GW1-2021-05964_Well Construction - GW1_20211025

-SWELL CONSTRUCTION RECORD
For intorngl Use ONLY: "
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook ' : .:.. � .,> ;..,a
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2043 A 3"A0"1- 1 ft' �
NC Well Contractor Certification Nwnber
'15i<L ,, i:fo.,jm.... ,t i. ...a Q IN. 1g1 i t .cd'e ma
FROM I TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. O ft e ft. _ :, iln.
Company Name YiT. t• e
's:�l IY R�C•AS •$ .(�. "0 'a t'g' ;~.'b �v#�.�.. -r,3 ,.,y.m..,.s..
FROM TO DIAMETER' THICKNESS r MATERIAL '
2.Well Construction Permit N:_LI j ft. 1t. !Ia.
List all applicable well perm is(Le.County,State, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER I lSLOTSIZF. I THICKNESS i MATERIAL
❑Agriculhtrsl gM�/unioipaUPubiic ft. ft. to
OGeothermai(Heating/Cooling Supply) t�Residential Water Supply(single) ft. ft. In.
❑hidustrial/Commercial ❑Resideutial Water Supply(shored) j N-�- ..NJ+.�.2�t e�^'..}3i �.v. :a.�i4rl,Y t:.ir<e`.)-'.•i"'A Rf nt'.tU.) `�Y'��»',"k k•,- y 'i
3„FR M[. I TO MATRRiAL EMPIACEMENTMETIIOD fi AMOUNT
❑Irrf anon .ft. ft. fn f
Non-Water Supply Well: ft , tc
OMonitoring ORecovery -'" w r
Injection Well: fL ft.
gAquifer Recharge OGroundwater Remediatiou
FROM TO MATERIAL EMPLACEMENT METHOD
gAquifer Storage and Recovery 08al pity Barrier ft, ft,
OAquifer'rest gStormwater Drainage R fi
OExperimental'rechnology USubsidenco Control
4;5?X #):t}Cs 'aFf`b tiitl2t `iivat.9
OGeothermai(Closed Loop) OTracer FROM TO DESCRIPTION color,bardo aoll/mck type,arain lira Ole.
OGeothermal Heatin Coolin Return 00ther "plain tuider#21 Remarks) ft. ft. an
ft. ft.
4,Date Well(s)Completed: Well ID# /y� A ft. ft.
$a.Well Location: ft, ft. 1t
t,on proces
Facility/Owner Name Facility ID#(ifapplicabll+e) ft. ft.
Physical Address,City,and Zip gg��'� ^y, ��� 2t't i'
it Ago,
County parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
� ��/ Srgnattua of Certified Wall Contractor Date
6.Is(are)the well(s): "rmanent or 13Temporaty By signing this form,1 hereby cerify that the well($)was(were)constructed In accordance
with 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well; ❑Yes or 1]*N&-- copy ojthis record has been provided to the well owner.
If this is a repair,flli out known well construction information and explain the nature of the
repair corder 421 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
8.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: (ft,) 24s. Fo All WeIIY: Submit this forin within 30 days of completion of well
For multiple wells list all depths iirdi ferent(example-.3@200'and 2@100') constttction to the following:
I
10.Static water level below top of casing: 2,Q (ft.) Division of Water Resources,'Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Cente`,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (iu.) 24b.For In'ecti n Wells ONLY: hi addition to sending the form to the address in
RO�c� 24aabove, 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 Centel',Raleigh,NC 276994636
13a.Yield(gpm) _� Method of test: Air list _ 24c.For Water Su &In'ection W IIts',
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 2 Q�• well construction to the county health department of the county where
constructed.
t
Fort GW-I North Carolina Department of Envirouonent and Natural Resources-•Division of Watcr Resources Revised August 2013

f
a'
Q(Otecr
�� Macon County NEW WELL CONSTRUCTION
o " Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
l Smith • 081921 P • 083320-S
jt645
le-Family Well, Residential • 6568715064 4.85
Sunset Trace Trail
to L on Iotla Church Rd., stay on Burningtown Rd. to Lower Burnin town Rd:, R on Sunset Trace TH. to#645.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Any question call MCPH.
Diagram (Not to Scale)
Proposed
Well Area
PL
Sign 2S'
Grave1 r'-vewa R�
Y
t
- 122'
ti
4
m
ti
v
C
Ex.ST
r —OSWW Initial& ,
Repair Areas
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 fad or
circumstance 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 oflcohtamination. 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. QU S?(828) 49-2490
Issue Date: I.0/7/2021 Tanner Stam�y REHS 2712 / !�'.' LAG uthorized State Agent
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