GW1-2021-00829_Well Construction - GW1_20210215

WELL CONS')RUCTION RFCORll
Ilia form can be used for single or multiple&volts For Internal Usc ONLY:
I.Well Contractor Information:
Mitchell Dean Cook -142WATER ZONES9.
FROM TO OESCRD`TION
W 77777
11 Conlucmr Name ft, _y ' , 0,
2043 A —
--
NCWeIIConunnnrCartifientionNwober 16:Our TPR:(iASINa mWti.eNid wen, 0It:liIN If 01161 a '77777­--
MOM__ TO _ DIAM F.TER MATERIAL.
TERIAL.
Dennis Holland Well Drilling, Inc. o .]) �c
Cumpmry Nmnc '76._INNERCASINO',OR B - sell er ab I'[d lob _ "'
FROM TO DIA04 ER TIICKPIMS MATERIAL
2.Well Construction Permit q: /Q%h� '� eQ -P R. ---_ft. in. ----
List oil applicable well permor(i.e.Couny,State, Variance,la ectioq ate.)
ft. ft. in.
3.Well Use(check well use): - —17;(SCRP - 4
Water Supply Well: FROM TD _ NAM STER SLOT SIZE THICKNESS MATERW.
[lA riculmral ❑M//wlicipaVFublic
IF.
❑Geothermal(Heating/Gmling Supply) W<o1 dential Water Supply(single)
❑Industrial/Cmnmercial
esenta Water Supply(shared) 8 ROUT—. __
rth.. iino.. --
❑ obeli FROM 1'0 MATERIAL. EMPIACEMEINr AFITMOD&AMOUNT
Non-Water
�. 3 . ,a r
Water SPpply Well: ft. ft
OMonilorinit ❑Recovery ,x ' ft. ' ft. l — eJ
Infection Well: ft. fL
[.]Aquifer Recharge ❑Groundwater Remediation 19::5AN /O AYEI:rRAe:K'Ittpptifh e
UAyuifer Storage and Recovery (]Salinity Barrio MOM T I h1ATER1Ai. EMPLACEAIEI NIETBOD
0.
OAyuifer Test ❑Slonn Dram water age --- --- —
❑F:zperimental'1'echnology ❑Subsidence Control A. ft.
20.DRILLING LOG'(anuels dhiau it shecU`ifa mdety)'
❑GCothermal(Closed Loop) 12 Fracer FROM TO DK.SCR1P190N frnlor,Iuwdm ,rolVM, ZP, riot emJ
[)Geothermal Hearin CDolin Return 170ther(ez lain under#21 Remarks) D. f.
` l ft. ft ---
4.DAte Wells)Completed'C,l , d, Well ID.Y__/
ft. fL
Sa.Well Location: h.
i �j Ete� N o/a vile, N A. —ft ft.
I'miury/Owner Neme Facility lDe(ifapplicable)
fL ft,
357i RnSc> f.f. =/ lP�J -R. o. - ---
Physiosl Address,City,mid Lip -:21.NEMARKS. � _
Comsry Pamel ldcmificetion No.(PIN)
56.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Geld,one laolong is suf coma)
n
�_ _
SiFPanue of Cent rd WeII Cm,nacen Dam
6.Is(are)the well(&): G}Aermanent or CiTemporaty By signing this jinn,I hereby ce,t6 that the well(a)was(were)consuacled u.occordaacs
0111.IJANCAC 02C.0100 or 15A NCAC 02C.0200(Nell Consuacuoa Stembards and Flat,a
7.Is this a repair M an existing well: LlYes or L4146 +'Ropy of dtis recardhas been provided to the well owner.
If'his is a repa,q fill oat bs w,well ennslrmenon in/ormauan and expla,a,helpyw'.10f -
repnrunrferellremmks section or tin the bock o/thi.�(ann. 23.Site diagram or additional well details:
C Q,%r' use the back of this page to provide additional well site details or well
E.Number of wells constructed: t f[� 1 i/rn�eMietum details. You may also attach additional pages if necessary.
Fur mublple in)rction or nan-wmer supply well,ONL Y,vuh lire same roassracden,y eon
submit oneJurm. SLILIM[ITTAL INS'1'UC'HONS
9.'rotal well depth below land surface: -J'.LS S 1,.. ,,. (ft,)' 7,49. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Its,nil depths iifdherem/example-3@200'and 2@100) Construction to tire following:
10.Static water level below top of easing; /� (ft.) Division of Water Resources,Information Processing Unit,
llwanrlevel sabw,casmg,vse"-" 1617 Mail Service Center,Raleigh,NC:27699-1617
11.Borehole diameter: s" (in.) 24h. For Iniccliou Wells ONLY: to addition to sending the fomi to the uddress in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12,Well construction method: construction to the following:
(,c.eugtt,rotary,cable,direct Ptah,eta.)
_ Division of Water Resources,Underground Injection Control Program,
FOR WA,rER SUPPLY WELLS ONLY: ^� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gP m)... e'1 Method of test: Air lift 24c.For Water Supply&Injection Wells:
- � - — Alit) submit one copy of this form within 30 days of cmnplelims of
13b.Disinfection type: H & H Amount. 12 OZ.____... - well construction to the county health department of the county where
constructed.
Form G W-1 Nail,Caroline DeFsr oxen of Favimvment and Natural Resources-Division of Water Resources Revised Aopou 2013

C'otec�
m m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCT IONAUTHORIZA11ON
PRIVATE DRINKING WATER WELL
t Carolyn Rice Nolma
' � Y � 101410 P • 105010 S
Single Family Well, Residential - _6517463883 5 75
' • 3571 Rose Creek Road - - -
' • 28 N to L across McCoy Bridge onto Rose(reek Rd., to u3571 on L. Property across from SMdeer ROId.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2( Rules.
Maintain minimum setbacks as applicable. '
Well to be drilled on property.
Any questions call MCPH_
Diagram (Not to Scale)
-31' Sr,q
RO�n
h0', %Nell Are,i n l 50'
50;
PI i�40 Clun,ney
Well Area =J
cJ' n351'. Ro,c
i Crcrk Road
Sp/yin —
Ex. ST
Barn 50'Min Well Tdr � I'I-
Rp p, �10'Min
Repa ir Alfa
� Ifl I
114'
14
C.0( iBai k
H)
IP
This permit is valid for a period of five years—,epl thA a,i,,,y h, ...voked:;I a „❑ono.f c I,,roteiorned tray uw ha,o=,.n a n)ten <h nl a my Iau ,r
rrfum4ance upon which the perma s nsUtl. Well lo,atc, I ta.' nd m c it cn, a prat Y m,. t �='et state req Wat ,i 5. I ,all Inc msprtt,d ,ul epp-oven h1'ntamn(onnb/
{
PuV Haa'h bc;ore rt is pu[into us I' loca Gon of tl,,w,� Cq Plr I'll I I nmi p,, I ri[vn I I FJ•I,. rlr i� geld)is NOi
guL¢mLeec at any Sae by M(PH.
A V'JLLI.HEAD COMPLETION INSPE(-IION MUST BL APPROVED B[ I ORE IINN_ PUIVLR IS GPAN1I O, l II WFI I IS PI ACED IN10
SIRVICL PLLASI ',CI I[Di1'_I A WFI.I_HEAD INS!'! CI ION Al I I PHNIP II1SfAl I Al IUN. QUESTIPNS7 (828),449-2490
1l�Issue Date RI ` //: ]2 7/Z0]0 fanner `tnmi•y, HS J/LY �� Au[hoi i;'c'd.5tr32 Agent