
Far+nulttple wells list all depths ((different (example- 3@200',ind 2@a 10Q)'_
I0, Static water level below top of casing:
if water fea•et is shave crrstn us "�t. •• (ft,)'
g, e
11. Borehole diameter: ._ (in.)
24b. For In ectlnn 41'eils: In addition to sending the form to the address in 24a
Facility tD# (if applicable)
/3'1267 Hun7cisv4p'//e- Con cart/tod
Physical Address, City, and Zip n-(.GI Zl
x 079
ft.
ft.
Signature of Certified Well Contracts
12 /7 /2020.
Li a; z
Byargni:g 1/11s jh n, I hereby certify that the welts) were (were) can a, ;,i ,a accordance
with 1SA NC.AC 02C.OJOQ or /SA NI"Aru 02C.0200 W // Construc,tan Standards and that n
copy of this record ha, been provided to the welt unmet
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,
S11IIIVIITTAL INSTRUCTIONS
24a, For Ail Wails: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617Mail Service Center, .Raleigh, NC 27699-1617
above, also Well construction method: submit one copy of this form within 30 days of completion of well
(i.e. auger, rotary, cable, direct push, etc.) to. construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground injection Control Program,
( 1636 Matt Service Center, Raleigh NC 27699 1 r5r; 13a, Yield (gprn) Method of test;
13b. Disinfection type:
Amount:
Form GWI
s -
24c, For Water p1Y ,gr [rtlection Wells;
In
to
the address(es) above, also submit one copy of addition
form swi di30adaays of
completion of well construction to the county health department of the county
where constructed,
North Carolina Department of Environmental Ouality - Division of Water Reenurepa

WELL CONSTRUCTION RECORD C;yV-
1. Well Contractor Information;
For Internal Use Only:
FitCEI 'EDN4G CQIDWR
SEP 2 O'2021
Company Name
2. Well Construction Permit #:
List all applicable well construction pennlis (Le, UJti County, State, Variance, etc:)
3. Well Use (check well use):
LYater ,Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Ti i1tion
Nun -Water Supply Well;
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Gcothcnt al (Closed Loop)
Geothermal (Heating/Cooling Return)
OMunicipal/Public
QResidential Water Supply (single)
QResidential Water Supply (shared)
DGroundwater Remediation
©ISalinity Barrier
DStormwater Drainage
Subsidence Control
Tracer'
Other (ex lain under #21 R
4. Date Well(s) Completed: 0402020
5a. Well Location:
Co10ais/ % .e .J,'r1 e
Facility/Owner Name
Well Contractor Name
L/369R
NC Well Contractor Certitncntion Number
Wm/ken bill Efi !LCC 1 .1 c')
WeI1 IA# a''1 t`.{j- 3
arks)
/ Facility ID//#(If applicable)
1u rrt hrc fri //C " Canter?" Ref /'tinder VJ l/e Physical Address, City, and Zip 2 'OI?
k fen der �0/02
County Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one int/long is sufficient)
3 : yArt i/ N 80.'Os-Z9 W
6. Is(are) the well(s) ;j;Permanent or Temporary
7. is this a repair to an existing well: I Yes or No
If this is a repair, fill out known welt cansrruuilon information an explain the nature of the
repair under tt21 remarks section or an the back of this fsrrn.
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;
For multiple wells list all depths ifd yferent (example- 3(4)20t1` and 2@a 100')
10, Static water level below top of casing:
limiter level is above casing: use "+
F'•••'
11. Borehole diameter; (in.)
12, Well construction method;
(i.e. auger, rotary, cable, direct push, etc.)
(ft,)
(ft.)- .
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gprn) Method of test;
13b, Disinfection type: Amount;
Form GW1
F1tOM TO
ft.
ft,
ft;
ft.
150.1.410
110
ft.
16 INNER,,c;
DESCR IP'rtvN
WQROS
LE REGIONAL OFFICE
OA:S1N.C' or muitl easel) rvigly Oli TO DII<TNi$I1(ffriippiltcaGlb)
.AMr'PI•`,1t ! t IIC'K.NFSS I �rATP;ttIAr,
BRGM TO
13ft. 2
ft.
3`1 sei.i EN''
F1tWM TO
ft
in, I
` RT'LTtikNG iti/t/WDitintclosad4laup
DLAMETOn
1 In, SG/f yi7
In,
ft.
ft,
23
ft, _Is) ft.
0. ft
DIAMET
tn.
in.
SLOT SIZE
.ono
FROM ro
0 ft,
17 It
ft.
2/ '
19 ft,
2/ ft,
ft,
/GRrt;YE AC-`K
ft,
ft,
Mal FFRIAL
Pt✓c
1 tn1CILNItSs
'cll Yv
tvtA•rZRLAL ._I
Pic �1
EMPLACEMENT METIIOD & AhitJUNT
I.; PLAI:MENTM:R'rtlon
&Lc ' rw f.#. _I
Ze. UR1T'IiIN( O (tYttiik a dl#tn• nqi sheets ifaei ss
1iwat _re DESCRY ;ON tn..0 ri6n�rJuess, sut!lrouk type, (rain sity, ntv,i
ft, I'j ft' fid,le Red Si
.32
rL
t
2? ft.
f� ft,
11 /
l I�rr?urrL SA4cyi
ft. ft,
ft.
2'1 ft,
ft.
21; iti'INLAii2 &:::
ft.
22, Certification:
'gesture of Certified Well Contractor
12/2/2020
Date
By signing this tarn, 1 hereby certify that the ivel/(s) was (were) construcled in arc ,,ce
with 114 NCAC 0,2C .0100 ar 154 NCAC r C ,0200 Freil Construction Standards and
copy of ads record' has been provided 1r the well awrrep,
23, Site diagram or additional well details;
You may use the back of this page to provide additicnal well site details or well
construction details, You may also arlach 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 Mall Service Center, Raleigh, NC 27699-1617
24b. For tnjectfon Weir: 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 Sc Ie I etion %Yells: In addition to sending the form to
the address(es) abovo, 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.
North Carolina Department of Environmental Quality • Division of Water Resnnrre..t

RECEIVEDINCDEQiDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contmctot Name
2973
\C Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2, Well Construction Permit#:
List all applicable well permits /i e County. Slate, I'oriante, Injection. etc.)
3. Well Use (check well use):
For Internal Use ONLY:
SEP 2 0'2021
14. WATER ZONES
FROM
40 rt.
TO
70
ft.
WQROS
DES (<RIPT
MOMESViLL wRFGLONAL
rFICE
ft.
ft.
15. otrrcR CASING (fur multi.caced welts) OR LINER (if applicable)
FROMDIAMETER
TO
THICKNESS
MATERIAL.
ft.
ft.
in.
Si, INNER CASiNG: OR TIJRING (geothermal doted -loop)
FROM
TO
DIAMETER
TR(CIINESS
MATERIAI-
0
ft.
35
ff.
2
In.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
E ,'Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
0 Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-19-20 Well ID# MW-64
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 latilong is sufficient)
35.413329 -80.804060
w
6. is (are) the well(s): t 1Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Fes or EJNo
1This ix a repair, fill out known well construction intimation and explain ilie nurture n/ the
repair under 21 remarks section or on the back of this finrm.
8. Number of wells constructed: 1
For multiple (Mecum, or non -water .supply wells ONLY with the same construction, :»n can
submit one/arm.
9. Total well depth below land surface: 70 (ft.)
For multiple wells list all depths if different (example- 307)200' and 2@l00')
10. Static water level below top of casing: 40 (ft.)
1f water level is ahore casing, use "
11. Borehole diameter: 2 (fn.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e. auger, rosary, cable, direct push. etc t
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Fonn GW-(
FROM
TO
DIAMETER
SLO r SIZE
THICKNESS
MATERIAL
35 ft.
70 rt.
2
in.
.010
sch40
pvc
ft.
ft.
In.
13 GROUT
FROM
0
ft.
TO
30
ft.
MATERIAL
Portland Cem
EMPLACEMENT ENT METRO!) & AMOUNT
Tremie
30
ft.
33 tt.
Bentonite Chi!
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (If appticAbk)
FROM MATER!AL
33
ft.
TO
70
ft.
#1 Sand
EMPLACEMENT METHOD
Tremie
ft.
ft.
20. DRILLING LOG (attach additional streets if nee my)
FROM
ft.
TO
ft.
DESCRIPTION (eider. hardness. aoiltsvt)t vine, grain sOe. etc.)
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
21. REMARKS
2 x 2 Pad
8" FMC
22. Certification:
-c
(3' z(
Srvinio •e of Cutiitie0 Well Contractor Date
ley signing MA JOrm. / hereby eerliJi, that the we//(s) was (mere) constructed in accordance
with I.iA N('A(' 02(' .0100 or 15.1 N('Al' 02C 0200 Well Construction Standar& and Altai a
copy of this record /,as here prorided 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 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 Mail Service Center, Raleigh, NC 27699-1636
24c. Fur }later 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.
North Catalina Department of Environment and Natural Resources -- Division of Water Resources Revised August 2013

WELI, CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Lest all applica ,/e well permits (le County, Slate, t'arionca, tricolor, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Comrnercial
❑ irrigation
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 Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 12-21-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well iD# PMW-65
Facility (Da (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 tat/long is sufficient)
35.412748 N-80.803857
W
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 nil known well construction infitrratian and explain the nature of the
repair under 2/ remarks .section or an the hack of this farm,
8. Number of wells constructed:
F'or multiple 'Meehan or non -water. supply nett, ONLY with the same construction, yaa can
submit one lour.
9. Total well depth below land surface: 40 (ft.)
For multiple welts list all depths iJ different (example- 3(ck200 • arni 2(iZ100')
10. Static water level below top of casing: 37 (ft.)
If water level is above coxing, use " "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
fi a auger, rotary, cable, direct push, etc..)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Pot n GW-1
North Carolina Department of Env iionntenr at
RECEIVED/NCDEQ/DWR
For Internal Use ONLY:
SEP`2 0'2021
14. WATER ZONES
FROM
TO
DESCRIPTION WC)HOS
37 tr•
40 ft
MOORESVittLE REGIONAL OFF
ft.
ft.
IS. OUTER (:ASiNG (for multi -eased wells) OR LINER (if ap
!feeble)
FROM
TO
DI%MErER
Tit CKNESS
MATERIAL
ft.
O.
In.
tn, INNER
CASING OR TIMING (geothermal tinned -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
25 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOTSI?.F.
THICI:NF_CS } MATERIAL
25 fit•
50 fit•
2 in.
.010
sch40 I pvc
ft.
ft.
in,
IB.GROUT
FROM
TO
MATERIAL
EMPI_.%CF.\IF T:NIETII€N1&AMOt:NT
0 it
21 fit•
Portland Cem
Tremie
21 fit.
28 ft.
Bentonite Chii
Tremie
ft.
ft.
19.,SAND/CrRAVEL PA(:K (Happlirable)
FROM
TO
?MATERIAL
EMPLACEMENTMr_THOD
23 ft.
40 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING, LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION iculur, hag J,w .xtrilirack type.ttr:da ,axe. etc•I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
2 x 2 Pad
8" FMC
22. Certification:
S tt,»Ati of CertifiedllContractot
(• «•2(
Date
Hy ,igiing this farm l hereby certify that Me wears) was (were) constructed in accordance
with l5A NC'AC 02C 0100 or 15A ,VC'AC .02C 0200 Well Construction Standards and drat a
copy of this record has heen prorhled m 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
CE
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. Far 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
xl Natural Resowces - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
RECEIVED/NCDEO/DWR
For Internal Use ONLY:
SEP2 0 2021
1. Well Contractor Information:
Kevin White
Weil Contractor Marne
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compare Name
2. Well Construction Permit #:
List all applicable weli permits (i:e Camay, Slate, Variance, Injection ow )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
Non -Water Supply Well:
RIMonitoring
❑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)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12/22-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
Well ID# MW-65D
Facility iDI (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field one IaUiong is sufficient
35.412748 N-80.803857
W
6. Is (are) the well(s): 21Pernanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or 1No
/J this is a repair, fill out known well construction int/brn,alion and explain the nature of the
repair under -21 remarks section or on the back of this Prot.
8. Number of wells constructed: 1
Tor nnthiple injection or !Um -water supply wells ONLY with the same construction, you can
submit one /itrnt.
9. Total well depth below land surface: 40
Pit' multiple wells list all depths i/dij/crent (example- 3@200' au(! 2(ig100')
10. Static water level below top of casing: 118
/J water level is above casing, use "
11. Borehole diameter: 2
12. Well construction method:
(ft.)
(in.)
a 1(4 HSA & 2• spoons; to 5/8 HSA & 4• PVC using & 8 7t8.4ir HAnnot,
(i.e. auger, rotary, cable, direct push. etc. )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
Fours G W-1
14. WATER ZONES
FROM
118 ft.
TO
150 ft•
WOROS
DESCRIPTION
OORESVILI F REGIONAL
wet
OF
re.
ft.
15. OUTER CAL$TNG (far multi -gated wilts) Olt LINER (if applicable)
FROMTHICKNESSI MATERIAL
TO
ft.
ft.
DIAM8TER.
in.
16. INNER CASING OR TUBING (geothermal etaeed•Ioop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
R.
tn.
17. SCREEN
FROM
ro
DIAMETER SI..OT SIZE. THICKNESS
I ATE O.%
ft,
ft.
In.
ft,
ft.
in.
IS. GROUT
FROM
TO
MATERIAL.
i;MPI ACF.MENT METHOD # AMOI.iNr
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional shoats if necessary)
FROM
ft.
ft.
TO DESCRIPTION Ruler.
ft.
ft.
do
oil/muck typr, rain
. etr.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Open rock hole
22. Certification:
Signature of Certified Well Contractor
Date
ICE
By .signing this farm. I hereby certi& that the well(s) was (were, constructed in accordance
with IBA NCAC 02C .0100 or ISA WA' 02C ,((200 Well Construction Standards and Mot (t
cony n/7his 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
constriction details. You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For All 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. Fur Infection Wells ONI.Y: 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.
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

