GW1-2021-00178_Well Construction - GW1_20211213

4
ELL CONSTRUCTION RECORD
this for ca m n be used for single or multiple wells For Intemgl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
IPT
Well Contractor Name FROM TO DESCR ION
1
2043 A a: ft 71 ft-
ft.
NC Well Contractor Certification Number IS 01J RR ffl oX,mtil" 3' S'''s'p' 'IN . (I'{`` "Pcd , ti ;y,..#<;•,. ._?
FROM TO DIAMFTERI THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc.
D . rr, ;
Company Name ✓C' ft. Lin. J
1:6iT1�INN RR;G•ASIty� .. .:IITFI z` 0,1..erniel'c1.oied:+I.'.
2.Well Construction Permit#: 'he' _ FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable well permits(i.e.C.aun%,State, Variance,Injection,atc) ft, ft.
Ct. ft. in.
3.Well Use(check well use):
FROM TO DIAMETER ISLOTSIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft, ft. in.
OGcothermal(Heating/Cooling Supply) esidcntial Water Supply(single) rt ft. in.
Olndustrial/Commercial OResidential Water Supply ll (shared) ;G Q •T N. L., >„ ••.
11 Y t
❑lt•rri ation FROM To MATERIAL I EMPI,ACEMENTMETIIOD&AMOIINT
Non-Water Supply Well: D ft. ft.
OMonitoring ORecovery ft, ft.
G
Injection Well: fr fr.
OAquifer Recharge
OGroundwater Remcdiation 19 Dld ?,Vi
OAquifer Storage and Recovery 08alinity Barrier FROM To ^uTERIAL EMPLACEMENT METHOD
OAquifer'fest tr. fr.
OStormwatcr Drainage
❑Experimental'Iechnolo ft. ft.
gY ❑Subsidence Control
OGeothermal CI 19,"]Ri44(Closed Loop) Cs, H'6 iiid tioael.sY; <,,::i .,r, 'i'p) OTRtC07 ,bROM TO DESCRIPTION color hardy aolVrock rain alze etc.
OGeothermal(Heating/Coolin Return pother(explain under#21 Remarks) ft• fr.
4.Date Well(s)Completed: Well ID# /t/' //
ft.
Jif ft ft
Sa,Well Location: y
ft. ft. ��_ . . i; •41-�
Facility/Owner— Name
Facility ID#(if applicable) - DEG 3„_2•24- _—
f
ft.
Physical Address,Cory,and Zip ft
ii �+y�C`..t..:::f
Cowtry - / s [ -a
Parcel Identification No.(PrN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '^' / h/
(if well field,one lat/long is sufficient) 22.Certification:
�j�� �� J
N WtLlr/
Signature of Certified Well Contractor Date
6.Is(tire)the wcll(s): fd•Pe-rmanemt or ❑Temporary - '
By signing this form,I hereby cerll/y that the well(s)was(were)constructed Jn accordance
7.Is this a repair to an existing well: OYes or 10? with ISA NCAC 02C.0100 or I.SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repatr,fill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.Number of wells constructed:
You may use the back of this page to provide additional well site details or well For construction details. You may also attach additional pages if necessary.
multiple injection or non-water supply walls ONLY with Ilse same construction,you cnn
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft,) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') constniction to the following:
i
10.Static water level below top of casing: 141 (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" (iu,) 24b. For In'ectiom 3Yelis ONLY: hi 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 Well construction cable, method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.)
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 Supiply&Injection Wells:
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

• _ ' i
i
CLAY COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH DIVISION COUNTY WELL PERMIT#:
PO BOX 55--HAYESVILLE,NC 28904 #022-1111
PHONE[phone] FAX[phone]
PAGE# I
PERMIT TO CONSTRUCT OR REPAIR PRIVATE DRINKING WATER WELL
NEW: a REPAIR: VARIANCE: F-1 ABANDONMENT: El
ISSUED TO: KENNY LEDFORD
PROPERTY 241 THUNDERSTRUCK ROAD,ACROSS RIVER APPROX'/4 MILE ON RIGHT
LOCATION:
SUBDIVISION: N/A LOT#: N/A
TYPE OF STRUCTURE AND/OR FACILITY SERVED: SINGLE FAMILY RESIDENCE
WELL CLASSIFICATION: PRIVATE
CONDITIONS:
• PROPOSED WELL AREA AS INDICATED BY OWNER FROM SITE PLAN.
• STAY 25' OFF ALL PROPOSED STRUCTURES,AND 25' OFF CREEKS)AT ALL TIMES.
• MAINTAIN 50' OFF ALL PARTS OF THE SEPTIC,INCLUDING TANK.
• SEPTIC LOCATED ON OPPOSITE END OF HOUSE THAN PROPOSED WELL.(4"PVC
PLUMBING OUTLET LOCATED)
This permit is valid fora period of five years from the date of issuance 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 was issued. Well location,
installation,and protection shall meet all state rules and regulations. Well water quality and yield,during the entire life service of
the well,is NOT guaranteed by the issuance of this permit,Clay County Health Department,and the State of North Carolina.
O 8 oG Jaa l
l
AUTHORIZED STATE AGENT DATE
REVISED 12129120

. .. , fie
K
CLAY COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH DIVISION COUNTY WELL PERMIT#:
PO BOX 55--HAYESVILLE,NC 28904 #022-1111
PHONE[phone] FAX[phone]
PAGE#2 --CONTINUED--
SITE PLAN
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Owner: KENNY LEDFORD PIN: 651300910682