GW1-2021-01727_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD Pn,mtempl Cat oNI.Y --�—�
this fam can be,ued fit single o multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 14 wAl`Ek ONUS
I(�tR0A1 TO FCRN
Well Conuucior Nnmt ft R2043 A — —
NCWellCmncnworC,.rtifcaiian Nmnber .IS.OU FR(ASIN('(for i-w multard nulls OR LINFR IfR Iicahle
FROM TO DIAMETER ❑IiC.KN'FSS MATERIAL
Dennis Holland Well Drilling, Inc. a r f ;,
Cumpa ry Name 16..INNER CASING ORT-I1BING eo5hermal.hued Itt
FROM TO DIAMETER THIe KT'E.SS MATERIAL
2.Well Construction Perimt H:L?!Lj., -�._/� n __- fr I,
L�_r ell npp/knhle well!emriss('.e.Co nry. Sara, -rT}-
D1 n
3.Well Use(check well use): —.-. .�
17. RP.t;N _ .._ _
Water Supply Well: l' eROM11 TO piAA1Fl Y.R NUT CIZF. TII(KNF.CS h1ATr RIAL.
CIAltricultiold R fI in
Cl Gcothernial(Hutting/(looling Supply) L3R���esidentiol Water Supply(single)
Llhtdustriel/Colnmorciel faAcsidential Water Supply(Shared) 1fliOROUI - !. ,'<
F110M TO _ M1IATF.RIAI EM PLACE M ERfMETHOD&AMOUNT
❑on-W.te D fr.
Nml Wa[e�r Supply Well:
❑Maniloring ❑Recovery r fn ,)r: -,--ft /_-
Injection Well:
❑A uifer Rechar e - L)_ -
4 g f](iroundwnter Remediahon 19.SAND/ORAVF,+IS^PAOK�i�2ablei�';
—_
f lAumfer Storage and Recovery LlSaliniry,Harrier ta4M-_-- Tq meTeaul. EMrEAr.EmemmnlEnlnn
❑Ayui fer Test CIStonnwaler Drainage --- -- --- ---- — --
[l F.xperunentul'1'eelutology ❑ t. ft.
Subsidence Control
30.DRILL IN( LOG aria eh'addidim.l sheets ihatepsery)
[.CrCulhermfll(Closed Loop) lacer FROM TO __ 1)&SCRIPTtON(tltr hWoe�`
C1Gcolhermal(Heatin!{/Cooling Itetwn) f_lOther(explain under#21 Remarks) ft ft
/ h ft.
4, Date Well(s)Completed:0;2 Well IDN /11f1—_...... .
_—_ ft,
Sa.Well Location;
G IS /V\, rt. n.
Paciliiy/Owner Name PncililY iD#(if.,licable) - '-- ---- ----- ---_ ._�ql'-.. .. _.__ .
ft ft \))
Lvt t�/� Lraki .fZ /YI
I'hysic.l Address,Cay.and Zip — — -------- ---
21.RLMARKI_____
4
C[n Ty, Pmcel Identification No.(PIN) --- -_---- --_—"-
-____________— _
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one l.Vlong is SUIieimlQ
v v �1
�- S"ast..m"I cmified Wdl Covu.mo. Date
(.Is(are)the well(s): Mi•ermanent or OTemporary It sr rh,, ono. !herebe reru Iha,d wet!si u e ronsnucred a ncarrdn.oe
r going I N F. n,(war/
u4ih!SA NCAC 01C.01l10 or ISA NCAC fl:C 0100 R'el(Cnnvnmunn s'mndards and Ihnr a
7.Is this a repair to an eliding well: ❑Yes or PfNnI copy p/Ihis racnrd has heen provideJra rht waf.rowner.
l/rlrla is a rapnlr,fitl mrr known wet!%onrrn¢non infnrmnrinn end a+plou'the mature ucflhe
o,p undo,s21 rernarkr eamron or err the backofrhik/orm, 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
g.Number of wells constructed: cunsnuction details. You may also mmeh additional pages if necessary_
pLr rnnhipfe rn/ectlmr or non-were,snppfy walls ONLY Ivirh the r.me "lv&"cflon,YVo cmr
mbnm aye form. SUBMIT"1'AL.INS'I UC'I IONS
9.Total well depth below IaoU surface p (fIJ 24a. for All Wells: Submit this form within 30 days of completion of wcl!