RECEIVEDINCDEOIOWP
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, inc.
Compan1 Name
2. Well Construction Permit #:
List all applicable well permits (i,e. ('unity, Stale. )'snares, Infection, etc./
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
Non -Water Supply Well:
II Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recover•
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
OExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12-23-20
5a. Well Location:
Colonial Pipeline Company
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2l Remarks)
Well lD# MW-66
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.413549 N-80.804759 W.
6. is (are) the well(s): OPermanent or ❑Temporary
7. is this a repair to an existing well: Dyes or iNo
11 this is a repair, fill out known well construction iitfarnnation am! explain the nature of the
repair under ,21 remarks section or on the hack this jam
8. Number of wells constructed: 1
For multiple injection or nor -water supply wells ONLY with the same construction, you can
submit one farm
9. Total well depth below land surface: 54 (fL)
l;or multiple wells list all depths if different (example- 3@200' 100' and 20100')
10. Static water level below top of casing: 37 (ft.)
ll Wolff lore/ is above casing, use " '
ill. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
a auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form OW-1
For internal Use ONLY:
SEP 2 0 2021
14, WATER ONES WOROS
FROM
ro
DESCRIPTION AL OFFICC
37 fi•
54 ft.MOORESVILWetREGION
ft.
ft.
15. OI)'1'RR CASING (for
ntaltl.cased wens) OR LINER Of applicable)
FROM
TO
DIAMETER
MATERIAL
rL
ft.
tn.
16. INNER CASING OR TUBING
(Seethermrl cialed-loop)
FROM
TO
IMAMEK
THICKNESS
MATERIAL.
0 ft.
34 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE.
THICKNESS
MATERIAL -...
34 ft'
54 It
2 in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
TO
AI.-tTERIA .
EMPI .ACEMENT METHOD & AMOUNT
0 ft•
29 ft•
Portland Cem
Tremie
29 ft.
31 ft.
Bentonite Chi
Tremie
ft.
ft.
19, SA ;RA
PiCK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
31 ft.
54 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additional &beets if aeceasa ')
FROM
TO
DESCRIPTION (solar,. hardne„ c, ,nil/rock type, grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
fr.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
S ignatuie of Certified Web Contractor
Date
Ny .signing this /arm, i hereby certiifY that the well(s) was (were) cansiruceed in accordance
with 15.4 NC.1(' 02(' .0100 or I Srf A2'A(' 02(' 0200 Will Construction Standards and drat a
copy of uisis rrcard 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 web
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. Fur 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
Noitb Carolina Department or Environment and Natural Resources— Division of Wale! Resources Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
WeII Contractor Name
2973
NC Well Contractor Certification Nurnber
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i e. ('Minty, State. f'arltane, In/ratan, elc
3. Weil Use (check well use):
For internal Use ONLY.
SEP2 0'2021
I4. WATER ZONES
FROM
37
ft.
TO
45
ft.
WOROS
DESCRIP tin ORESVILLE REGIONAL OFF4C
wet
ft.
ft.
15, OUTER
FROM
ft.
T.
1ING (for ntulll cased wells) OR LINER (If ap kettle)
rim l(NFss 1 MATERI;SI..
ft.
16. INNER CASING OR
FROM
TO
DIAMETER
in.
SING (geothermal cltaed-loop)
DIAMETER
rtuck"NPSS.
MATERIAL.
0
ft.
30
ft.
2
in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural .
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
°irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal(Ctosed Loop)
❑Geothermal (Heating/Cooling Return)
°Recover'
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-21-20 Well ID#
5a. Well Location:
Colonial Pipeline Company
MW-67
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Panel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/Ion0 is sufficient)
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
'MATERIAL
30 ft.
45 rt.
2
in.
.010
sch40
pvc
ft.
re.
in.
18. GROU'T
FROM TO
p ft. 24
fa
MATERIAL
Portland Cem
EMPI.A('EMENT METHOD Sc •>,MO1;NT
Tremie
24 ft.
27 ft.
Bentonite Chi
Tremie
ft.
ft.
19. St tt WGR:1t'EI- PACK (lf 5pplituble)
FROM
TO
MATERIAL
EMPLACEMEtv"T METHOD
27 ft.
45
ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach additional sheets if maturity)
FROM
ft.
TO
ft.
DFSCRIPTION (tutor, hardncr,, wit/rock type, grain doe. do
ft.
ft.
D.
ft.
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
22. Certification:
35.413269 N-80.804708 -Cr Lt 4j -
Signature of Certified Well Contractor
6. Is (are) the well(s): I2(Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, jili out known well construction iafitrmation and explain the nature al the
repair under 21 remarks section or on the back cif this farm
8. Number of wells constructed: 1
For nmltiple injection or non -water supply wells ONLY with the same construction. you can
submit ow farm.
9. Total well depth below land surface: 45 (ft.)
I•irr multiple wells list all deptlu if di/ferenl (example- 3L 200' and 2@l00')
10. Static water level below top of casing: 37 (ft.)
I/n•afer level is above casing, use .' "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2' spoons
(i.e auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW-I
Date
Rv signing this /ornt, 1 hereby certify that the well(r) was* (were) constructed in accordance
with ISA N('.4(` 02(' 0100 or ISA N('A(' 02(' .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 INSTUCT'IONS
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 thrm 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
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple %•ells
I. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Cenification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
/,i.st all applicable well permits (i.c. Como,. State, Variance, to/echoer, .etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
0 Residential Water Supply (shared)
Non -Water Supply Well:
EMonitoring 0 Recovery
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
0Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooline Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-23-20 Well ID# MW-68
Sa. Well Location:
Colonial Pipeline Company
Facility/Owner Nance Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PIN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sutf,cientl
35.413056 Y-80.805275
6. is (are) the well(s): 21Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
1/ I1n.s is a repair, Jill aril kuawn well construction infrmatimn and explain the nature al the
repair under .:2 / remark,' section or on the back ql this him.,
S. Number of wells constructed: 1
For multiple hr/colon or nun -wafer supply ur//s ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 50
For multiple wells list all depths if di/lereui (example- 30200' and 26i,100)
10. Static water level below top of casing: 37 (it.)
// water level is above casing, use "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fom, Gw.
North Cmolina Department of Environment an
For Internal use ONLY: J t r 4 V L u L 1
WQROS
14. WATER ZONES OORFSVIl I F REGIONAL OFFb
FROM
TO
DESf:IfIPT'1 .
37 ft.
50 ft.
wet
ft.
ft.
15. OUTER C:ASIN(s (far multi -eased we11e) Ott LINEtt (ifaptltcabte)
FROM
TO DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
16. INNER C.ASiNG OR T ING (genthdrmal elated -loon)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
35 ft.
2 in,
sch40
pvc
ft.
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLDT SIZE
TRICKN1 SS
MATERIAI,
35 ft.
50 ft.
2 in.
,010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
MATERL4L
EMFIA(:EMENT NMETIIOD&A:MOINT
0 ft'
31
Portland Cem
Tremie
31 It
33 ft.
Bentonite Chi
Tremie
ft.
ft.
19. S)ND/(.RAV£L
PACK of *mile bla)
FROM
TO
MATERi,AL
EMPLACEMENT METHOD
33 fL
50 ft'
#1 Sand
Tremie
ft.
f6
20, DRILLING
LOG (attseb additions] abeets if necessary)
FROM
TO
DESCRIPTION Icnlar,liar ne.. zaillract: type, grain sire, etc.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified We Contractor
1.71' 4-(
Date
Sy signing this firm, I hereby certifi- that the we//(s) was (were) constructed in accordance
with iSA N('A(' 02(' .0100 or /5,4 PICA(' 02C .0200 Well Construction Standards and Mat a
copy a/ 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 Iniection 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 tollowing:
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.
d Natural Resources - Division of Water Resources Revised August 2013

RECEIVEDINCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List n// applicable well permits (/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:
Monitoring
Injection Weli:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal(Ciosed Loop)
❑Geothermal (Heating/Cooling Retum)
For internal Use ONLY:
14. WATER ZONifS
FROM
48
It.
TO
60
ft.
0 '2021
WOROS
MO0RESV LLE REGION
DESCRIPTION
wet
CE
ft.
It.
1S. OUTER CASING (for multi -cased welt) OR LINER (if applicable)
FROM 'THICKNESS
TO
ft.
(1.
DIAMETER
in.
MATERIAL
Ib. INNER CASING OR TURING (geothermal sliced -leap)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
Lt.
30
ft.
2
in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
❑ Munro ipaf/Pubfic
❑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) Completed: 12-16-20 Well ID# MW-69
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IDe (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
35.413842 N -80.804434
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ©No
/f this is a repair, /ill out known well construction infr,rrnaion and explain the nature ql the
repair tinder ,2i remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY a-1tb the same construction, you can
submit one form.
9. Total well depth below land surface: 60 (ft.)
For multiple webs list all depths f /))lerea (example- ./C200' and 2 r 100')
10. Static water level below top of casing: 48 (ft.)
/J water level is above caving, use "
II. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4 HSA / 10 5/8 HSA
(i.e auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form G W-1
FROM
30 ft.
TO
60 ft.
O1tJIETeR
2
In.
SLOT SIZE
.010
THICKNESS MATERIAL
sch40
pvc
ft.
rt.
fn.
iS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
26
ft.
Portland Cem
Tremie
26
ft.
ft.
28 ft.
ft.
Bentonite Chit
Tremie
19. SAND/GRAVEL PACK of applicable)
FROM
28 ft.
TO
60
ft,
MATERIAL
#1 Sand
EMPLACEMENT' :METHOD
Tremie
ft.
ft.
20. ORIO.LING LOG lauaeh additional sheen II mom)
FROM
TO
ft.
ft.
DESCRIPTION H=uhm har,Inras. tail/ruck type. train the. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. RZMARKS
22. Certification:
Signature of Certified Contractor Date
By ,signing this Awn!, l hereby cerrifv that the well(s) was (were) constructed in accordance
e,1J, ISA NCAC 02C' ,0/00 or i5.-; MIA' 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 paces if necessary
SUBMITTAL INSTUCTIONS
• 2A• ZA
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,
North Carolina Department ofEnvitonntent and Natural Resources— Division of Water Resources Revised .August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single ur multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam 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:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
Industrial/Commercial
❑ irrigation
❑Municipal/Pub lic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ZMonitoring ❑Recover
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ENperimental Technology
❑Geothennal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Storrmwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-20-20 wen ID# MW-70
52. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 tat/long is sufficient)
35.413302 N-80.804380
w
6. Is (are) the well(s): lJPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or (?1No
If this is a repair. Jill out known well construction information and explain the nature of'dne
repair under remarks .section or on the back of this Arm.
8. Number of wells constructed:
For multiple injection or ,um -water supply wells ONLY with the same construction, you can
.submit one Jornt
9. Total well depth below land surface: 48
For multiple wells list all depths i/ diJJerent (example- 3@2011' and 2@100')
(it.)
10. Static water level below top of casing: 39 (ft.)
1Jlr•ater fere(is above casing, use "- "
(1. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(I.e. auger, rotary, cable, direct push, etc 1
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY.
SEP 2 0 2021
14. WATER ZONES
FROM
TO
DESCRIPTION WQfiOrd
39 ft.
48 ft.
MOORESV4,,HEGIONAL OFFIC
ft.
ft.
IS. OCTER CASING (for tnulti-eased wNtsl OR LINER Of ap lcable)
FROM
TO
DIAMETTR
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR'EURING ( cothermal slimed loop)
FROM
TO
DlAMLI ER
THICKNESS
MATERIAL,
0 ft.
33 fr.
2 in.
sch40
pvc
ft.
fr.
in,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
33 ft•
48 ft.
2 in.
.010
sch40
pvc
ft.
fr.
in.
I9. GROUT
FROM
TO
MATERtA -
EMPLACEMENT METHOD ds AMOUNT
0 ft'
28 ft.
Portland Cem
Tremie
28 a•
31 ft.
Bentonite Chi
Tremie
ft.
ft.
19. SANU/t RAVEL t' ek (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
31 ft.
48 ft.
#1 Sand
Tremie
ft.
ft.
20, DRILLING
LDG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTIONlenlnr. Iran miss, eniVrrrxk type. ..taut .ize, etc.)
ft.
fL
ft.
ft..
ft.
ft.
et.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
8" FMC
2 x2 Pad
22. Certification:
Signature ofCertifred Weil Contractor Date
Ny signing this Jorm, I hereby retitle that the nell(%) was (were) co structed in accordance
with 15A N('A(' 02(' .011M or IBA N('AC 02(• .0200 Well Construction Standards and that a
copy (Olds 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, 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. Fur 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 tollowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Wilier Snppty Sr Injection Welts:
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 Nnrth Carolina Depart -Molt ent ofEnvironntent and Natural Resources - Division of Water Resources
Revised August 2012

