GW1-2021-03067_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD For IntemQl Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 awATER BONES
Mitchell Dean Cook FROM TO DESCRIPTION
Well Contractor Name •J?,0 ft • `
2043 A ft. FL l
NC Well Contractor Certification Number 15'OUTER'CdSLYG foirmulti-casedzwells OR<I NNER if b' lielable
FROM TO DIAMETER!. THICKNESS MATERIAL
10 Dennis Holland Well Drilling, Inc. ft a • ft. i5o/C-21 /0 VC
Company Name 16:INNER CASING OttTUBING 'eofbermalitloseYi loo
FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0,0 52,6 /O ft. tc is
List all applicable well permits(i.e.County,State, Variance,Injection,etc) it. ft, in.
3.Well Use(check well use): 17 SCREEN+
Water Supply Well: FROM I TO I DIAMETER i I SLOT SIZE THICKNESS MATERIAL .,
ft. ft. in.l
❑Agricultural ❑Mun ipaUPublic
❑Geothermal(Heating/Cooling Supply) I esidential Water Supply(single) ft' fa t°'p
❑industrial/Commercial ❑Residential Water Supply(shared) lti};GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrl ation O . ft, ft.
Noo-Water Supply Well: - ft O• ft
❑Monitoring ❑Recovery a 4
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:;SAND/GRAVEL PACK'lfa liceble
❑Aquifer Storage and Recovery ❑Salinity FROM TO MATERIAL EMPLACEMENT METHOD Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage fL fc
❑Experimental Technology ❑Subsidence Control
20:DRiLLING'tiOG attacl'addrtioail shEeM ff uecmba
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hartinen,soillreck type,train size etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
/ ft. ft.
4.Date Well(s)Completed:OA"d /7-21 Well ID# V, .W ft. fa
I
5a.Well Location: ft. ft.
9- iel JQ *.,.4 •S ft. ft.
Facility/Owner Name Facility iD#(if applicable)
ft. ft.
LDf'- 4 Xar. AJati / 1414kovy k-ime ft. ft. ��gg1n
Physical Address,City,and Zip --7 21`REMARiGS
/111aceh "l-5 4zz .?1�S4B Y ,
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
r
35a 6 -37,24d' N 83°.zo ShS. 7S8 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): anent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or .$INo 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 remarkc.rection or on the back of ihisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �Jtn S (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfjerent(example-3@200'and 2@100') construction to the f0110wing:
10.Static water level below top of casing: /00 , (ft.) Division of Water Resources,
rces,information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Injection Wells ONLY: L!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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celntcr,Raleigh,NC 27699-1636
13a.Yield(gp m) Method of test
q Air lift24c.For Water Supply&Injection Wells:
oG
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resowces Revised August 2013

?Cpee�r
�4 .m Macon County NEW WELL CONSTRUCTION
o� ;r Public Health CONSTRUCTION AUTHORIZATION
'a a' PRIVATE DRINKING WATER WELL
KCLIarks
utton&Sutton Inc. Daniel Wuycheck) • 1©0520-Pin le Famil Well Residential7502034548ot 4 Section 1 Hicko Knoll Falls Chapel Rd. Lon E. Hickory Knoll Ra.,coo throu�h ate 2073 and keep right. Lot is 'directly past#2026 on L.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well to be drilled on property.
Any questions call MCPH.
Diagram (Not to Scale) P
Pavement
Ends �c o��
.........
1
....................
A� ��s
Pooesslso�1 R �� kgo��F.y�ofo
Cut Bank oda
..................
75'
Co��cre
75' 1(9
Oak Mo�`�P�ut gank
ti Q
`
�� © Hickory
10
09 i
��`�. ,�ao 1p0,% s,
Min
�S-
1'r 10'
op 2 BR op,Min � _...�
20'i well '
Area
2S Alin ( 20' Ex.Shared
Well
a
Reservoir Tank
I
This permit is valid for a period of five years except that it may be revoked at any time if it Is determined thatthere has been a material change in any fad or
circumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.The well shall jbe inspected and approved by Macon County
Public Health before It Is put Into use. The location of the well indicated by MCPH is to provide protection from possible sources oficontamination. Flow volume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?�(828, 9-2490
I
Issue.Date: 10/16/2020 Tanner Stamey, R 2712 Authorized State Agent