WI0800235_Well Construction Record(s) (GW-1)_20100918

WELL CONSTRUCTION RECORD (GW-1
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
]Agricultural Municipal/Public
)Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Non -Water Supply Well:
Recharge
Storage and Recovery
Test
rental Technology
mal (Closed Loop)
XGroundwater Remediation
Salinity Barrier
E3Stormwater Drainage
Subsidence Control
t3 Tracer
MOther (exDlain under #21
4. Date Well(s) Completed: 9/18/2010 Well ID# I R88-I W01
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
OnSIOW
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latAong is sufficient)
3,839,167.936 N 284,707.739
6. Is(are) the well (s)OPermanent or OTemporary
W
7. Is this a repair to an existing well: Dyes or E)No
If this is a repair, fill out known well construction information and explain the nature ofthe
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- l is needed. Indicate TOTAL NUMBER of wells
drilled:__
9. Total well depth below land surface: 60 (ft.)
For multiple wells list all depths fdifferent (example- 3@200' and 2@I00')
10. Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter: 8 _ (in.)
12. Well construction method: GeOprObe 8140 ROtOSOnIC
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING for multi -cased wells) OR LINER (if applicable
FROM TO DIAMETER 1 THICKNESS MATERIAL
0 ft-
40 ft•
4 in. Sch 40
PVC
16. INNER_ CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER THICKNESS
MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN
FROM
TO
DIAMETER
I SLOT SIZE
THICKNESS
MATERIAL
40 ft•
60 ft.
4 'n'
0.02
Sch 40
VeeWire
ft. I
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft-
34 ft-
CementlBentonite
Tremmie - slurry
34 ft.
38 ft.
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (if a plicable
FROM TO I MATERIAL EMPLACEMENT METHOD
38 ft 60 1 #2 Sand Tremmie
ft. ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
M
Signature of Cred Well Contractor Date
By signing this.forin, 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:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: _ 24c. For Water Sum& & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
1.3b. Disinfection type: Amount: completion of well construction to the county health department of the county
J where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
Municipal/Public
(Heating/Cooling Supply) OResidential Water Supply (single)
>mmercial Residential Water Supply (shared)
ell:
4onitoring
LJ Recovery
Injection Well:
]Aquifer Recharge
3$Groundwater Remediation
3Aquifer Storage and Recovery
fDSalinity Barrier
Aquifer Test
[]Stormwater Drainage
]Experimental Technology
Subsidence Control
-t, - , 1-1
[3Tracer
Return) { j0ther (explain under 921 Remarks)
4. Date Well(s) Completed: 10/1/2010 Well Imo# I R88-IW02
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
3,839,160.634 N 284,726.801
6. Is(are) the well(s)E)Permanent or Temporary
NN'
7. Is this a repair to an existing well: [3Yes or E)No
I/'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 ofthis form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I G W-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 60 (ft )
For multiple wells list all depths ifdii ferent (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
IL Borehole diameter: $ (in.)
12. Well construction method: GeOprObe 8140 ROtOSOC1IC
(i.e. auger, rotary, cable, direct push, etc.)
1 14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
It.
ft.
ft.
15. OUTER CASING for multi -cased wells) OR LINER (if a hpp cable)
FROM TO
DIAMETER I THICKNESS
MATERIAL
0 ft' 140 It'
1 4 in. SCh 40
1 PVC
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER
THICKNESS
MATERIAL
ft. ft. I in.
I
ft. ft. in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 It.
60 It.
4 in-
0.02
Sch 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 It.
34 ft'
Cement/Bentonite
Tremmie - slurry
34 It.
37.5 It-
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK ifa licable
FROM I TO MATERIAL
EMPLACEMENT METHOD
37.5 It. 60 It- I #2 Sand
Tremmie
ft. ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
I DESCRIPTION (color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
It.
ft.
ft.
ft.
ft.
ft.
It.