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Nam,
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List n/1 applicable well perinity (i: e. Conroy. Stale, t ariance, Injection, etc
3. Well Use (check well use):
For internal t.ise ONLY
SEP2 0 21721
14, WATER ZONES
FROM
37
f.
TO
65
ft.
WOHUS
OFsoctinoiN MC)OHESVILLE REG
wet
AL OEFICE
rt.
ft.
1S, OUT CASING (,for tnrltt•eased welts) OR LINER Of appliuhle)
FROM DIAMETER
TO
THICKNESS
MATERIAL
ft.
ft.
rn.
lb, INNER CASING OR T'RING (geothermal hosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
50
ft.
2
in.
sch40
pvc
ft.
in.
IT. SCRE
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Munieipal/Pubiic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
CA Mon itoring
0 Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1/5/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
wal ID# MW-71
Facility iD6 (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld. one lat/long is sufficient)
35.414153 N-80.804562
6. is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or IENo
1/this is a repair, fill out known MI construction information and explain the nature of the
repair under .. 21 remark,. section or on the hack o/this /itrm.
S. Number of wells constructed: 1
for amhiple injection or non -water supply wells ONLY with the same construction, fall can
submit one pow
9.7'otal well depth below land surface: 65
For multiple nx'lls list all depths if different (example- 3@200' and 2 « /00')
(ft.)
10. Static water level below top of casing: 37 (ft.)
lJ water level is above casing, use "- "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(1 e anger, rotary, cable, direct push, etc.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Foi OW-1
FROM
50 fit.
TO
65 ft'
DIAMETER
2
in.
SLOT SIZE
.010
THICKNESS
sch40
MATERIAL
pvc
ft.
ft.
in.
18. GROUT
FROM
0
ft.
TO AIATF.RIAL
42.5 ft' I Portland Cem
F \I E'E_ 1 r T.tl fv3T METHOD ;k .MOUNT
Tremie
42.5 er.
47
ft.
Bentonite Chil
Tremie
ft.
ft.
I9. t' AND,/GR-11,'Et, P. CK ((f applisablel
FROM
TO
MATERIAL.
EMPLACEMENT METHOD
47
ft.
65
ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach additional streets if necessary)
FROM
ft.
1'0
ft.
DESCRIPTION DOtn, hardness, soil/rock rune, groin size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well t'unrraelur Date
Hy signing this /orne / hereby certify that the well(s) Was (were) constructed in accordance
with 15A NCAC 02(' 0100 or 15A NC A(' 02(' 0200 Well Construction Standards and that a
caw of this record has been prorided ro the well owner.
23. Site diagram or additional well details:
You may use the back of [his page to provide additional well site details or well
construction details You may also attach additional pages if necessary
SUBMITTAL INSTUCTiONS
24a. Fur 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: ht addition to sending the foam 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. Fur 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
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

RECEiVEDINCDEOIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
•
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cornpam Name
2. Well Construction Permit #:
List all applicable well permits (.e. County, State, Variance, injection, etch
3. Well Use (check well use):
For Internal -Use ONLY
14. WATER ZONES
FROM
52
ft.
TO
54
ft.
pI V vimev11.LE
5ti).2' 0 '2021
w0nEGc)NRi_ @`fit E
wet
ft.
ft.
15. OUTER CASING (far multi-cmai wells) OR INNER (if apt lcnble)
FROM
ft.
TO
ft.
DIAMETER
In.
THICKNESS
MATERIAL
16. INNER CANING OR TUBING (geothermal elute+! -lump)
FROM
TO
DIAMETER
TIIICKNF S
MATERIAL
0
ft.
40
ft.
2
In.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
@Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
@Monitoring
0 Recovery
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1/9/21
5a. Well Location:
Colonial Pipeline Company
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
0Subsidence Control
❑Tracer
DOther (explain under #21 Remarks
Well MW-72
)
Facility/Owner Nance Facility IDS (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 ladlong is sufficient)
35.414969 N-80.804731,
6. is (are) the well(s): 1@Permanent or DTemporary
7. Is this a repair to an existing well: DYes or EJJNo
If this is a repair. fill ail known well construction its/rtrmatioa anti eeplain the nature oldie
repair under ..2/ remarks section or on the back of this /brm.
8. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one torn,
9. Total well depth below land surface: 54
For multiple. wells list oll depths it different (example- 3(200' and :NN m)
10. Static water level below top of easing: 51 (11.)
1J neater /erel is above casing, use " "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(ft.)
(i•e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form G W-1
FROM
TO
MA:NIETER
SLOE SIZE
THICKNESS
MATERIAL
39 ft.
54 It.
2
In.
.010
sch40
pvc
ft.
ft.
in.
18, GROUT
FROM
0 ft.
TO
32
ft.
MATERIAL
Portland Cem
EMPLACEMENT METHOD & AMOUNT
Tremie
32 fr.
34
ft.
Bentonite Chil
Tremie
ft.
ft.
19, SAN1l/('R:1VM. PACK. (ifopplkabtc)
FROM TO MATERIAL
36
ft.
54
ft.
#1 Sand
EMPLACEMENT METHOD
Tremie
ft.
ft.
30. DRILLING LOG (attach additional abeetn if necesaary)
FROM
ft.
ft.
TO DESCRIPTION (calm. bar homy, nut/ruck tvi,r, /exit, .eitr. etc,)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
(
Si matur rtilie
11 (ootraetor
L)• ' 2/t
Date
/3y signing this torn, i hereby certify that the a eil(s) uas (were) constructed in accordance
with 15.4 NCAC 02( 0100 or ISA NCA(' 0 1' 0200 Well Construction Standards and that a
copy re this record has been provided to the well meter.
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 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 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
North Carolina Department of Environment and Natural Resources- Division of Wate, Resources Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Narne
2973
N(.' Well Contractor Certification Number
Parratt-Wolff, Inc.
Cornpan} Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Lr/rctlwt, del
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
°Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
lil Mon itoring
ORecovery
Infection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1/10/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
OOther(explain under#21 Remarks)
Well iD# MW-73
Facility iDtf (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC. 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No: (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field_ one lat/tong is sufficient)
For Internal Use ONLY
SEP2020
WQROS
ESVILJ F RFC.IONAL OFFICE
14. WATER 21iNFs
FROM
TO
DESC'df1A'fItIR
ft.
ft.
ft.
ft.
IS. OUTER C,ISING (for multi -cased webs) OR LiNE:R (if app leabtel
FROM
ft.
TO
ft.
DIAMETER..
THICKNESS
MATERIAL.
16. INNER CASING OR TUBING (geothermal clised-loop)
FROM
TO
DIANS TER
THICKNESS
MATERIAL
0
ft.
30
re.
2
in.
sch40
pvc
ft.
ft.
in.
17.SCREEN
FROM 1 TO
30 ft•
45 ft.
DIAMETER SLOT SIZE THICKNESS
2
in.
010
sch40
MATERIAL
pvc
ft. I ft.
tn.
la. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
25
ft.
Portland Cem
Tremie
25
ft.
27 ft.
Bentonite Chil
Tremie
ft.
ft.
19. SA
FROM
27
ft.
u.
A
TO
45
PACK (ifipplfahle)
ft.
a.
MATERIAL
#1 Sand
EMPLACEMENT METHOD
Tremie
29. DRILLING LOG (attach sdditiaaidsheets If neeevaty)
TO
FROM
ft.
a.
ft.
ft.
DESCRIPTION (cpinr, hard
sailireek type. grata sire. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
35.412179 N-80.805693 w u�
Signatwe MT.:nin ell Contractor
6. is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: Oyes or ONo
1/ this is a repair, )'ill oat know,, well construction iijiirnmtian and explain the nature oldie
repair snider ,21 remarks. section or on the back t/ this /tirm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one Arm.
9. Total well depth below land surface: 45 (ft.)
Far multiple welts list all depths 11 different (example- 3 icp200' and 2@0001
10. Static water level below top of casing: (ft.)
11 water level is nhore casing, use '' "
! I. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Foot' GW-1
Date
By signing this form, 1 hereby certi/y that the well(s) was (were) constructed in accordance
rrilh 15A N('.4(' 02C 0100 or /5.4 NCAC 02(' .0200 Well Como -action 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. Fur 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 welt
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
North Carolina Department of'Fnvironment and Natural Resources — Division or Water Resources Revised August 2013

RECEIVEu/I\ Uc.wiI ••'•
SEP 2 0 2021
WELL CONSTRUCTION RECORD
.rhos form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan} Name
2. Welt Construction Permit #:
list all applicable well permits (i.;:. County. Stare, Cariance, nun, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Comm ereial
O Irri nati on
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Gr Monitoring O Recovery
Injection Well:
C Aquiter Recharge
OAquifer Storage and Recovery
uAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 2/8/21
5a. Well Location:
Colonial Pipeline Company
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
DSubsidence Control
OTracer
OOther (explain under #21 Remarks)
Well ID# MW-74
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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. eec Iat/long is sufficient)
35.414272 N-80_"804149
6. is (are) the well(s): OPermanent or OTemporary
7. is this a repair to an existing well: ❑Yes or (?)No
IJthis is a repair, Ii/I oat known well construction information and explain the nature a/ die
repair under ,21 remarks section or on the back a/this /irrm.
S. Number of wells constructed: 1
For multiple injectiotr ar non -water .supply wells ONLY with the saute construction, you can
srtbolt one farm.
9. Total well depth below land surface: 33 (ft.)
For multiple wells list cd! depths if different (example- 3@200' and 2(4100')
10. Static wa ter level below top of casing: 30 (ft.)
/f water level is above casing, use " - "
it. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i e auger, rotary, cable, direct gash, etc.1
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
For Internal Use ONLY:
WQROS
MOORFSv1L�E RE£IONALnFFICE
14. WATER ZONES
FROM
TO
DESCRIPTION
30 f<•
33 ft.
wet
ft,
ft.
IS. OUTER C-1SING (farmultbcased wefts) OR LINER (irapp liable}
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TU11LNG (geothermal eloaed.lbap)
FROM
TO
DIAMETER
THICKNESS
MATFR1AL.
0 rt.
18 ft,
2 in.
sch40
pvc
ft.
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS i MATERIAL
18 ft.
33 ft.
2 In.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIA,
EMPI.ACEM.ENT METIIOD&AMOUNT
0 ft•
13.5 ft.
Portland Cem
Tremie
13.5 ft•
15.5 ft•
Bentonite Chi!
Tremie
ft.
ft.
19. SAND/CRAVEL
PACK
(Nappueabiet
FROM
TO
MATERIAL.
EMPLACEMENT METHOD
15.5 fr.
33 ft.
#1 Sand
Tremie
ft.
ft.
20, DRI LLINS
LtiG.'(attaeh
additional ahecis if oeeestary)
FROM
TO
DESCRIPTION (color. lia.. In,eiktor I. ivpr, fr.lin ',itr, elf.(
ft.
ft.
ft.
ft.
ft.
ft.
ft.
_ _..
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARk.S
8" FMC
2 x2 pad
22. Certification:
Sig�?ntrmc nt'Ccll Contractor
Date
Hv signing this (im i hereby cerlifi• that the well(s) was (were) constructed in accordance
with 15A N('.1(' 02C 0100 ar l5A N('AC U?(' .0200 Well Construction Standards and that a
copy of this record has been provided to the wen 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 fonn within 30 days of completion of well
construction to the tollowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. Fur 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.
Forst GW-I North Carolina Department or Environment and Natural Resources - Division of Water Resources
Re%iscd August 2013

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC' Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable well permits (i e ('atuny, Stale: 1 oriance, hjrction, cic.)
3. Well Use (check well use):
Water Supply Well:
❑.Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrieation
For Internal Use ONLY:
IA. WATER ZONES
FROM
To
MOORESVILLE
DESCRIPTION
RECEIVED/NCDEO/I)WI
SEP 2 0 2021
WORDS
REGIONAl OFFICE
41
ft.
46
ft.
wet
ft.
ft.
I& Otrl'ER CASINC; Iltir multi cased *tits) OR LIN R /ifappHcahte)
FROM TO I DIAMLI LK
ft.
ft.
In.
THICKNESS
MATERIAL
ia. INNER CASING OR TUBiNG (xeotherntal clued -loop)
FROM [HAM I hit
0
ft.
TO
31
ft.
2
in.
THICKNESS
sch40
MATERIAL
pvc
ft.
rt.
in,
17. SCREEN
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
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: 2/9/21
❑Recovery
❑Groundwater Remediation
@Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under#21 Remarks)
Well ID# MW-75
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. MN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35.414285 -80.804117
6. is (are) the well(s): 12IPermanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or JNo
If this is a repair, Jill out known well consrrucu0u a firrmatim, and explain the mtntrr of the
rop air under -21 remarks .section or 0n the back q/ this /ornm.
8. Number of wells constructed: 1
W
For multiple injection or nun -water supply wells ONLY with the same construction. you can
submit one Jnrm.
9. Total well depth below land surface: 46 (ft.)
For multiple wells list all depots if different (example- 3@200' and 20l011)
10. Static water level below top of casing: 41 (ft.)
if water level is above casing, else "
1 I. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fonn G\-I
FROM 1 TO
31 rt.
46
ft.
DJAMerER
2
in.
SLOT SIZE
.010
THICKNESS MATERIAL
sch40
pvc
ft.
ft.
In.
la. GROUT
FROM
0
ft.
TO
27
ft.
MATERIA .
Portland Cem
EMPLACEMENTMI.THOtt AMOUNT
Tremie
27
ft.
ft.
29 ft
fL
Bentonite Chik
Tremie
19. SAND/GRAVEL PACK If applicable)
FROM MATERL\E.
29
ft.
TO
46
ft.
#1 Sand
EMPLACEMENT METHOD
Tremie
ft.
ft.
20. DRILLING: LOG (attach Additional tkssta if
FROM
ft.
ft.
'1'0
ft.
ft.
DE'SCRIPTION Irntnr. t,onuncc�. sei /pork
erun %1On, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REM,ARKS
8" FMC
2 x2 pad
22. Certification:
(2.2-
Siam ltore of Certified Well Contractor Date
By .signing this farm, l hereby certify that the sell(.° 'vas (were) constructed in accordance
with !SA NCA(' 02(' .0100 or 15,1 N(`AC 02(' .112th) Well ('anstr,wiioo Standards and that a
copy (phis retard has been provided to due 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. Fur 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.
North Carolina Department of Environment and Natural Resowces - Division of Water Resources Revised Auuust 2013

