GW1-2021-00280_Well Construction - GW1_20210125

WELL CONSTRU TION RFCORll
Thu loon can be,ucd for angle or multiple wdb For lntornal Use ONLY,
I.Well Contractor Information:
Mitchell Dean Cook wATER7.ONEs . ----
FROM TO oEsra[PTIOY
Well Connector Noma �� ft. ft. —"---
2043 A
n. n
NC Well Coumcmr Certification Nwnbar 1S:f 13R`.ciASINl2 for mali4e6ed eW'D-tIIIN RIUVI `Itiable T
mom TU DIAMETER llll(:1 CS5 MATERIAL
Dennis Holland Well Drilling, Inc. 43 ' fL 3.,, b.
n
Company Nestle � -� N. ' ell
'16::INNRR CAgINO OR"fUE li' em6ermibdoied•lo0
2.Well Construction Permit N:.'y() 3 7 l mom TO DIAMf:n:R _ THICKNESS [At,
List all applicable well pasnbs(i.e.Count,.ytate, Yarlam",GJeaion,etc.)
n.
3.Well Use(check well use):
,lyg REE
Water Supply Well: — mom To umETea sl o or st¢s nucx=Ess nurextnt
OMuniuipel/1'ublic .
OAgriculhtral ft. ft. to. —
/�
OGeothernal(Heating/Cooling Supply) OResidential Water Supply 1 (single) ft• ff. to. - --"
❑Industrial/Commercial OResidential Water Supply(Shared) '> AUROUT 2 Obligation —
mom TO MATERIAL E_MPLACEMEMLn10U6_MOUNr
n . ✓ n.
Non-Water Supply Well: n. 4
OMoniloring ❑Recovery fe rt .,Y
Injection Well: fE ft. -
OAquiferRecharge 00roundwater Rensediation ; `:$' 'ifs 'Ocabe - —
-
OAquiferStorageandRecovery OSalinily Barrier mom rti nurl:aul. EMPLACEAIE METHOD
❑Aquifer Teat Is. R.
OSMrmwater Drainage
❑Experimental'rechnolo ft. fr.
BY OSubsidence Control
- (16 enech,adaiiibnel e6eele'if. sae " `•-"DGeothermal(Closed Loop) ❑Tracer 20.DRILLINFLmom ro UE.S(.RIPI'10N color buds ON/rackrats tiu err.
❑Geothermal Heatin •oolin Remm OOther ex lain under k21 Remarks) rt• a
p. R
4.Date Well($)Completed:0/J4 1./ Well IDq AJ,
h fE
Sa.Well Location:
R. Is.
1A, rt. Is.
Facility/Owner Nam. Facility ID#(if applicable)
ft. ft.
rE n
Physical Address,City,and Zip
•,Tcah
County Parcel Identification No.(PIN)
Sit.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(ifwen field,one IeDlong is sufficient) 22.Certification:
Ajr¢ •.�9 N fI3 /6 N- S• W _ o/-//f-an?,L
Sigtutwe ofComfied Well Connector Dau
6.Is(are)the well(s): fill ermeoent or OTemporary
9y signing this farm, !hereby cerl6 that the well(,rJ wus(were)mnsmurred in ncenrdnnve
Will iSA NCAC 02C'.O/0O ur ISA NCAC 02C.0200 Weli C'aostruc0.vr Standards and the:a
7,Is this a repair to an existing well: OYes or giIlf�o copy ofthis rec•0rdhas been previdedru the wel/owner.
if Ph"/s a repNe fill out ka0wa well consaaction olia v uhn,and esp/ain the nan„c of lire
rrpufr,ad,,all remarks.rectfon or on the back ofthisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: -, construction details. You may also attach additional pages if necessary.
Far multiple injection 01 non-wore,supply-,H&ONLY with the sane camhucdon,you can
0fi subm ors rm. SUBMITTAL INSTUCI'IONS
x -
9.Total well depth below land surface: .3OS {A 24a. fps Ag Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdif(erenl(example-3@200'and l®f00')--•� G^ calsttirchan to the following:
10.Static water level below top of using: p`.1 V (ft.) Division of Water Resources,Information Processing Unit,
ffwarerhvel uabove casing,use"+,, ��� - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6- (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
12.Well construction method:
24a above, also submit a copy of this form within 30 days of completion of well
(i e.eaga',rotary,cabin,direct push,CO.)J 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)_f.S Method of test• Air lift 24c.For Water Supply&Infection Wells:
136.Disinfection type: H
Also submit one copy of this funs within 30 days of completion of
H Amount: L 2 oz. well construction to the county health department of the county where
Constructed.
Form OW-1 North Caroline Detainment of Environment and Natural Resources-Division ofWatm Resources Revised August 2013

