GW1-2021-05963_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD
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This form can be used for single or multiple wells For Intemgl Use ONLY: •
1.Well Contractor Information:
Mitchell Dean Cook ,<, ..�1
FROM TO DESCRIPTION
Well Contractor Name ft ft.
2043 A *.' ft rt
NC Well Contractor Certification Number iPl.r0 Rk s' fo>;;iniila'If
FROM TO DIAMETER THICKNESS MATERIAL
Dennis=Holland Well Drilling, Inc. 61
ft.
Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i)6 z 4.,2 ft. fr. io.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): ft fr. 'in.
...:.E�.±^r:;-: ��'''�>,•�;s'.'-��:#�'a;`"'f rp�ii?Y:{,�,s`';..''v.'z��.;P�3�f rs,<.' <` �:�.��."t
Water SupplyWell: FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑A t7CUlhural ft. ft. in.
g ❑Muni ipal/Public
OGeothermal(Heating/Cooling Supply) esrdential Water Supply(single) It, to In.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMETIIOD&AMOUNT
011T, anon o ft. s fr.
Non-Water Supply Well: 41
❑Monitoring ❑Recovery
Tajac"On Well: ft fr.
OAquifer Recharge ❑Groundwater Remediation 11:f't;D!, ?V I✓? A faova 'f;;c ••5=rs •tom'�ih - _; d� %t.;t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidenco Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer at(` 6i'U to`ai.s €ete•.i a '%3 t ,,.ii '•,, 3_�,,n,
FROM TO DESCRIPTION color,bardn aollIn k type,grain size etc.
❑Geothermal Heatin Ccolin Return ❑Other(explain under#21 Remarks tr. ft.
4,Date Well fr. ft.$)Completed:(�JJ",20-,/ Well ID# /V, �/a .
ft. ft.
5a,Well Location: ft. ft.
UIc- lG'�
MCFfh/hcIS�+Cy/v7,2Z ft. ft.
Facility/Ownor arno Facility ID#(ifapplicable)
fa ft. If1$0 fID3ti0I1 f
YYe yo/ /e. c�C/� 7�s,, 1 ft. ft.
Physical Address,City,and Zip
=.:S.iY+''`l'�1} i�2ii'•' •-5-"��If,'tin'�:.iiiL'ei�',L'l`-2�ifs,.�t�'�/ '�'-C�`I'a`�.•�:t
Cowrty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwoll field,one lat/long is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): erma lent or ❑Temporary
By signing this form,!hereby eery that the well(s)was(were)constructed 7rr accordance
with 15A NCAC 02C.0100 or I.SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repAir to an existing well: ❑Yes or ogl o copy of this record has been provided to the well owner.
1jlhls is a repair,f ll out known well consrructlon informatlon and explain the nature of the
repair under#21 remarks section or on the back of lhlsform• 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: 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:P ..�0.,5 (ft,) 24a, &r AU lyelll: Submit this form within 30 days of completion of well
For multiple-wells list all depths ijdljferent(example-3@200'and 2 a 100') construction to the following:
14
10.Static water level below top
of easing: (ft) Division of Water Resources,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 Iniection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cablo,direct push,otc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 069:2 Method of test: Air lift 24c.For Water amply&Iniection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: �2 oz. well construction to the county health J&partment of the county where
constructed. /
Form GW-I North Carolina Department of Eruvironment and Natural Resources-'Division of Water Resources Revised August 2013

Q(otepr
�� .m Macon County NEW WELL CONSTRUCTION
o� ,d Public Health CONSTRUCTION AUTHORIZATION
30 S—0) 5 C'I) PRIVATE DRINKING WATER WELL
in-Wa
Morningstar Solutions Group Inc. I C7QrL l� �L. • 061921-p • 064921-s
Sin le-Fami Well Residential 6534531990 9.41
Wa ah Rd
ah Rd for 7.2 miles to drive on R across from Bantum Bend
Pennit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale)
Well \
Area \
27, 20'
�,20'
\ J--
� - '\ North
25� \
mi \ ;
Ridge \
Proposes \ ro
2 BR 155' \oC,
15' \
min \
f 0' \
STRepair Area+ -; '
60'
_��-----r> \
O r S0, to
stream
This permit is valid for a period of five years except that It may be revoked at any time If It Is determined that there has been a material change In any fact or
dycumstance upon which the permit Is Issued. Well location,Installation,and protection must meet state regulations.The well shall be 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 of contamination. Plow 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?[phone]
Issue Date; 7/17/2021 Justin Mintz, REHS 2177 "--5r L-ed State Agent
a