RECEIVED/NCDEQIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Weil Contractor Name
2973
NC' Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan} Name
2. Well Construction Permit #:
List all applicable we// perot(a (t e. County, SYun•, )%arionce, Injectirnn, etc )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
Monitoring
❑Munieipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
0 Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
❑Geothermal (Closed I..00p)
❑Geothermal (Healing/Cuo(ing Return)
4. Date Well(s) Completed: 2/10/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
0Tracer
❑Other (es slain under #2 1 Remarks)
Well ID# MW-76
Facility 1D# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (P1N)
5b, Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.414299 -80.804067
6. Is (are) the well(s): GaPermanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or 11No
// this is a repair, fill out known well construction inf/Prnwtiwn and explain the nature ojthe
repair under •:21 renarkv section or an the hack of this Prot
8. Number of wells constructed: 1
For multiple injection or non -water. supply wells ONLY with the same construction, you can
.vubnit one firm
9. Total well depth below land surface: 45 (ft.)
l' r multiple wells list all depths if different (example- 3(14200' and 2 ro100')
10. Static water level below top of casing: 35 (ft.)
1/ water level is above caving use " • "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i.e. auger, rotary, cable, direct push, etc)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fmm GW-I
For [atonal Use ONLY:
SEP 2 01021
14. WATER ZONES WOROS
FROM
TO
DESCRIPTION (TONAL C
RE
35 ft.
45 ft•
MOOR SVILLE
Wet
ft.
ft.
15. OUTER C,tSING (for rnulti•raeed «te11g) Ok LINER ttf apptIcable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
1 a INNER
CtSP G OR TURING (geoibernwl
daeed-1oap)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 fit.
25 ft.
2 in.
sch40
pvc
ft.
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
25 ft.
45 rt.
2 fn.
.010
sch40
pvc
ft.
fit.
in.
1L GROUT
FROM
TO
M LI.IAl
ESIPI„:ACEMENTMET1101/,tcA%IOLNT
0 ft.
21 ft.
Portland Cem
Tremie
21 ft
23 fit•
Bentonite Chi
Tremie
ft.
ft.
i9...''AND/GRAVRL PACK
(if rppllcable)
FROM
TO
- MATERIAL -
EMPLACEMENT �METtIOn
23 ft
45 ft.
#1 Sand
Tremie
ft.ft.20.
DRILLING
LOG (attach
aldditlaoal aheeb if neeeseaey)
FROM
TO
DESCRIPTION (Mae, h. aednese, toll/melt type, ervin ,4e-e, ets.1
ft.
ft.
ft.
ft.
n,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REM CR1vS
4" Stick up cover
2 x2 pad
22, Certification:
Sirruqute utCet1illed Well Contractor
Z �,I\
Date
By signing this Jbrnr, l hereby certrJy that the trell(s) wos (were) constructs& in accordance
with ISA MAC 02(' .0100 or ISA NC AC 02(' 0200 Well Construction Standards ane/ 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 of well
construction details You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTIONS
FFICE
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 lniection 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 Wens:
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
North Carolina Department of Environment and Nattual Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used fm-single or multiple swells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable leer! permits (i r ("rant State, I itrimtee. in/ection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
0 industrial/Commercial 0 Residential Water Supply (shared)
❑ irrigation
Non -Water Supply Well:
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormcvater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothemtal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under 421 Remarks)
4. Date Well(s) Completed: 2/24/21
5a. Well Location:
Colonial Pipeline Company
Well iD# MW-77
Facility/Owner Name Facility 1Db (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Pateal Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
RECEIVED/NCDEOIDWH
For Inrernal Use ONLY
SEP 2 0 2021
14. WATER ZONES
FROM TO
25 ft•
ft.
45
ft.
ft.
DESCRIPTION. _. _. _...... ..._.
MOORESZaLE REGION
AL 0
15. OUTER CASING (for multi -cased wells) OR LINER tiff sppllcabtet
FROM THICKNESS
TO
ft.
ft.
DIAMETER
in.
MATERIAL
to. INNER CASING OR TUBING (geothermal dated -coop)
FROM TO OfAMFTER THICKNESS
0
ft.
15
ft.
2
In.
sch40
MATERIAL.
pvc
ft.
ft.
in.
17, SCREEN
FROM
15 fL
TO
45 ft.
DIAMETER
2
in,
SLOTSIZE
.010
THICKNESS 1 MATERIAL
sch40
pvc
ft.
ft.
in.
t& GRO( T
FROM.
0
ft.
TO
10
ft.
MATERIAL.
Portland Cem
EMPLACEMENT METHOD $r AMOUNT
Tremie
10
ft.
ft.
13
fr.
ft,
Bentonite Chi!
Tremie
19. SAND/GRAVEL. PACK (If applicable)
FROM
To
MATER)At.
FMPI.9 FSIENT METHOD
13 ft.
45
ft.
#1 Sand
Tremie
ft.
ft.
20. ORft.I:ING I.OG (acted* additional sheets if necessary)
TO
FROM
ft.
ft.
ft.
ft.
DESCRIPTION (color. hardnera. ,oitirack ripe. grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
4" Stick up cover
2 x2 pad
22. Certification:
35.412725-80.807561 W b_a44 q . q- a l
Signature of Certified Well Contractor Date
By .signing this farm, 1 hereby rertifv that the well(.$) tray (were) constructed in accordance
with 15,4 WA" 01(' .0l00 or 15A N('.4( 0?(' (1201) Well ('rmstrucu/o,s Standards and that a
core of this record has been provided to the Ire)/ 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
For multiple injection ar non-iruler .supply wells ONLY with tiro same construction, you Can
Sabina sue Iwo? SUBMITTAL INSTUCTIONS
9. Total well depth below land surface: 45 III,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/ aii//ircut (example- 3@200 and 2 tit 100') Construction to the following:
10. Static water level below top of casing: 25 Division of Water Resources, Information Processing Unit,
U water level is above rasing, use '• " 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 2 (in,) 24b. For Iniection Wells ONLY: in addition to sending the form to the address in
8 1/4 HSA & 2" split S 24aabove. also submit a copy of this form within 30 days of completion of well
OOnS 12. Well construction method: p p construction to the following:
6. is (are) the well(s): 121Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ONo
1/ this is a repair, fill out known well construction infOrnuniou and explain the nature a( the
repair under 2/ remarks .section or on the hack of this /situ.
8. Number of wells constructed: 1
ICE
(ft.)
e auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
136. Disinfection type:
Method of test:
Amount:
Fount GW-I
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
lac. For Water Supply & Injection Wells:
Also submit one copy of this Corm within 30 days of completion of
well construction to the county health department of the county where
constructed
North Carolina Department of Environment and Natural Resources— Division of Water Resources Revised August ?0 t3

RECEIVEDINCDEU/uvvrs
WELL CONSTRUCTION RECORD
This form can be used tot single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name.
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable we permits (i.e County. State, 1'ariance, linection. 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)
SEP 202021
Far Internal Use ONLY:
WQROS
MOORESVILLE REGIONAL OFFICE
14. WATER ZONES
FROM
TO
DESCRIPTION
35 ft.
45
ft.
wet
ft
ft.
1S. OUTER CASING (far mntti-opted wells) OR LINER (if spElicable)
FROM TO DLi5IErER THICKNESS MATERIAL
(t.
ft.
in.
16. INNER CASING OR TIJRINO (geothermel etosed.lemal
FROM TO
0
ft.
25
ft.
DIAMETER
2
tn.
THICKNESS
sch40
MATERIAL
pvc
ft.
ft.
in.
17. SCREEN
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
FROM I TO
25 rL
50 rt,
DIAMETER
2
in.
SLOT SIZE
.010
THiCKNEM
sch40
DLATER.IAL
pvc
rt.
ft.
in.
111. GROUT
FROM
0
20
R.
ft.
TO
20
23
R.
ft.
MATERIAL
Portland Cem
Bentonite Chil
EMPLACF%IF\T dI ETHOII 4 AMOt:Nr
Tremie
Tremie
4. Date Well(s) Completed: 2/25/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Reined iation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well iD# MW-78
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
35.412904 N-80.807584
w•
6. is (are) the well(s): I227Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or E)No
If this is a repair, /ill out tannest well construction iiformation and explain the nature of the
repair ander ,21 remarks section or an the hack ul this than(
8. Number of wells constructed:
Par multiple inferno» or non -water .supply wells ONLY' with the same construction, you can
cubnii one tits"..
9. Total well depth below land surface: 50
For multiple wells list all depdxs tf dij/ere.nt (example- 3.r'20(I and 2@100')
10. Static water level below top of casing: 40 (ft.)
II hater level is above casing use "
11. Borehole diameter: 2 (in,)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i e auger, rotary, cable, direct push, etc )
(ft.)
FOR W.ATFR SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fo,mOW- 1
ft.
ft.
19, $AND/GRAN
FROM
23 fr,
TO
50
PACK fir applkabitl
ft.
MATERIAL
#1 Sand
EMPLACEMENT METHOD
Tremie
ft.
ft.
211. DRIi,(.ING LOG (auaeb additiana(sheets ifncctssaey)
DESCRIPTION (calnr. hardness, soittrack Npr. gram size. etc.)
FROM
ft.
rt.
TO
R,
ft.
ft.
ft.
R.
ft.
ft.
R,
ft.
fL
ft.
ft.
21, REMARKS
4" Stick up cover
2 x2 pad
22. Certification:
Signature of Certified Well Contractor Date
ay .signing this farm, l hereby cerii(i that the welt(s) was (were) ca ISMICktl in accordance
with 15.4 N('.t(' 02(010(1 or 15,4 N('.f(' O N' 0200 Well ('nnslruetton 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 Wells ONLY: Tn addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of welt
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:
Also submit one copy of this form within 30 days 0)' coinpletion of
well construction to the county health department of the county where
constructed
.3r 2./' Z‘
Nottl, Caeo),nu Department of Environment and Natural Resources- Division of Wate, Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Natne
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compum Name
2. Well Construction Permit#:
l.isv all applicable well permits li c Catnap, Stow, Variance, injection etc j
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑ Tndustrial/Com mere ial
°irrigation
Non -Water Supply Well:
E.Monitaring
injection
°Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experinmental Technology
°Geothermal (Closed Loop)
°Geothermal i ili:ating/Cooling Return)
RECEIVED/NCDEQ/DWR
For Intern Use ONLY:
SEP 2 0 2021
14. WATER ZONES
FROM
30 ft,
TO
48
ft.
DISCI ION
WQROS
MOORGSVILLE REGIONAL
0
ft.
ft.
15. OIJTF,R CASING liar mullf-eased wellii) OR LINER Of ap lic)
FROM THICSN£S,S 41 \TERIable.il_
TO
f.
ft.
O1a METER.
in.
14. INNER CASiNG OR TIMING (geothermal elroed•lnopt
FROM TO DI.iN£TER THICKNESS
0
ft.
18
ft.
2
In.
sch40
MATERIAL
pvc
ft.
ft.
In.
17. SCREEN
OMunieipal!Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑Recovery
FROM
18 ft.
ft.
TO
38 fr.
f.
Dt.[b1ETER
2
in.
In.
SLOT SIZE
.010
THICKNESS I NtATERIAI...
sch40 I pvc
18. GROUT
FROM
0
ft.
TO
13
ft.
MATERIAL
Portland Cem
EMP1. iCE.\MENT ,NIF.77 O1l dF:\MOI NT
Tremie
13
ft.
16 ft.
Bentonite Chit
Tremie
4. Date Well(s) Completed: 2/25/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
°Groundwater Reined iation
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
Well iD# MW-79
Facility iDA! (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
Sh. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Of well field. one lat/long is sufficient)
35.412541 N-80.807348
6. is (are) the well(s): 1221Permanent or °Temporary
7. Is this a repair to an existing well: ❑Y'es or ONo
1/ this is a repair, Jill our known well construction inJhrnation and explain the Manure grille
repair under •21 remarks section or on Use back a/this /arn.
8. Number of wells constructed: 1
Far nndtiple injection or non -water supple wells fhYL Y with I/te sane construction. you can
submit one fisrn,
9. Total well depth below land surface: 38 (ft.)
For multiple wells list all depths if (example. 3 rt ?i0 and 20100')
10. Static water level below top of casing: 30 (ft,)
/J water level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i a auger, rotary. cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form OW -I
ft.
ft.
I. S+iNfJ/GR 4VEL PACK Of applicable)
FROM
16
ft.
TO
38
ft.
MATERIAL
#1 Sand
EMPLACEMENT METHOD
Tremie
ft.
ft.
20. DRII,t.1NG LOG (attaeb addttianai sheets if uecesrtarY)
TO
FROM
ft.
ft.
DESCRIPTIOY realer. hardness. soit'rvek type. grain vvc_ ere;
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
rt.
21. REMARKS
4" Stick up cover
2 x2 pad
22. Certification:
, •Zr •2i
Signal re of Certified Well Contractor Date
By signing this Jam, 1 herehv ceriiJv that Use well(s) was (were) comma:Mil in accordance
with 15 t M'AC 02C .0100 ar USA NC AC 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 tollowing:
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.
Notch Carolina Department of Environment and \atusal Resources - Division of Water Resources Revised August 2013
FFICE

