GW1-2021-03169_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD For Intemtll Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
We1lContractorName fG fG 1 -
2043 A ft. ft
NC Well Contractor Certification Number i I:S:ita17mRtG` $ .6 :fote"mulli ells Ils'Q�i?>i I t e
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o . fG 3 , ft. 6 in. __ v�
Company Name `1'.'. E1tYGi1fSIPi O _=:B Gc Mr-
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: �W,7—J-a2 0 811'�-- 9- /O 8 48 ft ft in.
List all applicable well permits(i.e.County,State,Variance,Infection,etc)
fG ft. in.
3.Well Use(check well use):
r Ift wv.I
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑M�unicipaUPublic ft. It. in.
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. fG in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ',18
FROM nt
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑LTi anon d ft. ft
r t�
Non-Water Supply Well: �►wr
❑Monitoring ❑Recove ' iG `
ry
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 1 " lY?f '. r g'ar••:?'ri': s- '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it. ff.
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :GfiIst)G; 'ac re 8i'.og3<ee'tsi
FROM TO DESCRIPTION color,hardne.%aollirvck rain aim etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) ft. ft. !f"
ft. ft.
4.Date Well(s)Completed:da-o7=1/ Well ID# ft. ft.
Sa.Well Location: tr. ft. v
Jiff y1g77+ DJq Y1Q JV•/iq. ft. ft. rCG r•
FaciU /Owner Name
ty Facility IDH(ifepplicable) % fG
/-'o.'eex a 19_2 ft. &
raysical Address,arty,
ti7- _ 7n ..�!S`.w:,. :✓�,.�'r'f.':L.��a c5'9.ma's+.
47_a36_s O - 4 J-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if wall field,one lat/long is sufficient) . nn
3�.SIO 3q, 3.>6 . 4e N A3� la w
Signature of Certified Well Contractor Date
6.IS(ere)the well(s): anent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed In accordance
with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0< copy of this record has been provided to the well owner.
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 thisform. 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 ofwe constructed: construction details. You may also attach additional pages ifnecessary.
For multiple Infectionn s or non-water supply wells ONLY with the Brune consbacllon,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: 3.30 (ft,) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dtfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: 90 (ft.) Division of Water Resources,Information Processing Unit,
#'water level is above casing,use"+" 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 address in
Rota 24a above, also submit a copy of this`form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 54" 0 Method of test: Air lift 24c.For Water Supply&Injection Wells:
13b.Disinfection type: H
Also submit one copy of this form(within 30 days of completion of
H Amount: 1 2 oZ. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources ! Revised August 2013

` 613/2021 ENV Health Permit
' JACKSOIV
i The Jackson County Department of Public Health
S38 Scotts Creek Rd. Suite 100 * Sylva, NC 28779
Tel: [phone] * FAX: [phone]
Shelley Carraway
DIRECTOR
Shelley Carraway
Well Permit `
Reference Number: Permit Numbe is ! 2021-20802-9-10838
; PIN: 7620-67-0365 Application Date: 3/31/2021
Owner: WYATT, DAVID City: CHEROKEE NC
Address: PO BOX 2192 Zip Code: 28719
Lot Number: SUTTON BRANCH RD
Service Type: Well Permit Bedrooms: 2
Directions To Site: 1240 Sutton Branch Rd. on right.
Well Depth.
Case Depth:
Grout:
Yield:
Contractor:
Driller:
Well Type: Drilled
Well Size: 6 Inch
* WELL FOR SINGLE FAMILY RESIDENCE. Stay 50' from any part of septic system or repair area. Stay 25'
from any building perimeter. Stay 25' from creek, stream or river. Stay within property lines. Well shall be
cased to a minimum of 20' below ground surface. Stay out of any road right of way. Owner has approval
from DOT to directional bore water line across Sutton Branch Road to existing residence. Make sure all
utility lines are marked and follow all guidance set forth by DOT.
Attached drawing not to scale. THIS PERMIT EXPIRES ON 6/3/2026
;I 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.
`I 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
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_
Pee: $ 0 Receipt: _
EHS: Issue Date:
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ENS: Approval Dace:
signature: D'ate:
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doudapp.roktech.net/JacksonPernits/EnvHealthPermit/EmailWellPernit.aspx?EnvHealthpernit=14188 1/1

6/3/2021 ENV Health Permit P�' o—( 4
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3ackson County Department of Public Health
538 Scotts Creek Road, Suite 100
4'KSON Sylva, NC 28779 ' ' Well Permit
•r Phone: [phone] FAX: [phone]
- -PiWleNiri{h.% -
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Reference Number: Permit Number: 2021-20802-9-10838
PIN: 7620-67-0365 Application !Date: 3/31/2021
Owner: WYATT, DAVID City: ! i CHEROKEE NC
Address: PO BOX 2192 Zip Code: 28719
Lot Number: SUTTON BRANCH RD i
Service Type: Well Permit Bedrooms: 2
Directions To Site: 1240 Sutton Branch Rd. on right.
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Fee., _$32D.D0 eceiptc _
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EHS: f IFS Issue(Date:
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EHS: Approval Date:
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Sig a ur s-Y Aa,i�� '�� Uw ��'r k Date': to
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