&
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature er[ified Well Contractor 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 ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: 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
13b. Disinfection type: Amount: 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)
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring 17IRecovery
Recharge
Storage and Recovery
Test
ental Technology
trial (Closed Loop)
Return
XGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
er (explain under #21
4. Date Well(s) Completed:10/112010 sell ID# I R88-IW03
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility rD# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
3,839,144.917 N 284,715.039 W
6. Is(are) the well(s)�IX Permanent or OTemporary
7. Is this a repair to an existing well: DYes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 G W-1 is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface: 60
For multiple wells list all depths ij'dierent (example- 3 a 200' and 2 a 100')
10. Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter: $ (in.)
12. Well construction method: Geoprobe 8140 Rotosonlc
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
rt.
15. OUTER CASING (for multi -cased wells) OR LINER (if a plicable
FROM TO DIAMETER
THICKNESS
MATERIAL
0 ft. 40 ft- 4 in-
Sch 40
PVC
16. INNER CASING OR TUBING (eeothermal closed-loo )
FROM TO
DIAMETER
THICKNESS
MATERIAL
ft. I ft.
in.
ft.
1 ft.
in.
J 17. SC EF,N
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS MATERIAL
40 It•
60 It•
4 i"
0.02
Sch 40 VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 It.
35 ft-
Cement/Bentonite
Tremmie - slurry
35 ft-
38 ft-
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
MATERIAL
EMPLACEMENT METHOD
38 ft- 60 ft-
#2 Sand
Tremmie
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
rr
21. REMARKS
22. Certification:
Z;)a "r
Signature of rtified Well Contractor 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 ifnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: _ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfectioa type: Amount: - 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)
1. Well Contractor Information:
For Internal Use
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i. e. UIC, County, State, Variance,
3. Well Use (check well use):
Water Supply Well:
(Heating/Cooling Supply)
Industrial/Commercial
Non -Water Supply Well:
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Recharge
XGroundwater Remediation
Storage and Recovery
Salinity Barrier
Test
DStormwater Drainage
tental Technology
Subsidence Control
mal (Closed Loop)
E3Traccr
Return) I—IOther (explain under #21
4. Date Weu(s) Completed: 9/18/2010 Well ID# I R88-IW04
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3,839,154.998 N 284,697.746 W
6. Is(are) the well(s)EtPermanent or OTemporary
7. Is this a repair to an existing well: E]Yes or QNo
If this is a repair, f ll 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-I is needed. Indicate TOTAL NUMBER of wells
drilled:_
9. Total well depth below land surface: 60 (ft.)
For multiple wells list all depths ifdit ferent (example- 3 r@i 200' and 2 r@i 100')
10. Static water level below top of casing:
If water level is above casing, use "+ "
11. Borehole diameter: $ _ (in.)
12. Well construction method: GeOprObe 8140 ROtOSOC1IC
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.�
ft.
ft.
15 —OUTER CASING (for multi -cased wells) OR LINER (if a licable'
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 ft. 4 in. SCh 40 PVC
1 16, INNER CASING OR TUBING (geothermal closed -loop)
I FROM
TO DIAMETER
THICKNESS
MATERIAL
ft.
ft. in.
ft.
ft. in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 ft•
60 ft-
4 "
0.02
SCh 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft-
35 ft
Cement/Bentonite
Tremmie - slurry
35 ft•
38 ft-
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (ifapplicable)
FROM I TO MATERIAL
EMPLACEMENT METHOD
39 ft- ` 60 ft #2 Sand
Tremmie
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
I TO
DESCRIPTION (color, hardness, sail/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
I ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature o ertified Well Contractor 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 ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: 24c. For Water Suonly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: 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 W ater Resources Revised 2-22-2016

1IN aIIJree ►��3iI64CoxaH xK ) a-ff[ft.�i lI
1. Well Contractor Information:
Rickv Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
OAgricultural Municipal/Public
19Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
1ndustrial/Commercial OResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
] onitoring Recovery
Injection Well:
Aquifer Recharge I'kGroundwater Remedialion
Aquifer Storage and Recovery Salinity Barrier
D.Aquifer Test [3Stotmwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop) Tracer
Geothermal (Heating/Cooling Return) E30ther (explain under #21 Remarks)
4. Date Well(s) Completed:10/2/2010 Well ID# I R88-I W05
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latnong is sufficient)
3,839,160.757 N 284,655.037 N1,
6. Is(are) the well(s)oPermanent or OTemporary
7. Is this a repair to an existing well: E)Yes or E)No
If this is a repair, fill out known well construction information and explain the nature oJ'1he
repair under #21 remarks section or on the back of this Jorm.