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used foi single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan) Name
2. Well Construction Permit #:
List all applicable well permits (i e. County State, I irrianee, in/ectian, etc.)
3. Weil Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
O industrial/Commercial
❑Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothemial(Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3-8-21
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
° Recovery
°Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
❑Other (explain under #2l Remarks)
Well ID# MW-79D
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
35.412524 N-80.807414
w
6. is (are) the well(s): ©Permanent or °Temporary
7. is this a repair to an existing well: ❑Yes or EINo
If this is a repair, Jill out known well construction infornmtim and explain the nature if the
repair under 3i remarks section or an the Kuck al this Juror.
8. Number of wells constructed: 1
For multiple injection or non -water supply welts ONLY with the same construction, van can
stibnite one Awn,.
9. Total well depth below land surface: 154
(ft.)
Far nrtrliiple wells list all depths if dil/erent (example- J 200' and ? a 100')
10. Static water level below top of casing: 104 (ft.)
ifwmer level is above casing, use "- "
11. Borehole diameter: 2 (in,)
12. Well construction method: 8" casing and 4" Air Hammer
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW- I
For Internal use ONi.I'
SEP'(2 0 2021
14. WATER ZONES
FROM
30 ft.
TO
48
ft.
DESCRIPTIOV OOHESVALLC
wet
FlEGIONAI 0
ft.
ft.
FROM
IS. OUTER CASING (for mt,Ri-ee ed wepsl OR LINER (if appRamble)
THICKNESS MATERIAL
ft.
TO
it.
DIAMETER
in.
16 INNER CASING OR 7r1113ING.fgeotherouLl eiostt140.14
FROM TO
DIAMETER
THICKNESS
MATERIAL.
0
ft.
144 ft.
2
In.
sch40
pvc
ft.
rt.
in.
17, SCREEN
FROM
144 n•
TO
154 ft.
DIAMETER
2
in.
SLOT SIZE
.010
THICKNESS
sch40
MATERIAL
pvc
ft.
ft.
in.
IS. GROUT
FROM
0
ft.
TO
89
f6
AL,ATERRAL
Portland Cem
EMPt ,CEMENT METHOD ZE AMOUNT
Tremie
89
ft.
ft.
115 fit.
ft.
Bentonite Chii
Tremie
19. SAND/GRAVEL PACK (ifapplkable)
FROM
TO
MATERUI..
I'MPI.ACFSIFNT %ItTIIOD
115 ft'
154 ft'
#1 Sand
Tremie
ft.
20, DRILLING LOG (attach additional shins it neetssary)
TO
FROM
ft.
ft.
DESCRIPTION (color: hardnro, soitirsrk type, train site. etc.(
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21 REMARKS
22. Certification:
Sig inure of Certified Well Contract r
Date
-ICE
By signing des /ornl, I hereby cernjv dun the we11(.$) was (mere) constructed in accordance
with ISA Ne.4(' 02C .0)00 or 15A N('AC 02(' .0200 Well Construction Standards and that a
copy rJ ibis 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
23a. For All !Yells: 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 lnicction 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 tollowing:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Witter Supply & Injection Wells:
Also submit one copy of this tixm within 30 days of completion of
well construction to the county health department of the county where
constructed
North Carolina Department of Environment and Natural Resources — Division of Watet Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam-Name
2. Well Construction Permit#:
by/ all applicable well permits (i.r. ('aanv, .Sate. I irriame, btj'c7ian ¢ter.)
3. Well Use (Cheek well use):
Water Supply Welk
°Agricultural
❑Geothermal (Heating/Cooling Supply)
° Industrial/Commercial
° irrigation
Non -Water Supply Well:
t Monitoring
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (i-leating/Cooling Return)
4. Date Well(s) Completed: 3/2/21
IFor `ntcruai Ilse ONLY:
N. WATER ZONES
FROM
23.5 e.
TO
37
ft.
RECEIVED/NCDEQ/DWR
SEP202021
WQfOS
L.LE RPGIONAL OFFICE
DESCRIPTII4 ()ORESV
wet
ft.
15. O11 ER C.
ft.
FROM 'I0
Hi. 1Iv
FROM
0
ft.
ER C.#SING O
ft.
ft.
17. SCREEN
TO
17
ft.
multi -eased welts) OR LINER (if a. Me)
DIAMETER THICKNESS I MATERIAL
in.
ft.
ft.
RITIG (geothermal sirkred•laop►
DIAMETER
2
in.
in.
THICKNESS
sch40
MATERIAL.
pvc
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
DGroundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
Well ID# MW-80
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IDd (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
35.412182 N -80.806945
W
6. is (are) the well(s): ©permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction it jnrmatiau and explain the nature o/ the
repair under 2l remarks .section or as the hack of this Joan
S. Number of wells constructed:
I•irr multiple injection or nos-water.supp/p wells ONLY with the same conslructfnn, von can
submit one /aria
9. Total well depth below land surface: 37 (ft.)
fie multiple wells list all depths tI different (eranlp/e- 3@200' and 2.ni00')
10. Static water level below top of casing: 23.5
If water tell!! is above casing, use " "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e auger, rotary, cable, direct push, etc )
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW- I
FROM
17 ft.
ft.
TO
37 rt.
ig, GROUT
FROM
0
ft.
DIAMETER
2
in.
in.
.SI.07" SIZE
.010
111 ICKNEiSS
sch40
MATERIAL
pvc
ft.
TD
10
ft.
MATERIAL.
Portland Cern
EM PLACE E: METHOD .t: .4A101:NT
Tremie
10 n•
15 ft.
Bentonite Chi
Tremie
ft.
ft.
19, SdtND(6RAYEL PACK (lrapptkalik)
TO
FROM
15 ft.
37
ft.
MATERIAL
#1 Sand
EMIT a("&ME=NT SIETHOD
Tremie
ft.
ft.
20. DRILLING LOG (ortgeh+t4diHt>aat ahaxta if aftrssaty)
FROM DFSCRIPTION Iwlar, hardness, seiI/reek
TO
ft,
ft.
ft.
ft
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
ft.
4" Procover
2 x2 pad
22. Certification:
Signature nt'r <titiled WeII ('writc r
Date
Hy signing this farm. 1 hereby certify that the u•ell(s) was (were) constructed in accordance
with 15.4 N('A(' 02C 0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
copy of this record has been prar ided 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 ;,II 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 subrnit 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.
North Carolina Department of Environment and Natwal Resources- Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Welt Contractor Name
2973
NC Welt Contractor Certification Number
Parratt-Wolff, Inc.
RECEIVED/NCDEQ/DWR
For Intel nal Use ONLY:
EP20Z021
14. WATER ZONES
FROM
ft.
r0
ft.
DESCRIPTION
WQROS
MOORESVILLE REGIONAL OFFIC
ft.
ft.
IS. OUTER CASING (for multi -eased wells) OR LINER (if eppllcable)
FROM TO DIAMETER THICKNESS MATERIAL.
ft.
In.
Compaq) Name
2. Well Construction Permit #:
i.ix! all applicable. well pernnts (i. e County: Slate, Variance, Injection. etc
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
industrial/Commercial
❑irrigation
Non -Water Supply Well:
g Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (i lean ngg/Cooling Return l
4. Date Well(s) Completed: 3/3/21
16. INNER CASING OR TURING (aenthermal cttncri-trap)
TO
FROM
0
ft.
17
ft.
DIAMETER
2
in.
TIIICK?IE.SS
sch40
MATERIAL.
pvc
ft.
ft.
in.
17. SCREEN
❑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)
Well ID# MW-81
So. Well Location:
Colonial Pipeline Company
Facility/Owner Nance Facility ID11 (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
3h. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one ladlong is sufficient)
35.411672 N-80.806653
6. is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or No
1l this is a repair, fill out known well construction inlirniatiurr and explain the nature ol'the
repair under 21 rentarkr .section or on the hack q/ this /Lrm,
S. Number of wells constructed: 1
For multiple injection or non -water vnpp(v wells ONLY with the same construction, you can
submit ,meflow.
9. Total well depth below land surface: 37
For mittp(e wells list all depths if di/Jerent (example, .?@200' and 2@l00')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "
1 I. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(R•)
(i.e. auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
Farm GWI
FROM
17 ft'
TO
37 rr,
DIAMETER
2
in.
SLOT SIZE
.010
TH'CNN Fi4
sch40
MATERIAL
pvc
ft.
ft.
In,
19 GROtrr
FROM
0
ft.
TO 1 MATERIAL
12 ft• I Portland Cem
EMPL{CE\I E:\T METHOD ,14 AMOUNT
Tremie
12
ft.
ft.
18
ft.
ft.
Bentonite Chi
Tremie
to, SAnm/GRgV€L PACK (if applicable)
FROM
18 ft'
TO
37
ft.
MATERIAL
#1 Sand
EMPLA(E!t1ENT METHOD
Tremie
ft
ft.
20. DRILLING
FROM
ft.
TO
ft
ddidornd sheet* if necessary)
DESCRIPTION mtor. ltttrrinrss, soillrnck type, grain 4Zr, eft.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
n.
1. REMARKS
8" Flush Cover
2 x2 pad
22. Certification:
Signature of Certified Well Contractor
Date
Hy .signing this farm, l hereh' certify 111ai the well(a) stay (were) constructed in accordance
with 15,4 N('AC 02C 0100 or lid N(a(' 02(' 0200 Well Construction Staiulards and that a
cope 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.
SUBMiTT.AL 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 forth within 30 days of completion of well
construction to the tbliowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For %ruler 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.
Notch Catalina Department otEnvitonnient and Natural Rcsowces - Division of Water Resources Revised August 2013

