GW1-2021-00400_Well Construction - GW1_20211230

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WELL CONSTRUCTION RECORD
This form can be used for single,or mititiple wells For Intemgl Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook
FROM T-0 ~rc DESCRWrION t'
Well Contractor Name 5o ft. /, ft.
2043 A % ft.
NC Well Contactor Certification Number i• :=0 R`t'" f:foiaimi5l $" ( Q )({' �' :r, ),r=¢
FROM TO DIAMETER THICKNESS4 MATERIAL
Dennis Holland Well Drilling, Inc. 6` fr. ft, „ un. X J PVC_
Company Name ;t
'rt IlyCrr� _-t .i' r'
FROM TO DIAMETER'. THICKNESS MATERIAL
2.Well Construction Permit#: Q 4/9��../� to tr. in.
List all applicable well permlis(i.e.County,State,Parlance,Injection,etc..)
3.Well Use(check well use): ft fr.
Water Supply Well: s'B{ I!10.....-
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL ^
OAgricultural OMunicipal/Public fr. fa in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fa In. i
Ohidustrial/Coinmercial %. it' 1t +#";';;,.r.?';.G=I#:a<< F.i`�:''l;';Y. et yr4wr kR•;r ;yt3 esidential Water Supply(shared) +.�5 a a•' t _41 .,•A '_
❑hri alien
FROM TO MATERIAL EMPI,ACEMENTMETHOD&AMOUNT
O ft. ft. `lam'T
Non-Water Supply Well: -
❑Monitoring ORecovery ftaO r ft
Injection Well: ft. ft.
OAquifer Recharge OCroundwater Remediation 'li ' :R/ ?•V .pit;a r, •e'' r g"; t3-=';' sr iw't; =rs3:.,:W ;K%;ts
❑Aquifer Storage and Recovery ❑Sal pity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
ft. ft.
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control to fr
rf a i'9 al.s 'BftT:i . ., s ti r o.i.'::3ti
OGeothermal(Closed Loop) OTracer FROM TO 0 DESCRIMON color hardness,sollfrock type,grain size etc.
OGeothermal Hearin Coolin Return ❑Other ex lain wider#21 Remarks) fr. ft.
ft. ft.
4.Date Well(s)Completed:/02-ZZ-21 Well ID#
i ft. ft.
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Sa.Well Location: `
vFn
ft. ft. D
Facility/Ownor Name Facility ID#(if applicable)'
ft. ft. SECT(
•16C.�t�� l % �»i /�� v�• L e�'f ft. ft. r i' ..r'SS►NG UNf'
Physical Address,City,and Zip
k(+y �: ;,�.;•:;;:, ti„_ '' }a': ,`�'�1�diHr �`iv.'-"•tnE�lvt"-./•t�`:�`i,_.t
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Pareqqq
per,
Comity ol Identification No.(PIN)
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Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Certification:
Signature of Certified Well Contractor Date
6.Is(are)the well(s): (anent or OTcrnporary
By signing this form,I hereby certo that the well(s)was(were)constructed tit accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an exlstin well: OYes or$ &JDio— copy of this record has been provided to the well owner.
If 1h1s Is a repair,fill out known well consrructlon lq ormatlon and explain the nature ojthe
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
8.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. OO SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: LA ?,!:I (ft) 24a. For AEI Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths ljdijjerent(example-3@200'And 2@100') construction to the following:
10.Static water level below top of casing: �� (fi) 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 Welts 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: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,otc.) G
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,!Raleigh,NC 27699-1636
13a.Yield(gpm)_ al ) Method of test: Air lift 24c.For Water Supply&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 to the county health department of the county where
constructed. 0
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

Q�ote�t
�m Macon County NEW WELL CONSTRUCTION
o r Public Health CONSTRUCTION AUTHORIZATION
� r
PRIV TE D NICNG WATER WELL
( a -
Permit Conditions M �^ I u'`t�- �-��� A"
Well shall be constructed in compliance with all NCAC 2C Rules. d S'F.�-, s ,�- _I-,
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
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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 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?[phone]
f&'Nq ?MT 7
Issue Date: //I It /74 _Authorized State Agent
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