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:
9. Total well depth below land surface: 110 (ft.)
Ior multiple wells list all depths ifdifferent (example- 3(a)a 200' and 2(a1a 100')
10. Static water level below top of casing: _ (ft.)
If water level is above casing, use " + "
11. Borehole diameter: 8 (in.)
12. Well construction method: Gus Pech Rotosonic
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO__J
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER (if applicable)
FROM TO DIAMETER THICKNESS
MATERIAL
0 ft. 90 It. 4 in. SCh 40
PVC
16. INNER CASING OR TUBING (eeothermal closed -loop)
FROM TO DIAMETER
THICKNESS
MATERIAL
ft. ft. in.
ft. I ft. I in.
17. SCRE N
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
I MATERIAL
90 ft
110 ft
4 in-
0.02
Sch 40
JVeeWire
ft.
ft.
in.
j 18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
80 ft.
Cement/Bentonite
Tremmie - slurry
80 ft•
87 ft-
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
87 ft
110 ft
#2 Sand
Tremmie
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessarv)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grAin size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature o�/citified Well Contractor 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: _ 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
13b. Disinfection type: Amount: _ 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

1. Well Contractor Information:
Rickv Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
QAgricultural Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
nlndustrial/Commercial DResidential Water Supply (shared)
F7)IlTigation
Non -Water Supply Well:
Recharge
Storage and Recovery
Test
.ental Technology
nal (Closed Loop)
XGroundwater Remediation
Salinity Barrier
E] Stomtwater Drainage
Subsidence Control
Tracer
under #21
4. Date Well(s) Completed: 9/28/2010 Well ID# IR88-IW06
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latnong is sufficient)
3,839,148.959 N 284,657.160 W
6. Is(are) the well(s)JDPermanent or Temporary
7. Is this a repair to an existing well: []Yes or gDNo
if this is a repair, fill out known well construction information and explain the nature gl'the
repair under 921 remarks section or on the back of this.lbrm.
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-
9. Total well depth below land surface: 110 (ft.)
For multiple wells list all depths ifdrfferent (example- 3 a 200' and 2 a )00')
10. Static water level below top of casing: _ (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Guspech ROtosonlc
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
-
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER ifa licable
FROM TO DIAMETER
THICKNESS
MATERIAL
0 ft. 90 ft. 4 in.SCh
40
PVC
16. INNER CASING OR TUBING geothermal closed -loop)
FROM TO DIAMETER THICKNESS MATERIAL
l ft. I in.
l
It.ft. in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
90 ft.
110 ft
4 in-
0.02
Sch 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
81 ft
Cement/Bentonite
Tremmie - slurry
I81 ft
88 I'L
Bentonite
chips
ft.
I ft.
19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL
EMPLACEMENT METHOD
88 110 ft #2 Sand
Tremmie
ft. ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
ES
DCRIPTION color, hard ness,soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature o rtified Well Contactor Date
By signing this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i. e. UIC, County, Slate, Variance,
3. Well Use (check well use):
Water Supply Well:
(Heating/Cooling Supply)
Non -Water Supply Well:
Aquifer Recharge
Storage and Recovery
Test
rental Technology
real (Closed Loop)
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
XGroundwater Remediation
Salinity Barrier
OStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/28/2010 Well ID# I R88-I W07
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
3,839,129.004 N 284,650.033 W
6. Is(are) the well(s)J Permanent or OTemporary
7. Is this a repair to an existing well: E]Yes or E)No
1/This is a repair, fill out known well construction information and explain the nature oflhe
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-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 110
Tor multiple wells list all depths if'dii ferenl (example- 3@200' and 2@100')
10. Static water level below top of casing:
1f water level is above casing, use
It. Borehole diameter: 8 (in.)