1?VELL CONSTRUCTION RECORD
This form can he used tot single tit multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cunlpam Name
2. Well Construction Permit #:
List all applicable well peroritr lie (roomy. Shut, l ariatic•e, Infection, etc.1
3. Well Ilse (check well use):
Water Supply Well:
❑Agricultural
❑Geothernal (Heating/Cooling Supply)
❑ Ind ustr ial/Commercial
❑irrigation
❑Municipal/Puhlic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
©Monitoring I:Recovery
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Rcmcdiation
❑Salinity Barrier
❑Storinwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7-18-21 Well ID# MW-81 D
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
13900 Huntersville-Concord Road, Huntersville, NC 28078
Facility IDt (if applicable)
Physical Address, City, and Zip
Mecklenburg 4660193695/1921204
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field. one let/long is sufficient)
35.411707
N-80'806545
w
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
1/this is a repair, fill otti known well conctruc•rion inJnrntat)rnr and explain the nature nl lite
repair muter =21 retuark,.ercnaa or on the hack of'ihie /oral
0. Number or wells constructed:
1•i,r multiple ,,vicettom or non -water supply hells ONLY with the same construction, }vet eau
submit one farm,
9. Total well depth below land surface: 113 (B )
For multiple wells liar all depths if different (example- 3 a 200' cmd 2(`l00)
10. Static water level below top of easing: 25_ (ft.)
i f Crater keel is above razing, ass " • "
11. Borehole diameter: 2
(in,)
12. Well construction method: s 5/8 HSA & 2" spoons & s" Air Hammer la" PVC Casing
(i.eauger, rotary, cable, direct push, etc.)
FOR WATER StUPPLV WELLS ONLY:
13a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
Farm CiW.I
For Internal Use ONLY:
14, WATER ZONES
FROM
TO
DESCHIP1ION
25 ft,
113 ft.
Wet
ft.
ft.
iS. OUTER CASING (tar
muld-easa4 wells) OR LINER (if ap likable)
FROM
TO
DIAMETER
'fII It KNESS
MATERIAL
ft.
ft.
in.
16,1NNEA
(, tfijNG Uit TiIHING
(geothermal aired -loop)
FROM
TO
DIAMETER
THICKNESS
MVFERIAI..
0 ft.
98 ft.
2 in,
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
(HAM r.f'ER
SLOT SIZE
'I'H1(:KNESS
DATERIAL
98 ft'
113 ft.
2 in.
.010
sch40
pvc
ft.
1't.
In.
18. GROUT
FROM
TO
MATERIAL
EMI'LtLRMENI'MLTHOD .tEAMOUNT '
0 ft'
89 ft•
Portland Gem
Tremie
89 ''
94 ft•
8entonite Chit
Tremie
ft.
ft.
19. tNt1/GHA.VEL
PACI..
((t*Polk ailtle)
FROM
TO
MATERIAL.
EMI'I..t(.T: Ni E:1'r Mt:-rHOt)
94 ft•
113 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLINGt
LOG'(i(t isb
xdd(tiuuuti'shaeta if tiecessury)
FROM
TO
DESCRIPTION Ieulur, harJna,, euit/ruek type, go Jill err.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
it.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
8" Flush Cover
2 x2 pad
22. Certification:
Signature 01'0'eru01e,I Well Contractor
Date
Nv signing this farm, I hereby certify Ana the well(a) was (were) constructed ill accordance
with ISA Nt'A(' 02(' ,0100 or iSA MAC 1)2' .U200 Well (instruction Standards and that it
copy of this record hoe been provided to the u•eil owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details ur well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INST(ICTiONS
24a. For All IVe115: Submit this form within 30 days of completion of well
construction to the tollowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
24b, For Injection Welli ONLY: 6i 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 tbllowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. loot• Water Su,.pfliy.& 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:
Ninth Carolina Department of F.nvironment and Natural Resources — Division ot'Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compel)) Nance
2. Well Construction Permit#:
List all applicable Well permits (i c (',,iu,f SOW. t irriance, hrjcctton, etc )
3. Well tlse (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrialCommercial
❑ irrigation
Non -Water Supply Well:
21 Monitori ng
❑MtticipaliPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recover'
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/2/21
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
°Other(explain under #21 Remarks)
Well ID# MW-82
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Nance Facility !DV (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 lan'tong is sufficient)
35.411508 N-80.806448
6. is (are) the well(s): @Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or L(No
!J )his is a repair, fill out known well crnasvrttction inJarnmtion and explain the nature of the
repair under 421 remarks section or on the hark c,J this /firm.
8. Number of wells constructed: 1
/or mralttple injection or nor! -water supply wells ONLY with the same construction, you can
submit one fount
9. Total well depth below land surface: 39 (ft.)
For multiple nrel/s list all depths i/ different (example- 302(N)' and 2 i l00)
10. Static water level below top of casing: (ft.)
11 waver lorel is above casing, use " "
IL Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i.e auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fain) GW-1
I5, OUTI?It CASING (format +/AilOR LINER Qf epplicab►e)
FRONTDIAMETER
ft.
RECEIVED/NCDEQ/DWR
For Internal Use ONLY:
SEE 20`2021
14. WATER ZONES
FROM
ft.
TO
ft.
DESCRIPTION
WQROS EFI
MOORESVILLE REGIONAL OC
R.
n.
r0
ft.
in.
MATERIAL
16. INNER CARING OR T:MIN(i (geothermal etnsed-too
FROM
0
ft.
TO
14
ft.
DIAMETER
2
In.
rutcl:NEss
TIIICri\F1 S
sch40
)
MATERIAI.
pvc
ft.
ft.
In.
17, SCREEN
FROM
14 ft.
TO
39 rt.
DIAMETER
2
in.
SLO I' SIZE
.010
THICKNESS
sch40
MATERIAL
pvc
ft.
ft.
in.
IS. GROUT
FROM
0
9
rr.
rt.
TO
9
12
ft.
ft.
MATERIAL
Portland Cem
Bentonite Chii
EMPL 10EM ENT ..\IETIIOD & AMO1 iNr
Tremie
Tremie
ft.
fr.
19, SAND/GRAVEL PACK Of *mineable)
FROM
TO
MATERIAL
EM PLAC EM ENT M EffOD
12
ft.
ft.
37
ft.
ft.
#1 Sand
Tremie
20. DRILLING
FROM
ft.
ft.
I.QG (a tack additional shccte If neenaary)
TO i DESCRIPTION (coiu, hat
ft.
ft.
+tness, roilirurk type. grain she. etc)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
8" Flush Cover
2 x2 pad
22. Certification: / \
Signe re of Certified Well Contractor
Date
By .signing this Jiarm, 1 hereby certi& that the well(s) +vas (wen!) constructed in accordance
with /SA NCAC 02( .0100 or 15A N('AC 02(' .0200 Well Construction Standards and !loot a
cagy 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
SLBMITTALINSTUCTIONS
24a. Fur 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 W'el11 ONLY: In addition to sending the form to the address in
24aabove, 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:
Mao submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
North Catolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Nurnher
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.e, Comity, State. Variance, Infection, We)
3. Well Use (check well use):
RECEIVFD/NCDEO/DWR
For Internal Use ONLY:
5FP 2 O'2021
t4 WATRR ZONES
ROM
TO
DESCRIPTION
38 fit.
ft.
44.5 fit'
ft.
©nos
MOORES'Yi'0 F REGIONAL OFF
w
15. OUTER CASING (for multi-eaad wets) OK LINER (if _p2flcable)
FROM THICKNESS
TO
DIAMETER
MATERIAL
ft.
ft.
in.
IA, INNER CASING OR TURI,
FROM
TO
DIAMETER
rmal doted -loop)
THICKNESS
MATERIAL
0
ft.
24.5 fit.
2
in.
sch40
pvc
ft.
ft.
In.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑ irrigation
❑Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitori ng
❑Recover•
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/5/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑ Sal May Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# MW-83
Facility IDH (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 Iat/long is sufficient)
35.413250 N-80.808001
W
6. is (are) the well(s): OPermanent or ❑Temporary
7. is this a repair to an existing well: DYes or 0Nu
1/ this is a repair, fill out known well cota'trnwtiotn information and explain the nature q/ the
repair tinder . 2I remarks .section or at Ore hack q/ this form.
8. Number of wells constructed: 1
For multiple injection or non-waer supply wells ONLY with the same construction, you can
submit one them.
9. Total well depth below land surface: 44.5
For multiple wells list a1/ depths if different (example- 3@2 00' and 2@100')
l0. Static water level below top of casing: 38 (fit.)
If motet level is above casing, use „ "
11. Borehole diameter: 4 (in.)
12. Well construction method: 10 5/8 HSA & 2" spoons
(ft.)
fi e auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form G W- I
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS MATERIAL
24.5 ft.
44.5 rr'
2
tn.
010
sch40
pvc
ft.
rt.
in.
1R. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
20 fit.
20
22
ft.
ft.
Portland Cem
Bentonite Chi
Tremie
Tremie
ft.
rt.
19 SA.NDIGRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLxC12NENT METHOD
22 fit.
44.5 fit.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach tualtinetal sheets if necessary. )
FROM
ft.
TO
ft.
t5SCRIPTIOIti Irular. h.trdners,,aittroch t,pr, ,nin .rae, err.)
fit
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. R
r
8" Flushmount
2 x2 pad
22. Certification:
Signature of Certified Well Contractor Date
By signing this fora, 1 hereby certify Mat the well(s) was (were) constructed in accordance
with I SA N(A(' 02( 0100 or ISA NC1(' 02(' 0200 Well Construction Slaedardr and that a
cow nJthis record has been provided to tier 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 iNSTUCTTONS
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. Far 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.
CE
North Carolina Department of Environment and Natural Resowces - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple evells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
VC Well Contractor Certification Number
Parrett -Wolff, inc.
Compam Name
2. Well Construction Permit #:
List ail applicable n'r// permits (i e. (ornrn:, State, Variance. Injection
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑irrigation
Non -Water Supply Well:
2Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/6/21 well ID# MW-84
0Municipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
(ft.)
(ft.)
SUBMITTAL INSTUCTEONS
24a. 'u .1 I R'rlls: Submit this form within 30 days of completion of well
construction to the following:
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
❑Other (explain under #2l Remarks)
For Internal Use ONLY:
14. WATER
36.5 ft.
DECEIVED/NCDEQ/DWR
G02021
WQROS
NAL OFFICE
imminerDESCRIPTION
ulti e� ty�� CIl OR I. ER Efa livable
Bentonite Chi
L PACK if
#1 Sand
sch40
sch40
ENIPL%CE:Mt ENT :METH fD & ,t `001;NT
Tremie
Tremie
E;M1PL10EWENT MTT00D
Rfl, JNG LOG attach rtddidauat sheets if
ineenviaryl
DESCRIPTION teeini.
e+esc, SoiUiack h e. train size. etc./
8" Flushmount
2 x2 pad
22. Certification:
Signe ure of Certified Wv11 Cuntnciur
By ,signing this' Jlrm, 1 hereby certify ,hat the well(s) way (,were) constructed in accordance
e
with !SA NOW 02C 0100 or 15.4 ,VC A(' 02(' 0200 Well (o ntrttction Standards and that a
copy of this record has been provided to the n•el/ 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.
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infecti n'IVeI(M 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,
24c. For Water& Inlecti l�
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
loon GW-1 constructed
North Carolina Department of Environment and Natural Resources - Division of Water Resources
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Facility ID# (if appli)
14511 Huntersville-Concord Road, Huntersville, NC18 Physical Address, City, and Lip
Mecklenburg
County
Parcel identification No. (PrN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35.413196
N-80.807938
6. Is (are) the well(s): ©❑Tem
Permanent or W
porary
7. Is this a repair to an existing well;
No
this is a repair, Jill out known well comumcnmthi/Urination andes or�explain the nature of the
repair under remarks sec -Wait or on the back ojlhislirnt.
8. Number of wells constructed: 1
hie multiple injection or non -water saps ur//.s OtVLY with the s'utne consrruction, tort car
submit one lirnt.
9. Total well depth below land surface: 36.5
bar multiple wells list all depths if di(li'rent (example- 3 200' and ?@100')
10. Static water level below top of casing: 32
((water level is abawe casing use "
11. Borehole diameter: 4
(in.)
12. Well construction method: 10 5/8 NSA & 2" g
(i.e. auger, rotary, cable. direct push, etc) goons
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
tilethod of test:
13b. Disinfection type;
---•_ Amounh
1636 Mail Service Center, Raleigh, NC 27699-1636
Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compare Name
2. Well Construction Permit #:
List all applicable n e// permits (t c• ('artn!R State
3. Well Use (check well use):
, Variance. byection, etc,/
Water Supply Well:
❑Agricultural
❑Geothermal ((Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irri • ation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply. (shared)
Non -Water Supply Well:
)1Monitoring
injection Well
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
OGeothemtal (Closed Loop)
OGeothennai (Heating/Coolin• Return)
ORecover.
❑Groundwater Remediation
❑Salinity Barrier
❑Storm water Drainage
❑Subsidence Control
❑Tracer
❑Other (ex .lain under #21 Remarks)
Facility/Owner name Facility lb# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
4. Date Well(s) Completed: 3/9/21 Nell ID# MW-85
5a. Well Location:
Colonial Pipeline Company
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iat/long is sufficient)
35.413253 N-80.807913
6. Fs (are) the well(s): OPermanent or OTemporary
7. Is this a repair to an existing well: OVes or ©No
1/ this is a repair, IN out known well cfutsiruction u(lormation and explain the nature of the
repair writer 21 remarks .section OP an the back n/'this Jam.
8. Number of wells constructed: 1
For multiple inJectiou or non -water supply wells ONLY with the same construction, Carr can
.submit one limn', -
9. Total well depth below land surface: 36
blur multiple wells list all depths it different (example- 3@200' and Ir I00') i rt.j
10. Static water level below top of easing: 30
11 waterkeel it above casing, use " '• (ft.)
11. Borehole diameter:
(in.)
12. Well construction method: 10 5/8 HSA & 2" spoons
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Form GW 1
4
Method of test:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM TO ..
DESCRIPTION
SEP 2 0 2021
WQROS
NAL OFFI
ft.
14. TNNE11
15. OUTER CASING (for malH-eued we&>< OR LINER if a Mel
FROM TO -.. s DIAMETER TRICF.SS M tTERf1I.
ft. in.
SINE: OR TUBIN( (geothermal cimett4nnp)
FROM TO DIAMETER I Of IC "KNEES M%TE:RI.AL
In.
16 rt.
ft.
Itt ' GR(M
FROM
ft.
19, SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
EMPLACEMENT METHOD
DIAMETER
sch40
MKT:NESS
sch40
MATERIAL EMPLACE
Portland Cem
Bentonite Chi
%IATERIAL
=^i'r METHOD & AMOtaNT
ft. 36
ft.
#1 Sand
ID, DRILLING 1 OG attach addirtonrl sheets ifnee etaa
ri7i1.tiltiro-arenr�. DFSC'RIPTION (mhm, hardness, salt/rock ty e. ,gin size. etc.l
22. Certification:
Tremie
8" Flushmount
Signanu� of Certified Well Contractor
2 x2 pad
Dote
By .signing this farm, 1 hereby certify that the well(.$) was (were/ constructed in accordance
with ISA NCA(' 02C (Ii00 or 1.5.4 NCAC 02(' 0200 Well Construction Standards atul that a
copy a/ 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 W Its 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 Si Injection w'elLs:
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.
North Carolina Department of Environment and Natural Resowces - Division of Water Resources
Revised :lugust'013