• I
1
JAC
C U
KTg:�Y
The Jackson County Department of Public Health
538 Scotts Creek Rd.Suite 100+Sylva, NC 28779
Tel: [phone] - FAX: $28.586-3493 j
Shelley Carraway s
DIRECTOR
Shelley Carraway
Well Permit
Reference Number: Permit Number: 2020-20269-9-10580
PIN: 7527-20-6413 Application Date: 12/30/2020
Owner: KYZER,HERBERT L City: CAMPOBELLO SC
Address: 40 CEDAR HILL DR Zip Code: 29322
Lot Number: 172 SINGING RIDGE RD _
Service Type: Well Permit Bedrooms: 0
i f Directions To site: Punnklntown Rd to Sassafras Rd to Singing Ridge Rd.
a
Well Depth:
Case Depth: 1
Grout:
Yleld:
Contractor: i
Driller:
Well Type:
Well Size:
Stay 25' from any building perimeter. Stay 100' from any septic system and repair area. Stay 25' from 'e
Creek,stream or river.Stay within property lines.Attached drawing not to scale. Stay out of power line
right of way. Stay out of any road right of way.
4
THIS PERMIT EXPIRES ON 1/12126.
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS
Remarks: DOCUMENT DOES NOT GUARANTEE YIELD OF WELL OR POTABILITY OF WATER.
ATTACHED WITH YOUR WELL PERMIT IS A SCREENING REPORT WHICH SHOWS ANY KNOWN SOURCE OF
RELEASE OF CONTAMINATION THAT IS LOCATED WITHIN A 1000 FT RADIUS OF YOUR PROPOSED WELL.
SITE. THIS IS A GENERAL LOCATION WHICH ONLY INCLUDES SITES THAT ARE IN DEQ'S SITE }
INVENTORIES, AND IN NO WAY REPRESENTS THE EXTENT OF THE SITES KNOWN OR SUSPECTED
i CONTAMINATION. THERE MAY BE OTHER SITES THAT ARE NOT COVERED BY DEQ'S AUTHORITY THAT
COUNTY HEALTH DEPARTMENTS WILL WANT TO CONSIDER. DIRECT ANY QUESTIONS TO YOUR LOCAL
�:. COUNTY ENVIRONMENTAL HEALTH SPECIALIST REGARDING SPECIFIC KNOWN RELEASES OR ANY
FURTHER WATER SAMPLING THAT MAY BE RECOMMENDED.
fSLg, $33220.00/ Re.Cg1RL
EHS: Issue DaSe: f fr L1
t
F11$ ARagmiti Date; _
§l9nature: I f
5i
k
j

^741% Jackson County Department of Public Health
JAC 538 Scotts Creek Road, Suite 100
CO O Sylva, NC 28779 Well Permit
,T„„,,,,„ Phone: [phone] FAX: [phone]
Reference Number: Permit Number: 2020-20269-9-10580
PIN: 7527-20-6413 Application Date: 12/30/2020
Owner: KYZER, HERBERT L City: CAMPOBELLO SC
Address: 40 CEDAR HILL DR Zip Code: 29322
Lot Number: 172 SINGING RIDGE RD
Service Type: Well Permit Bedrooms: 0
Directions To Site: Pumkintown Rd to Sassafras Rd to Singing Ridge Rd.
i
i
5 �
E (
N/ J /�0.•r i.
_—_
`7
�-
lao+
Fes;. $320.00 �Rt;Bc
a e' l
— _
Issug,Date*
4
}
EHS, _ 9Rpr v Date; --
e
i
gna pate:
(
i