12. Well construction method: _Guspech
(i.e. auger, rotary, cable, direct push, etc.)
Rotosonic
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS
MATERIAL
0 ft. 90 ft. 4 in. SCh 40
PVC
16. INNER CASING OR TUBING (geothermal closed-loo )
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
90 ft•
110 ft•
4 in•
0.02
SCh 40
VeeWiire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft.
80 ft.
I Cement/Bentonitel Tremmie - slurry
80 ft.
87.5 ft-
Bentonite
chips
tt.
ft.
19. SAND/GRAVEL PACK it applicable)
FROM
TO MATERIAL
EMPLACEMENT METHOD
87.5 ft•
110 tt• #2 Sand
Tremmie
ft.
ft.
20. DRILLING LOG attach additional sheets if necessa )
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
Y ft.
21. REMARKS
22. Certification:
Signature o. ertified Well Contractor 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:
(ft.} 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Environmental Quality - Division of W ater Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
Rickv Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance,
3. Well Use (check well use):
Supply
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring Q Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
(Closed Loop)
Geothermal
XGroundwater Remediation
Salinity Barrier
E)Stormwater Drainage
Subsidence Control
Tracer
Other (explain under #21
4. Date Well(s) Completed: 9/21 /2010 Well ID# I R88-IW08
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (ifapplicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3,839,147.884 N 284,640.028
6. Is(are) the we[ l(s)0Permanent or Temporary
w
7. Is this a repair to an existing well: E]Yes or E)No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back o/'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: 110
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100�
10. Static water level below top of casing:
lfwater level is above casing, use
11. Borehole diameter: 8 (in.)
12. Well construction method: Guspech Rotosonic
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells OR LINER if a plicahle
FROM ] TO DIAMETER
TAICKNESS
MATERIAL
0 ft. 190 ft. 14 in.
Sch 40
1 PVC
16. INNER CASING OR TUBING (geothermal
closed -loop)
FROM I TO
j DIAMETER
THICKNESS
MATERIAL
ft. ft.
in.
ft. ft.
in.
17. SCRE
N
FROM
TO I
DIAMETER
I SLOTSIZE
THICKNESS
MATERIAL
90 ft-
110 ft
4 in-
0.02
Sch 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft,
80 ft.
Cement/Sentonite
Tremmie - slurry
80
87.5 ft
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO ] MATERIAL
EMPLACEMENT METHOD
87.5 ft 110 ft #2 Sand
Tremmie
ft. ft.
G
NRILLINLOG (attach additional sheets if necessary
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, groin size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
1
1
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
T>Q.rr�ra-
Signature o't crtified Well Contractor 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 ojthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division ofWater Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Rickv Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
(Heating/Cooling Supply)
Dmmercial
Non -Water Supply Well:
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recharge
?Groundwater Remediation
Storage and Recovery
D Salinity Barrier
Test
E)Stormwater Drainage
ental Technology
Subsidence Control
rlal(Closed Loop)
OTracer
nal (Heatint?/CoolinQ Return)
MOther (explain under #21
4. Date Well(s) Completed: 9/20/2010 well ID# I R88-I W09
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
3,839,068.572 N 284,316.649 W
6. Is(are) the well(s)EIPermanent or OTemporary
7. Is this a repair to an existing well: QYes or x)No
tf this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 60
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
Ifwaterlevel is above casing, use " + "
11. Borehole diameter: 8 (in.)
12. Well construction method: C'ji mppr:h RntnSnnie
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING for multi cased wells) OR LINER (ifapplicable
FROM TO DIAMETER
THICKNESS MATERIAL
0 ft. 40 ft. 4
SCh 40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
I TO
i DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 ft•
60 ft• 4 in•
0.02
Sch 40
VeeWiire
ft.
ft. in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
32 ft•
I Cernent/Bentonite
Tremmie - slurry
32 ft •
38 ft.
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (ifa applicable
FROM TO ,if
EMPLACEMENT METHOD
38 I'L 60 ft. #2 Sand
Tremmie
ft. ft.