WELL CONSTRUCTION RECORD
This form can be used toe single or multiple welts
1. Well Contractor information:
Kevin White
Weil Contractor
2973
NC Well Contractor Certification Number
Parratt-Wolff, inc.
Company Name
2• Well Construction Permit#:
List a/1 applicable well ',ennui. %; 'minty ,State, )'ariance, Injection ere)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
Industrial/Commercial
° irriation
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: 3/14/21
5a. Well Location:
Colonial Pipeline Company
FacilityiOwner Name
14511 Huntersville-Concord Facility lD# iifapoeable)
Road, Huntersville, NC 28078
Physical Address, City, and Zip Mecklenburg
County
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
°Subsidence Control
❑Tracer
❑Other(ex .lain under #21 Remarks)
wen rn# MW-86
Parcel identification N-)
Olivet: field. one fat/long is sufficient)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal den
35.412011 beets:
N -80.805826
6. is (are) the wells W
(): I2lPermanent or °Tempora
ry
7. is this a repair to an existing
well: If Mirr is a repair, fill out known well consrufcvirm inr tali or an,©�p/ain the nature n/ the
repair under +21 ren,urkr xectio, or on the back of ilak firm,
S. Number of wells constructed: 1
Far multiple injection or non -water supply wells ONLY with the .same construction, eau can
submit one Ain
9. Total well depth below land surface: 46
lair
maniple welts Ilan all deptbx ij different (example- 3@200' and 2(p)10')
10. Static water level below top of casing:
/f water /ere/ is abate casing, use " '•
1 I. Borehole diameter: 4
(in.)
12• Well construction method: 10 5/8 HSA & 2" S
lie. auger, rotary, cable, direct posh, ac i poonS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
I3b. Disinfection type:
Fonu G\V-I
Method of test:
Amount:
(ft.)
(ft.)
RECEIVED/NCDEQ/DWR
15�EUM =R CASING!for mf( u/t aTEked wells OR L � DIAS LINER Ifa i,NuWe
METERi?trase�rs
iS. GROUT
DIAMETER
Bentonite Chi
PACK ifa.. tcahle
#1 Sand
sch40
sch40
EMPLACEMENT :N ETIIOD Nr ,&NMOI NT
EMPLACE, .s-r:uE'fnitD
20, DRILLING LOG -eh Mddiumtsl
Al the Warman
su
FRO DESCRIPTION fruit",
hardn
22. Certification:
2 x2 pad and cover
Signuture of Certified Well Contractor
Np srgaing this berm, 1 herehy certify that the well(r) nos (were) constructed it accordance
with /5A N('A(' 02(' 0/00 or /SA ,V( AC 02e 0200 Well Construction Standards and that a
copy 4/ this record has been prorided w 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
SUBMiTTAL1NSTUCTIONS
construction
24a. for All l Wells: Submit this form within 30 days of completion of well
to the following.
Division of Water Resources Information
Unit,
24b. f�rr infeeti--- o Well ONLY: In addition to sending the form to the address in
24aabove, 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 Su lv.±K 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
um od, t r, gain die, etc.)
North Catalina Department of Environment and Na
1617 Mail Service Center, Raleigh,
7699-16l7
g NC 27699-16t7
rural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRU TION RECORD
This Corm can be used fo; sink or mttitrplr t ells
I. Well Contractor Information:
Kevin White
�L'all Cuntrnctnr Namz
2973
NC' Walt Contactor Certification Number
Parratt-Wolff, Inc,
Campan} Name
2. Well Construction Permit #:
List all applicable weii permits (Le, Cann% State i iwianc'v. infection etc.,i
3. Weil Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
t industrial/Commercial
ClIrri _ . tion
Non -Water Supply Well:
Monitoring
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heatin Cooling Return)
4. Date Well(s) Completed: 4/23/21
5a. Well Location:
Colonial. Pipeline Company
Facility/Owner Name
°Municipalfpublic
❑Residential Water Supply (single)
°Residential Water Supply (shared)
0 Recover'
❑Groundwater Remediation
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under #2l Remarks)
Well iD# MW-87
Facility [De (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
P!tysicat Address, City, and Zip
Mecklenburg
County
Parcel tdentificatinn Na (P[N)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat//Iong is sufficient)
35.415094 N-80.804553
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: °Yes or No
I/ lhis is a repair, fill out know, well construction ia/itrma,j n anexplain the wane oldie
repair ender :2I remark+..section or on the back of this jinni,
8. Number of wells constructed: 1
/'or multiple injection or non -water supply wells ONLY with the same ennslract1an, pin can
submit one
9. Total well depth below land surface: 55
For rtadtip/e wells thrall depths if different (cramp/e- 3 .Y111' and 2 a Nit)')
10. Static water level below top of casing: 45
U water level Cs above casing use "
11. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4 HSA / 10 5/8 HSA / & 2 e. auger, rota. cable, direct push, spoons
M
IS CASING for4nullf.casedLINER if
DIAMETER a °
ft.
19 GROUT
22. Certification:
DiA:METER
DIAMETER
4 in,
Portland Cem
Bentonite Chi
#1 Sand
sch40
sch40
tNIPLACEMEN-IRiETI1OD & AMOUNT
rtddi*lanai sheets If'neseaes
DESCRIPTION rotor. hurduesr, ialltrarkr ;r, -_rain
2 x2 pad and 6" Pro Cover
Sitn a urn of Certified Well Contractor
Date
ily .signing this farm, I hereby cern/I that the ;re//(s) was (were) constructed in accordance
with /SA ty( •,4r ()2t'.010Ni or 11A RAC 02(' .0200 Wen Communion Standards and that u
cap, of this record has been proridecl 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
(ft.) 24a. For i1----I� Wr�is: Submit this form within 30 days of completion of well
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:
Amount:
construction to the following:
Division of Water Resources,Information Processing
Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. i ar InieeHon Wes a 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 SuAniy dit tricolor Wells:
Also submit one ropy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed,
Form GW- I
Noah Carolina Department of Environu;ent and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single ar multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cmnpary Name
2. Well Construction Permit #:
?.tst all applicable wed permits (i.e ('aroay Stale. I'ar?om'e: It jectiun, etai
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
Olrri,ation
Non -Water Supply Well:
tZtvionitoring •
lltjectiun:-Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (ticatin• Coohii Return)
°Municipal/public
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
°Other (expl;un under 421 (femarks)
4. Date Well(s) Completed: 4/28/21 Well 104 MW-88
5a. Well Location:
Colonial Pipeline Company
Facility/owner Nante Facility IOk (ifapplicable)
14511 Huntersvilie-Concord Road, Huntersville, NC 28078
physical Address, City, and Zip
Mecklenburg
County
Fame( identification No (PIN)
5h. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwett field, one lat/long is sufficient)
35.415269
(in.)
12. Well construction method: 8 1/4 HSA / & 2" spoons
(i,e. auger, rotary, cable, direct push, etc )
N -80.804274
6. is (are) the wetl(s): ppermanent or °Temporary
7. Is this a repair to an existing well: OVes or 2JNo
If this is a repair, /111 not known well construction inliwoalion and explain the nature of the
repair under 21 remarks section or on the hark of this fitrnt.
8. Number of wells constructed: 1
For multiple in/eclion or mitt -water supply we/Ls ONLY with the .same construction, you can
submit one Ihrtn,
9. Total well depth below land surface: 63
hat- multiple wells list all depths iJdifferent (example-3''' "' (ft.)
10. Static water level below top of casing: 50
1J water leret ix above casing, use " "
11. Borehole diameter: 2
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:
-----•-_.— :amount:
Form OW-1
(ft.)
EOM
ft
FROM
38 ft.
Fur Internal Use ONLY
FROM
63
TO
DESCRIPTION
fr.
—m
Wet
fr.
or mu/tLeased willsOa OR:LI R a u.11cabte it veTER
rt.
in.
16. INNER CASING OR TIMING thermal d
a3iiTRi DLANirfER
0
fr.
ft.
TO
43
ft.
2
in.
sch40
MATERr.At.
pvc
FROM 10 pt.AMETER SILT SIZE THteu,+lces
AtATE:RtAf.
63 Et.
ft.
ft.
2
in.
TO
40 rt.
.010
Portland Cem
Bentonite Chi
l'L SAND/GRAVEL PACNMI
K ifa: Sltspble
FROM
40 (t.
il
20. MULLING C OG
rt.
eb:additional itheeta If ,
DESCRIPTION (color, hardnesr, xurl/rsrtt t . ,ruin .stee. etr:
pvc
FMPLAC"kNIENT:rIE'fHOD & AMOUNT
Tremie
MAnntAL
#1 Sand
F<M pi ..ACk.MF,:NT METHOD
ft.
ft.
ft.
ft.
11111111111
22. Certification:
- 'l
Ny sighing this farm, 1 hereby cerr!/i, that the ur//(t/ was (were) constructed is accordance
with 13,4 NC,i(• 02( ,0100 or 1SA NOW 03('.0200 Well Construction Standards and that a
copy al 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. Fur All Writs: Submit this form within 30 days of' completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Dail Service Center, Raleigh, NC 27699-1617
24b. I r iniecfion 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 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.
North Carolina Depmnnrnt of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL C NSTRUCTION RECORD
:'his Simi can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Welt Contractor Yams
2973
NC We Contractor Certification Number
Parratt-Wolff, Inc.
r oniitarn >lame
2. Weil Construction Permit #:
/du id/applicable stet! pertrtity /i. a ('ow,ttt 57ate, Variance face: tan, etc)
3. Well Use (check well use):
Water Supply yVeil:
°Agricultural
°Geothermal (Heating/Cooling Supply)
Olndustrial/Commercial
Dim-ation
Non -Water Supply Well:
21 Monitoriti,P
injection Well:
❑Aquifer Recharge
ClAquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (Ileati I' Coolin.
❑Municipal/Publie
°Residential Water Supply (single)
©Residential Water Supply (shared)
°Groundwater Rernediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
Return) ❑Othertev lain under#21 Remarks)
4. Date Well(s) Completed: 4�29�21
Wen tD# MW-89
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
14511 Huntersvilie-Concord Road, Huntersville, NCte28078
Physical Address, City, and Lip
Mecklenburg •
County
5b. Latitude and Longitude in Parcel identification No. (PIN)
Of g degrees/minutes/seconds or decimal degrees:
Latitude
field one Id Log is sufficient)
35.415251
N -80.804103
6. is (are) the wellOs
tilPermanent or °Temporary
7. Is this a repair to an existing well;
Il No
dtis is a repair. Jill aut known well cruts'tructiuntWi r,es aton andr explain the where nl the
repair under .21 reraarkc .section or on the buck q/ tit/s,/itru,
g. Number of wells constructed: 1
.sahotn one four.
For Mithiple injection or non -water supply wells ONLY with the surne construction, Joni can
9. Total well depth below land surface:
53.8
Par
multiple wells list all depths if dil/i rera (tsatnple- 3.n'f!(!' aetrJ (lf1(1')
10. Static water level below top of casing: 52
invoke level is above caving, use '•
(ft.)
11. Borehole diameter: 2
(in.)
12, Well construction method: 8 1/4 HSA /
fie auger, rotary, cable, direct push, etc. ter spoons
FOR WATER SUPPLY WELLS ONLY:
(3a. Yield (gpm)
13b. Disinfection type:
(t'L)
1��FR fi,1Si�utultremt
tb. i® .1uvtNLi OR'Ctrg-
n� lip
33.8 rt.
Portland Cem
sch40
sch40
itlet.A('F,MENE' METHOD & AMOUNT
Bentonite Chi _
11111111111111111
!�� AYF I. PACEir• !feeble
IEMININ
MATERIAL
#1 Sand
2 D t c LOGh addttt III
Mornallim DESCRIPTION (cater.ha,dnesr..mlpreclsev•e.train sirr`etc.
Tremie
2 X 2 Pad & Cover
22. Certification:
Signature ottenitied Well Contract
Date
it
1Iv si�,r/ug this Arm, 1 hereby /r !]A ,V(AC (1r(• WOO or 13At,V(;that
ie the
irc//(t) ti as (a•erei constructer( tit accordance
copyofphis record has been provider! to die a elllotr•ner200 pc 11('oustnrc tin++ ,1%unclards and drat a
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
2�ta. •n t
W bl Submit this form within 30 days of completion of well
construction to the following;
24c. For Water Su i
well construction toone ttheocounty health f this form vdepartment,ofithe c untyon or
where
Form GW- constructed. 30
North Carolina Depannieot of Environment and :Natural Resources - Division of Water' Resources
Method of test:
Amount:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. Fo."r iaktfio ONLY: In addition to sending the form to the address in
construction to the following:
24a above, also submit a copy 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
& ect(on Wells:
Also 6t
submit
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells ,
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan} Vamt
2. Wc1I Construction Permit #:
List all applicable wellpermits (da i'otuttt. ,Stu
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
OGeothermai (Heating/Cooling Supply)
O Industrial/Com m erc ial
0Trri:ation
Non -Water Supply WeII:
(Monitoring
Injection Well:
OAquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
❑Experimental Technology
OGeothermal (Closed Loop)
OGeothemtal (HeatinoCoolini Return)
4. Date Wells) Completed: 6/2/21
5a. Well Location:
Colonial Pipeline Company
Facility/(honer Name
Facility tD4 (if applicable)
14511 Huntersvllle-Concord Road, Huntersviiie, NC 28078
Physical Address, City, and Zip
Mecklenburg
Count;
Parcel identification No (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
bar muhiple hells list all depths if r/ilji'rent (esmuphe- 47000' mrr11%u100')
10. Static water level below top °leasing: 49
If water /ere/ is short' casing, use "
11. Borehole diameter, 4
(dwell field, one IaUlon is sufficient)
g
35.414239 N-80.804402
6. Es (are) the weil(s): GJPermanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or 1No
/(this is a repair. Jill aai known teed construction hijormttimt and explain the nature of file
repair tinder : 21 remarks section or an the back i f ibis, jarnt.
8. Number of wells constructed: 1
Far tanlripie injection or non -water sapp(v n ells ONLY with the sane cnns'traction, you can
submit one Jam
9- Total well depth below land surface: 74
(rt.)
te. t•ltriance. !/i iia11, erC.i
❑Municipal/Public
OResidentia) Water Supply (single)
OResidential Water Supply (shared)
Cl Recovery
❑Groundwater Remed lotion
OSalinity Barrier
❑Stormwacer Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
Well
MW-92
n MN
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gprn) Method of test:
13b. Disinfection type:
Form GW-1
Amount'•
(ft.)
22.
I4, WATER ZONES
FROM Tn
DESCRIPTION
I 0ItTER CASING far mutt) es ed wells OR if
FROM TO 4METER
ft.
FROM
rtifieation:
THIC���
G OR TUBING _ eathermal elirdted-laa
DIAMETER EirST1ra7
MATERIAL
Portland Cem
Bentonite Chi
MATERIAL
#1 Sand
sch40
sch40
m.._______EMPLACEIVI ENT METHOD & AMOUNT
EMPLACEMENT METHOD
DESCRIPTION (coinr. hm'dness. sa4Uroah ry r. pram .she ere.
Signature ofCerfihc `all Contractor
Dare
By .signing this lawn, / hereby certiji• that the we/4s; was (here) constructed in accordance
Frith 15,4 //('AC 02C 0100 or 13A Ne4C 02( 0200 Well f'anstrrrctinn Standards and that a
corn al dos recant 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. f'or ;lip W"i is 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 WelIs.ONLY: In addition to sending the form to the address in
241aabove. 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. Fur Water Supply &: In cedar 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.
North Carolina Department of Environment and Natwat Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be ascd for single or multiple welts
1. Well Contractor Information:
Kevin White
Ardl Contractor Name
2973
N(' Well Counactor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
1. sr all applicable well pernt4s (i e r ountrs Satte. t :rrranc 2, hoectiaq etc.}
3. Well Use {check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (ilttatinu/Cooline Return)
URecovery
❑Groundwater Remedlation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Rertla
4. Date Well(s) Completed: 6/3/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
Well WD# MW-93
35.414267 N-80.804281
6. is (are) the well(s): EaPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
if this is a repotr, /ill our known well construction it f rrnratiar and explain the /taut', o/ the
repair raider remarks ,section or on the hock o/ this /tiro,.
8. Lumber of wells constructed: 1
Par nrtrltiple tolerator or non -water supply wells ONLY vldt the some eansrrucrian, you car
submit one /tart.
9. Total well depth below land surface: 62
I•.sr nndtiple wells list all {depths i/ dill:rent (esatup/r.. 3 200' and 2r1� /(0')
10. Static water level below top of casing: u 52.5
lJlrate' level is ohm's' casing, use ": " (ft.)
II. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type:
Form GW-I
Amount:
41
!For Inks nal Use ONLY
14. WATER ZONES
FROM j TO
ft.
ft.
OFSCRIPTIO
Ft. ' ft.
15. OUTER CASING (far multl-tased wells) OR A.INRR {ifspptkxlrtej:
FROM I TO ONM ETFR THTCTCNFSS HATER IAL
fr. ft. In.
I6. iNNER CASING OR TUBING (reotherm21 closed -loon}
FROM TO DIAMETER
0 rr' 42
ft.
17.SCREEN
FROM TO
42 ft• 62
ft.
M. GROUT
FRO1t
0 ft.
39
ft.
ft.
It SAND/GRA
FROM
ft.
ft.
ft.
ft.
ft.
2
tn.
fn.
THWRNFSS
sch40
DIAMETER SLOT SIZE
2
In.
In.
.010
MATERIAL
pvc
SS MATERIAL
sch40
pvc
TO I MATERIAL
39 fL l Portland Cem
41 ft• j Bentonite Chi'
ft.
EMPLACEMENT METHOD ffi AMOUNT
Tremie
Tremie
TO
63
20. DRILLIN
FROM
ft.
ft.
TO
PACK('
ft.
ft.
pplk A )
MATERIAL.
#1 Sand
OG (attach additional*
ft.
ft,
tit if
ces
EMPLACEMENT METHOD
Tremie
ESCRIPTION Kato,. hanirtess;sniU,vek one. Gain stu; ern!
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
ft.
4" Pro Cover
2 x2 pad
22. Certification:
Ct, ?? 2
Signal re of Certified Well Contractor
Date
Hy signing this /irrnr, / hereby certi/y dot the well(s) was (were) constructed in accordance
with I5A MCA(' 02C 0100 or 15A WA(' 02C.020(/ Well Construction Standards and that a
copy of this record los 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 Wets: 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 iniectioo 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
North Catalina Department of Environment and Natural Resources— Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used fot single or S multiple wells
J. Well Contractor Information:
Kevin White
ell Contractor
a"--
2973
Contractor Cc:lineation Number
modeolff
att-Wolff, Inc.
Company Name
2. Well Constr
list n11 a action hermit #:
applicable well permits (i.e "onn'• Sarre. l urta,c'e, /ir/ectinn,
3. Well Use (check well use): e I
Water Supply Well:
❑Agricultural
❑Geotherml (Heating/Cooling Supply)
° industrial/Commercial
❑Irrigation
Non -Water Supply Well:
21Monitoring
Infection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
©Geothermal (Hcating/Ct,oling Return)
°Municipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
=Recovery
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑ Tracer
°Other (ex lain under #21 Remarks)
4. Date Well(s) Completed: 9-16-21
5a. Well Location: `— Well ID# MW-94
Colonial Pipeline Company
Facility/Osvnrr Name
14511 Huntersville-Concord Road, Facility ID# (if applicable)
Physical .address, City, Huntersville, NC 2807$
ry, and Zip
Mecklenburg
County �- --
JpfiNo
thriven field, one lat/tong is sufficient)
5b. Latitude and Longitude in degrees/minutes/ cconds or decimal degrees:
35.415916
-80.804501
6. Is (are) the well(s): ppermanent or ❑Tern
7. Is this a repair to Porary
an existing well:
jdris is a repair, Jill out knower well c•onstractiah in/Urination and explain the nature o the
repair under -? �Na
/ renmrks section or on the back of this farm,
8• Number f
Fiirn,hr multiple constructed;
P / tan or non -water supply wells ONLY with the s
suhntit are farm.
awe construction, you can
9. Total well depth below For multiple wellslistland surface: 47
all depths if rli/Ierent (example- 3 200' and 4'
10.Static wlevel below C nl-Qcloo')
top of easing: 37
h water level is above casing, use " - ••
11. Borehole
diameter: 4
Well construction 12. (in.)
tieruction method: 6 5/8 HS
auger, rotary, cable, direct push, ete )
A 2" spoons
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type;
Frn'n, GW-I
(ft.)
(ft.)
Method of test:
Amount:
Mal& ASIIYCtfnrmW�®azievt3k LINERirnb/e
16. INNlrR CASING ING
rumI etuted-/tny
SLOT SIZE
18GROUT
®
EMPLACEMENT METHOD
.,•...�, s AMOUNT
ell rddttlanal Areal If arc$-
0F;S(•tt1PTioty refer. harJnea, C/Itreek
6" Stick up Cover
22. Certification:
Signatureof iticd Well Contractor
By signing thin" fin -in I hereby certi(p that the ur// '
with 154 N(q<' 02(' OIIIl1 or 15;1 N<;tl• 0
(l °' l (were) constructed in sand that
a
copy of this record /has been provided to the well o?�0 Well
Construction t
au'ner, Standards are/ that a
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 SUBMITTAL IN pages if necessary
0 0, size, err.
STL CTIONS
24a. Fur All Wells: Submit construction t� oth� following ft this form within 30 days of completion of well
Division of Water Resources, Information Processing
1617 Mail Service
Center, Raleigh, NC 27699_ Unit,
24b. Fur Inieetton 11' 1617
24a above,, alsosob is ONLY: In addition to sending
2 asabove,n to the following; copymit a of this form within 30 daysyof c to the address in
of completion of well
Division of Water Resources, it
1636 Mail Service Center, Raleigh,
NCInjection7Control Program,
24c, For Water Su 1 Re In•ection W Also submit one copyells:
well construction one to ie of tore within 30
county health department
of completion of
constructed partment
North of the county where
Carolina Depart,t1Y1i. of Environment and Natural Resources - Division of Water Resources
Date
Revised August 2013

