GW1-2021-00403_Well Construction - GW1_20211230

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WELL CONSTRUCTION RECORD For Intemtl Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
•-FROM TO DESCRIPTION
Well Contractor Name O ' ft. ft
2043 A l9 'ft. , IL
NC Well Contractor Certification Number id l+i LR'`"1{11i _foc'iii'"u]"`'"s .F{Ulii!.o1I2Il. t i:' cab
FROM TO =DUMETERTAICIWESS MATERIAL
Dennis Holland Well Drilling, Inc. ft , ft.Company Name
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: LDd/,;Z/ _/� fa ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) {t ft,
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) t�sidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =" '`�yr _
*,� FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Lli at10n
a , ft ft
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediationii "1+(D/ 'VIRAIKr t cr b e'`
• ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft. ft. MATERIAL EMPLACEM1IENiI'METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control .,- 6NIMA
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIMON color,hardam sollfrock type,erain aim etc.
❑Geothermal (Heating/Cooling Return []Other explain under#21 Remarks) ft• ft.
ft. ft.
4.Date Well(s)Completed: �.?-/2a2/Well ID# /�.�,4, ftft. 6
�^ }
So.Well Location: a
/ ft. f
6 cis+ry f�S 6 dJ-I/L Eul&fle c try: 1A, ft. fL
Facility/ wnerName Facility ID#(ifapplicable) {p ft.
y� rt '..
J20 L/.//aaa Azz ft ft.
Physical Address,City,and Zip duly {
737
/4QrrA _ ti59/5��i9��G
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
�_� Signature of Certified Well Contractor Date
6.Is(are)the well(s): Mffrmauent or ❑Temporary By signing this form,I hereby certo 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: ,❑Yes or 111?167 copy of this record has been provided to the well owner.
If this 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
8.Number of 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: .2/JS-' (ft.) 24a. For AD Weill: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-3@200'and 2@100') construction to the following: I
10.Static water level below top of casing: 1/J' (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: 6" (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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,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) 16/) 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.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

�� •m Macon County NEW WELL CONSTRUCTION
o �d Public Health CONSTRUCTION AUTHORIZATION
," • a' EMLLEq PRIVATE DRINKING WATER WELL
W10_
uglas Odell Lewis • 100121-P • N/A
Village RoadWell, Residential • -IL65914 99836 0.96
st Hickory Knoll off Hickory Knoll,turn R on Old Cabin Rd., to strai ht onto Village Rd., first on left.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
r '"
Diagram (Not to Scale)
O`a Cabe�d' •
House
r�umbing observed
Drive
X Y 92'
35 05'57"N
83 21 53-'W
�° Propo
� Well 25'
Shed
80,
P
N
Angle Iron Pipe
r
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]
Issue Date: 11/13/2021 Charles Womack, REHS 1300 OIL n 01,1070rized StateAgeift
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