Fm nndnpla well,I.....l dcpnrs y`osff.ranr(ererrrpfe-3(a;200'and 2((D100') construction to the following.
10.Static water level helow top of casing:_ (ft.) Division of Water Resources,Information processing L'nil,
//wmar lev.to nbove casing,ore"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b. For Injection Wells ONLY: In addition to sending the form to the addn_ss in
Rotary 24a almvc, also submit a cop for
y of this fon within 30 days of compaction of well
12.Well construction method; construction to the hollowing'.
p a.note,,rotary,table,direo push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR W'ATFR SI1Ppi.Y WFLIS ONLY: ) 1636 Mail Service(enter,Raleigh,NC 27699-1636
13R,Yield(gpm) p�J Method of test: Air lift 24c.For Water Su d_.@ I Jection Wells:
-- Also subnut ono copy of this Cairn within 30 cluysof completion of
13b. _
Disinfection type. H.$ H Amount: 2 oz. well construction to the county health department of the county whore
am#rucicd.
Ibnn(i\4-1 North Carol...P,aament of Fo,ion mere at and Neuaal R"oal,,s-Division of Water Resoi es Keviscd Auquvi 2013

+ 4�ace�r
M a c o n C o u n t y NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
�11 PRIVATE DRINKING WA FR WELL
1 �5
i E Ise Miller
011 1 1) • � Of,on file
r Shaied Well, Rt'vdentlal �. 3?65901987A8 _ n/a
Lot k 113 airel Mo_unlsain 1 states _ _..._... . -.-1
r 4415> Tc ,entee' L Cr laurel Mtn f st > Lot ` IS on riyht across.from LSII house , new (i
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules-
Maintain minimum sethacks as appllcabie. '
Maintain new well constw(tion on pre-deter ruined approved new well location un left, uphill side Jf drlVeNdy marked with blue flag_
Due to the reyue;ted shared well status maintain minimum 100'frorn ,r.tinq sepbr ,y;tPr1r.
C lick to enter text
Diagram (Not to Scale)
sp= .35': 4' 19.106":A
Laurel Nlounuml Estates Road 83* 1?' 14.4.36" It
Y F
I'MI)OScd Ilou;e
lilt , Cle-trine not
staked
diccr:inn ditch
Installed OSW W
I
This permit is valid fat a period of five years, r n r I n I I .. 1 a 1,0 t - r u r- a .- I ,ny
r'.r -tl,!c upon *Oil 010 -''rn,1a _cJ. VIr11 o:": 1 ii, rr1 prrr r _. relul,i rl Ir v r -.IraLa t Ind r i or! C
V;e H n l 1-==rirr it ,pi,t -I. T ,0 o,of(h PICPi1 -_ Oplil l r1 1, ",.1 r i D.
7r_ cs1 at an9 litcby r1(P!'
A WELLHEAD CON PI ETIOIJ IN Silt`(CI ION MUST BE APPROVfE1) [it 10RE FINAL. POWIR IS G RAN IFD OR TIIF. 1NI-LI_IS 1'1A(7 D IN10
SERVICE_ PIFA';f S(IIIDUII A WFI.LI-II-AD WSPf CTION AFIIR PU 1,11' INS I Al I A PION. QUESTIONS? [phone]
Issue Date. I09/2071 Ilarold I audoth, PCItS )189 C:--- ..__ __.-_ it uthorrxcd State Aq,,i,!