GW1-2021-07640_Well Construction - GW1_20211201

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WELL CONSTRUCTION RECORD For Interns]Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook A• ; rr>,s.. ^� . 4.}:: .,;,1 t�.; h.. 4 _{. �•�k,
••F1tOM TO. DESCRUTION
Well Contractor Name 3 Jy,5"1, J rit
2043 A M J t�
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o - ft. ��it, in: vc
an Com Name a ii'i:lo� d
Company `11Ye;Ir : ..EIt? e1YS11!JCki ;.-.:blfV:.t aT f ._ Min
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 9 41 9a I P fc I ft.
List all applicable well permits(i.e.County,State,Variance,Injection,etc..)
ft. ft. . in.
3.Well Use(check well use):
£?•.t€.` E` .'1;; i'i �ei:.�F!�-':i.'y�'zr'�` ,.u•.#,tS`>.'�d."'.a` :i+'Of
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑A ricultural ft. ft. in.
g C7M�u ticipa!/Public ,
OGeothermal(Heating/Cooling Supply) [3ifesidential Water Supply(single) ft• fa in. I
❑hidustrial/Commercial U. ;.N .?l�;=ri `° �.
❑Residential Water Supply(shares!) - ,M ut� ��� a:�rr-s. � �• • -"
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oi ri I_ r ft. a ft.
Non-Water Supply Well: -
OMonitoring ORecove ft. I ft.
.20
Injection Well: ry ft tr, _
OAquifer Recharge OGroundwater Remediation Rl'+a ii b i 'u= :+: ru/:• '- a�yn � J;t;
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology ❑Subsidenec Control ft. ft,
OGeothermal(Closed Loop) OTracer "�•tCb '?'' t�€Lt1�t a '�tim'- f'ro ails"ttt:f :: -air- .� n-•;:�'':z�:.,�t�;t .
FROM TO DESCRIPTION fcolor,hardaMo$111racktype,%rain size etc.
OGeothermal (Heating/Cooling Return OOther(explain under#21 Remarks tr, ft. ( i=
u^
4.Date Well(s)Completed: ft. ft
l Well ID# 11L �{_ t
ft. to
Sa,Well Location: fn ft. t,r�
SEC
ray re AA Ga hn , _ ft. fa ttvrvr<I�ryHl lUl'l i�?Cry;�IP.Ii' ��
Facility/Owner Namo Facility ID#(if applicable)
ft. ft.
226 li�noi Laae_* ft. fa
Physical Address,City,and Zip
a .C'':;;r
County Parcel Identification No.(PIN)
i
Sb.Latitude and Longitude in degrees/!minutes/seconds or decimal degrees: 22,Certification: I
(ifwoll field,one lattiong is sufficient)
N a, j 5 3� 7 W 6✓9 �r� � //-08-_Z0_2 /
Signature ofCartified Well Contraotor Date
6.Is(are)the well(s): OKermanent or OTemporary
By signing this form,I hereby cerl fy that the well(s)was(were):constructed In accordance
with 1 SA NCAC 02C.0100 or I.fA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or 1JK5 copy ofthis record has been provided to the well owner.
If thls Is a repair,fill out known well construclioh information and explain the nature of the
repair under#21 remark T.ecilon 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
S.Number n 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:_few D_5 (ft) 24a. For A We 1 : Submit this form within 30 days of completion of well
For multiple wells list all depths tfdii fereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: . )' p (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Infection 'yells 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: construction to the following:
(i.e.auger,rotary,cable,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) 3 Method of test Air lift 24c.For Water SupL1t�&Injection Wells:
Also submit one copy of this form I 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-1 North Carolina Department of Buvironment and Nahtral Resources-Division of Water Resources Revised August 2013

Q10teer
M��; Macon C o u n t y NEW WELL CONSTRUCTION
ti r d Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Carol McCann • 090821-P • Romy Inv
Single-Family Well Only setbacks Residential • 6591800448 1.47
• • 270 Kooi Lane
' Georgia Road to Left on Tessentee Road to Left on Kooi Lane to #270
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 50'minimum to septic system/repair area.
Diagram (Not to Scale)
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Permitted �a
Well Site !I c
koo� 090821-P i M
ry`a lane
o° 3, 1
e l from C/t (C/l 1
2„� �} N6o' Lli
,l 'c ~� Q�
tV� �O S6, j
Ex.S/T Lr : kv Dry Draw lPower
`f Pole
c - s
la
a 1 fD
Propel 1 ine i a
Z. N 1�
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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
circumstance upon which the permit is Issued. Well location,Installation,and protection must meet state regulatlons.The well shall be Inspected and approved by Macon County
Public Health before It is put idto use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. 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?[phone]
Issue Date: 10/28/2021 Jonathan Fouts, REHS 1979 5 Authorized State Agent
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