WELL CONSTRUCTION'
This form can be used for single RECORD
S or multiple wells
1. Well Contractor Information:
Kevin White
Wail Contractore
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
CompanS Name
2. Well e Construction
L/sr all opp/cable ,,/ Permit #:
pcpurin' (i
3. Weil Use (check well use):
Water Supply Welt:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
°industrial/Commercial
7It'ri „anon
nrurrr, .S'Rne, f brinncr, Injection, ate J.
N0n-Water Supply Well:
°Monitoring
injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (1fettttne/Coobn Realm)
°Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
°Salinity Barrier
❑Stormw'ater Drainage
❑Subsidence Control
°Tracer
❑Other(ex lain under #21 Remarks)
4. Date Well(s) Completed: 9-23-21
5a. Well Location; Well fD# MW-95
Colonial Pipeline Company
Facility/Owner Name
14511 HUnterSVllle- Facility ipi/ (i .7,p1 cable)
Physical Address, City, and Zip
COncord Road, Huntersville,
NC 28078
Mecklenburg
County
Parcel Identification No (PIN)
Orwell field one ler/Iong is sufficient)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
^tees:
nr -80•806554
6. is (are) the well(s): ppermanent or °Temporary
7. Is
For inn
Slte diagram or additional
submit the back of this me ennstrvtcrron, goer
9. Total well depth below land surface: 60
l'br nml/ip/e wells list al/ d Pages if necessap�
W
14 ER ZONIS
60 2
Wet
IS, e�tT>sRc,�srN
FROM f+ far mold -cased wells OR LINER
� DIAMETER (ff soolicablei
IC IIYNon
t��
FROM
9.
ttiAV�(i',##cah4�
4�t 60 ft.
#1 Sand
ZO�GLOG ®
(athtch•dditlrayirbeetriTeca4an
To DESCRIPTION
ft.
color, hardness, wit/rock n r, :rain va ,
a etc.t
DESCR/Pl'IO,N
sch40
E.MPL,tCEMrryT METHOD & AMOUNT
il•17�
22. Certification:
6" Stick up Cover
this a repair to an existing
(//las this a sting well: °Yes
repairpair•./ill out known ,cell construction a fhrnrarror and explain lain the nature n
under =?! renrarks.rectiorr or an the hock a/ this/brm.
p al the P uled to the well owr, Construction Standards and that a
$• Number of wells constructed: 1 23.er,
You well details:
/v u„ may use is s construction details page to provide additional well site details or well
You may also attach additional
Contractor
Signature ofC`ertitted t8 c 1 Contra
Nv shelling dos %atop, / lrrrehv Date"'----
/3, with ell i g I /o.' n1 , ceraly that the well s
copy C 0100 or ISA NC t 02 /) was (wrrc) umarruc'tee/ in accordance
pY o/ r/ur recap,/ has' been ( 0200 lY�// ('[ucs. tar.
dhp(e irfe[•tian or non-
one r tt'mersupP. clip ONiY with rlreSa
/i rut,
depths (,/{/darer! /eratnple-) ru20JG' and 1r
ilk Static water level r�/GGq
//,rmerlevel rsabot below tap' casing: 35
e caving, rose ^ -
11. Borehole diameter. Q'
(in.)
12. Well construction ( a a method: 6 5/8 2rr
uger, rotary, cable, direct push, HSq spoons
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
lib. Disinfection Method of test:
type:
Amount:
Form G W- I
Nook Carolina Department ofEnviron
con
SUB;b1ITTAL LNSTUCTIONS
{fL) 24a. For All Wells:
construction �e following it this form within 30
days of completion of well
(ft.) Division of Water Resources,Information
Unit,
tab. F_or tnler.han N
24a above gills ONLY: In addition to sending
also submit a copy of this form o the Form to the -
construction to the toll H�thin address in
of Water Resources, Llnderground injection Contr
1636 Mail Service Center, Raleigh, NC 27699_1636
1617 Mail Service leigh, Processing Center, Raleigh, NC 27699.1617
owing 30 days of completion of
Division well
Control Program,
24c. For Writer 5
submit one uco #v .St [n a�ctitln Wells:
Alsol submit
topyeof thiisyCorm
twithin .30
days of completion of
department of the county where
men{ and ..\aoual Resources — Division of Water Resources
constructed
Revised August 2013

Water Supply Well:
❑Agricultural
❑Geothermal (}Ieating/Cooling Supply')
° industrial/Commercial
❑ irrigation
Non -Water Supply Well:
©Monitoring
Injection tiV'ell:
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
C lGeothermal (I{eating./Coolifk Retool/
WELL CONSTRUCTION RECORD
This form can be used for single or multiple was
1. Well Contractor information:
Kevin White
Well Contractor N�
2973
NC Well Contractor ertification Number
Parratt-Wolff, Inc,
Company Name
2. Well Construction Permit#;
List all app/irah/u me// pernutr (i.e. Coumv..srolet ) brianec, /0/ec'[ioa. r1r, J
3• Well Use (check well use):
°Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply, (shared)
°Groundwater Rernediation
°Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under #21 Remarks)
Well ID# MW-96
Physical Address, Ciry,
, and Zip
4. Date Well(s) Completed: 9-28-21
5a. Well Location: `—
Colonial Pipeline Corn
Facility/pruner Name pant'
Facility 1D# (if appli
14511 Huntersville-Concord Road, Huntersville, 28078NCteMecklenburg
County
IdentificationParcel
5b. Latitude and Longitude in degrees/minutes/ econdsor decimal deg ees:
of well field one tat/long is sufficient)
35.415589
N -80.806413
6. is (are) the wells ;
() Permanent or ❑Temporary
7. Is this a repair to an existing well:
Jjt/ti.s is a repair, fill out known well constroctimr i"/ ratali n anti el. plain the nature qI the
repair under ::?/ remarks section or on the back r f this lam.
e
8. Number of wells constructed: 1
submit ono lama
Far multiple injection or non -water supply wells ONLY with the sa me constractlon
9. Total well depth below land surface:
For multi !r
60
p w ells list all depths iJ dijferem ((arttp/ J(t1?I)0' ane! ]Ui /.70';
M. Static water level below top of casing: 30
11 water level is above casing, use •' • '•
(ft.)
11. Borehole diameter:
(in.)
nu can
W
12. Well construction
r.e. auger, rotary, cable, irect push,
h, et65/8 HSA & 2" spoons
FOR WATER SUPPLY WELIS ONLY:
13a. Yield (gpm)
Method of test:
I3b. Disinfection type:
Form. (i}y-1
Amount:
(ft.
For Internal Use ONLY,
DF_SC'R1I710N
IMAM TO
15. OUTER CASING for mufti -mud wells OR LINER if a , , Itcuble
DIAMETER
16. ilVirr.0 f' I. SING, OR
RING enthe frmoeir_ ,s 0a
tC71FRTx. 'rr.•r.�..�._
Portland Cem
Bentonite Chi
19. BAYEI PACK
Ka Warfel
#1 Sand
sch40
sch4Q
EMPLACEMENT METIIOD & AMOUNT
DRILLING L—h additional ors oecutrLDEtn1PTiON rotor,
hu0Mcss, rnf!'ructc
6" Stick up Cover
22. Certification:
Sif,nature of Certified Well Contractor
Qv signing
farm, / hereby igning this Dat¢r--------'—
witA cenijv Mai the ire//(s) ryas (were) cuut7rncred in accordance
NC'A' 02C .0100 or 15.i NC'AC 02C .0200 Well Construction Standards and chat 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
SUBMITT
AL 1 STUCTIONS
) 24a. For--- i-- H W�eIIo' Submit this form within 30 clays Y of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For inieetion Wells ONLY: In addition to sending
24a above, also submit a copy of this form within 30
construction to the following: the form to the address in
days of completion of well
Division of Water Resources Underground Injection Contro
l Program,
construction to the following:
1636 .Mail Service Center, Raleigh, NC 27699-1636
24c. for Water Su Iv& ln•ection Wells:
Also submit one copysclh
well construction toe ountytheatlth�detartmen 30 dntyofthocountion e
constructed p
?forth Carolina De county where
Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013