20. DRILLING LOG (attach additional sheets if necessa
FROM
TO I
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature oj�krtified Well Contractor 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 q/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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 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
13b. Disinfection type: Amount: l 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)
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
Lisl 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
Non -Water Supply Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
(Closed Loop)
Return)
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
XGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (explain under 421
4. Date Well(s) Completed:10/4/2010 weu ID# I R88-IW 10
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility ID# (ifapplicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latAong is sufficient)
3,839,049.114 N 284,322,562 W
6. Is(are) the well(s)ox Permanent or OTemporary
7. Is this a repair to an existing well: DYes or x)No
If this is a repair, fill out 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface: 60 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
Ifwaterlevelisabove casing, use
IL Borehole diameter: 8 (in.)
12. Well construction method: Guspech
(i.e. auger, rotary, cable, direct push, etc.)
Rotosonic
14. WATER ZONES
FROM
TO DESCRIPTION
ft.
ft.
R.
R.
15, OUTER CASING for multi -cased wells) OR LINER (if a livable)
FROM I TO i DIAMETER
THICKNESS
MATERIAL
0 ft' 40 ft' 4 in
SCh 40
PVC
1 16. INNER CASING OR TUBING (geothermal closed-loo )
FROM TO DIAMETER
THICKNESS
MATERIAL
ft. ft. in.
ft. I ft. in.
17. SCREEN
FROM
TO
DIAMETER
I SLOT SIZE
THICKNESS
MATERIAL
40 ft-
60 ft
4 'n
0.02
Sch 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
J TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 I'L
32 ft
Cement/Bentonite
Tremmie - slurry
32 ft-
34 ft-
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO I MATERIAL
EMPLACEMENT METHOD
34 ft 60 ft #2 Sand
Tremmie
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
I DESCRIPTION (color, hardness, soil/rock type, gnin size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
rt.
rt.
rt.
21. REMARKS
22. Certification:
Signature o ertified Well Contractor 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 ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: 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
13b. Disinfection type: Amount: 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)
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
nAgricultural
Municipal/Public
(DGeothermal (Heating/Cooling Supply)
Residential Water Supply (single)
DIndustrial/Commercial
DResidential Water Supply (shared)
Irrigation
I Non -Water Supply Well:
IMonitoring
EIRecovery
Injection Well:
Aquifer Recharge
XGroundwater Remediation
:(Aquifer Storage and Recovery
Salinity Barrier
Aquifer Test
OStormwater Drainage
Experimental Technology
Subsidence Control
} Geothermal (Closed Loop)
DTracer
I�Geothermal (Heatine/Cooline Return)
f10ther (exDlain under #21 Remarks)
4. Date Well(s) Completed:
10/4/2010 Wei IID#IR88-IW11
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility IDA (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
OnsIOW
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3,839,034.502 N 284,323.483 W
6. Islam) the well(s)oPermanent or Temporary
7. Is this a repair to an existing well: DYes or E)No
Ifthis is a repair, fill out known well construction information and explain the nature oJ'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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: _
9. Total well depth below land surface: 60
For multiple wells list all depths ifdifjerent (example- 3@200' and 2@100)
10. Static water level below top of casing: _
1f water level is above casing, use
11. Borehole diameter: 8
Clusnenh Rntnsnni
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
15. OUTER CASING for multi -cased wells) OR LINER (if applicable)
FROM TO i DIAMETER I THICKNESS J MATERIAL
i
0 ft. 140 ft. 14 in.
SCh 40 1 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
In.
+fftt
ft.
in.
17. SCR E
N
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 ft
60 ft
4 in'
0.02
Sch 40
VeeWire
ft. I
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
33 ft
Cement/Bentonite
Tremmie - slurry
33 ft
37.5 ft
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK ifa licable
FROM
TO
MATERIAL
EMPLACEMENT METHOD
34 ft-
60 ft-
#2 Sand
Tremmie
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
( FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.)
r ft.
ft.
ft.
ft.
ft.
ft.
I ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature o -ied Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 1 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:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1
1. Well Contractor Information:
For Internal Use
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, .State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
I Ir i anon
Non -Water Supply
Well: Monitoring DRecovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
XGroundwater Remediation
Salinity Barrier
[IStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21
4. Date Well(s) Competed: 10/2/2010 Well ID# I R88-IW12
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility 1D# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3,839,015.299 N 284,325.233
6. Is(are) the well(s)oPermanent or OTemporary
W
7. Is this a repair to an existing well: E)Yes or )No
If this is a repair, fill out known well construction in%rmation and explain the nature o/'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 1 GWA is needed. Indicate TOTAL NUMBER of wells
drilled:_ _
9. Total well depth below land surface: 60
For multiple wells list all depths if different (example- 3@2(1(1' and 2g,100')
10. Static water level below top of casing: (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Geoprobe 8130 Rotosonic
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM TO
DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if apRlicable
i FROM TO DIAMETER
THICKNESS
MATERIAL__
ft• 40 ft• 4 i"
10
SCh 40
-_
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO
DIAMETER I THICKNESS MATERIAL
fL I tt.
in.
ft. I ft.
in. -
17. SCRE N
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 ft.
60 ft•
4 i"'
0.02
Sch 40
VeeWire
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft•
33 ft•
CementiBentonite
Tremmie - slurry
33 ff•
37.5 ft.
Bentonite
chips
ft.
rt.
19.SAND/GRAVEL PACK (ifa licable]
FROM
TO
MATERIAL i
EMPLACEMENT METHOD
34 ft•
60 ft•
#2 Sand
Tremmie
ft.
ft.
20. DRILLING
FROM
LOG attach additional sheets if necessary)
TO DESCRIPTION (color, hardness, soil/rock type, gmin size, etc.
ft.
ft.
ft.
ft.
ft.
rt.
rt.
rr.
rt.
rr.
rr.
rr.
rr.
rr.
21. REMARKS
22. Certification:
�IiLqzaturc of rtified Well Contractor 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 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: 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)
1. Well Contractor Information:
Ricky Davis
Well Contractor Name
3011-A
NC Well Contractor Certification Number
Tri-State Drilling / Major Drilling
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:
IqAgricultural Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irlirritzation
Non -Water Supply Well:
Ijection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Return
ZGroundwater Remediation
Sal inity Barrier
DStormwater Drainage
Subsidence Control
]Tracer
under #21
4. Date Well(s) Completed: 9/27/2010 Well ID# I R88-j W 13
5a. Well Location:
MCB Camp Lej Site 88
Facility/Owner Name Facility tD# (if applicable)
J Thownson, DEMD / 12 Post Lane, Camp Lejunene, NC
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaOong is sufficient)
3,838,996.861 N 284,331.447 W
6. Is(are) the well(s)ox Permanent or OTemporary
7. Is this a repair to an existing well: E]Yes or No
Ifthis is a repair, fill out known well construction information and explain the nature ofthe
repair under #21 remarks section or on the back of this form.
8. For Geoprobei'DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 60 (ft.)
For multiple wells list all depths ifdi ferent (example- 3@200' and 2@100)
10. Static water level below top of casing:
Ifwater level is above casing, use "+"
11. Borehole diameter: $ (in.)
12. Well construction method: Geoprobe 8130 ROto-,onic
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
-
ft.
-
ft,
ft.
15.OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER THICKNESS MATERIAL
0 ft- 40 ft. 1 4 i° Sch 40 PVC.
16. INNER CASING OR TUBING (geothermal closed-l000)
FROM To DIAMETER
THICKNESS
MATERLAL
ft. ft. in.
ft. I ft. in.
17. SCRE
N
FROM
TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
40 rt•
60 rt•
4 in'
0.02
Sch 40
VeeWi're
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD&AMOUNT
0 ft.
34 ft.
Cement/I3entonite
Tremmie - slurry
34 ft
38 rt•
Bentonite
chips
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO MATERIAL
EMPLACEMENT METHOD
34 ft-
60 ft #2 Sand
Tremmie
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
I
22. Certification:
Signatutc 6i('crtified Well Contractor Date
By signing this form, 1 hereby certify that the well(.$) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A 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:
(ft.) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water SuDDIy & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: 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