GW1-2021-07848_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intomill Uso ONLY: z
I.Well Contractor Information:
Mitchell Dean Cook g E rteSE1212 .4 ,.Y;s v, ° , {I f . Y:3 _tea;: � f i�I rr3: ;►
FROM TO DESCRIPTION '
Well Contractor Name t/✓r r ft Ap
2043 A •7ft. ft.
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a - ft. A ft 4 10V in: e.
Company Name
FROM TO DIAMETER THICKNESS r` MATERIAL
2.Well Construction Permit#: ©7/ �oZ / -� fa fr. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
3.Well Use(check well ft fr, tn.
use): •.; I:IY ;;?;' ::sf�>_rrisi'r,-',;` ti',i;�v:,•.. .h adz ,+rt3 °Bru�c .drs>:=r f;�.r'A..
Water Supply Well: FROM I TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural OMunicipaVPublic ft, ft. in.
OGeothermal(Heating/Cooling Supply) Iidential Water Supply(single) ft, ft, in.
Oindustrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fr. �£t.
Non Water Supply Well:
OMonitoring DRecovery ft. 1 ftAoaa
Injection Well: fr. ft.
OAquifer Recharge ❑Groundwater Remediation rF�'+;
1...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
ft, ft,
OAquifer Test OStormwater Drainage
erimental Technology ft ft
OEx
P gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer "' .._FL 1B. 't" Hoiaels`'f•f , �; k�, . ,.,i a ;;,
FROM TO DE•SCRIMON color,hardoM soll/rock size etc.
OGeothermal Heatin Coolin Return OOther ex lain under#21 Remarks) fr. ft. r�tC
ft. ft. n
4,Date Well(s)Completed: - - Zf Well ID# A /A.
ft. fa �'• n
So.Well Location:
Jus-kji Lra, / fr. fa ;.,•err ;. tiG
�,�-;Y Facility/Owner Name Facility lDt/(if applicable) ,
£t. ft. ,t, ,otl
_780 ft. ft.
Physical Address,City,and Zip ���v
<( i' n[V�is:•' v C Y�: S fi.2. .'�5 n v`i[`L.j't -<lfc5! 'ct•'; '?"4',4
/VI a GOdZ 75 a lE T1a D5L-1 4TI
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County Parcel Identification No.(PIN) v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wolf field,one lat/long is sufficient)
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Signature of Certified Well Contractor Date
6.Is(are)the well(s): immanent or OTemporary
By signing this form,1 hereby cerl fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or XV10 copy of this record has been provided to the well owner.
Ifthis Is a repalr,fill out known well construction information and explain the nature of the
repair under#21 remarks.sectlon 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
FNumber wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injectton or non-water supply wells ONLY with die same consbucdon,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. Lor AD Well : Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100) constnuction to the following:
10.Static water level below top of casing: I o10 (pG) 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 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
(i.e.sugar,rotary,,cabiou lo,direct push,etc.).Well construction Rotary construction to the following:
method:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ Method of test: Air lift 24c.For Water Sugply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b,Disinfection type: H & H Amount: 2 OZ. well construction t� the county health Iepartment of the county where
constructed.
Form GW-t North Carolina Department of Environment and Nahnal Resources-Divisioh of Water Resources Revised August 2013

ajotect
�m Ma con C o u n t y NEW WELL CONSTRUCTION
o ,m Public Health CONSTRUCTION AUTHORIZATION
'a a' PRIVATE DRINKING WATER WELL
Justin Land • 071721-P • 021821-S
Sin le-Famil Well Residential 7524725131 26.69
• • 780 Cedar Wood Drive
• Highlands Rd.,L on Walnut Creek Rd., L on Ledford Branch Rd., R on Coman Rd., R on Cedar Wood Dr.,stay R at the
fork thru gates and go to very end.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Any questions call MCPH.
Diagram (Not to Scale)
S
\ o OSWW Repair Area
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food >100'
Gdol
/ l Spring
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>25'
Poplar
c Well Area
a 5'x 5'
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 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. 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?(82 49-2490
Issue Date: 10/25/2021 Tanner Stamey,REHS 27 uthonzed State Agent
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