GW1-2021-00179_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells w For Intemyl Use ONLY: z,
I.Well Contractor Information:
Mitchell Dean Cook � : =--m *_.�, hv: t • ;:.; � ,, . �• ;. x�i;t. �t.
' �FROM TO DESCRD)TION
Well Contractor Name ft.
2043 A �� eft. ft !�
NC.Well Contractor Certification Number !STIn_�4t $ t." oi+ii$itl
FROM Dennis Holland Well Drilling, Inc. TO DIAMETER THICKNESS MATERIAL
. fr.Cum 2 ft. TE„rn,
Company -. .
P YName ::1', A. ,E �C•i1e�(lY_CY,iO. •.8 _t' t'i _ e iiP l`'' `i E-�:� �a:rss';'%�-��?;ifi
FROM TO DIAMETER THICKNESS -MATERGII
2,Well Construction Permit#: ?_� — /J _ ft. ft, in
List all applicable well permlis(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): ft. ft, in.
�'(�A;:i�t:i•iti�^•'r''n�?.?;4r�t,'.fi?;[�iy:%iv:,`',,F•y':rtt2 *rcSa S'.13,c. '• :'y�Vs+-.x'l-';".'�_I
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural CMunicipaVPublic fr. ft. in. I I
CGeothermal(Heating/Cooling Supply) Ukesidential Water Supply(single) fr. fa in. I
Cindustrial/Commercial '.:.N'r v'=' <rt %i'z:rt:iak" z {s :tib e;sl s:fta i' ;4r 'sei
❑hri ation
CReSldelitlal Water Supply(Shared) •FROM TO MATERIAL EMPI.ACEM ENT METHOD&AMOUNT
� �
Non-Water Supply Well: ft. fr.
5 G9M
❑Monitoring ❑RecoverY r ft. ft
Injection Well: ft fr.
CAquifer Recharge OGroundwater Remediation
CAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 1 EMP.LACE51ENTMETHOD'• i
ft. ft. i
CAquifer Test ❑Stormwater Drainage
CEx erimental Technolo fa tt 1 3 p gY 'CSubsidence Control
4;.q`�.R._• f rD: x h h: Ho' .a �er6: ;, :ulv r n r ,�;p:. .;tl
CGeothermal(Closed Loop) CTlscer FROM TO DESCRD'T[ON color,hardo solUrock type,erala•size'etc
CGeothermal(Hn—tingtCOOliMEEturn ❑Other(explain under g21 Remarks) ft. ft.
;,�;:•,l
4,Date Well(s)Completed: fr2�Z2J Well ID# Al. /A
ft. ft. .
Sa,Well Location:
` ft. ft,
9 o-j l'r7 Q A A r ft, ft,
Facility/Ownor Name Facility ID#(if applicable)
ft ft.
l"lx+•t al r��b , >w..4 /�� za be ft. ft.
Physical Address,City,and Zip
��� •1' S�. f-#��� .'}$ '} lid:: `' bi,Z)�.i"�5�.�'��'�(J,LR.YU_{
h�. ZA.
Cowtty Parcel Identification No.(PfN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if woll field,one lat/long is sufficiout)
Signature of Certified oll Contractor Date
6.Is(are)the well(s): QWrmanent or []Temporary
By signing this form,I hereby cerl(fy that the wells)was(were)constructed In accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 10Yes or [ZlNo�- copy ofthts record has been provided to the well owner.
If Ihts Is a repair,fill out known well construction information and explain the nature of the
repair under#21 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
S.Number wells constructed: construction details, You may also attach additional pages if necessary.
For multiple innjection 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,) 24a. Ur Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200'and 2 tt 100) construction to the following:
10.Static water level below top of casing: / ' (ft,) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6x I
(in.) 24b.For Inie iog 3yeLs 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,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,jRaleigh,NC 27699-1636
13a.Yield(gpm)_ / Method of test: Air lift 24c.For Water SuRply&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 Lrnviroament and Nantral Resources-Division of Water Resources Revised August 2013

CLAY COUNTY HEALTH DEPARTMENT COUNTY WELL PERMIT#:
ENVIRONMENTAL HEALTH DIVISION
PO BOX 55 HAYESVILLE,NC 28904 022-1 13 6
PHONE[phone] FAX[phone]
PACE#2 —CONTINUED--
SITE PLAN
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Owner's Name:TOM MARSHALL
Property Location: THUNDERSTRUCK LANE—LOT#14 PIN#:'651300812126