GW1-2021-00431_Well Construction - GW1_20211206

WILL CONSTRUCTION RECORD For InternqI Use ONLY:
This form can be used for single or Multiple wells-----
1.Well Contractor Information:
A
Mitchell Dean Cook U.
FROM TO DESCRIPTION
Well Contractor Name
f.
2043 A Yo&4AzP1
ft. ft.
NC Well Contractor Certification Number t WO OW
FROM To DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. 419 'o In. , —
"
Company Name I I �
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit fk ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft ft, in.
3.Well Use(check well use):
0
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
ClAgricultural OMunicipaVPublic ft. fL in.
OGeothermal(Heating/Cooling Supply) GHICe—sidential Water Supply(single) ft. fain.
01ndustrial/Commercial OResidential Water Supply(shared)
OIrrigation FROM ft. TO fr. MATERIAL! I EMPI CEMENT METHOD&AMOUNT
Non-Water Supply Well: .604*,Vkl�,J a -,6,,2
opri 3 .
in ft ft
0 m 011ecovery At 6 0
Injection Well: ft. ft.
i 0Aqufei Recharge OGroundwater Remediation ...........
0 Aquifer Storage and Recovery 08alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test CiStomwater Drainage ft. ft.
OExperimental Technology OSubsidence Control to ft. i
OGeothermal(Closed Loop) OTracer —FROM TO DESCRIPTION(color,hardam solVrock type,e
rain atu etc.
ocleothermal Heatin Coolin Return) 00ther explain wider#21 ft.
Remarks)
ft. ft.
4.Date Well(s)Completed: Well ED# A6/
5a.Well Location: A ft. ft.
ft.
9 0 A ag­7' W'a.a't- ft. 7021
Facility/Owner Name Facility ID#(if applicable)
ft. ft. T
Physical Addreis,City,and Zip
A4 9.2 ajn
Cowlty Parcel Identification No.(PIN)
ie
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
7 N C_Y 9. W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 05firmanent or OTemporary
By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or -SVo-- 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 tinder#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
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: -ft.) 24a, For AU 3yglls: Submit this form within 30 days of completion of well
For multiple wells list all depths if&fferenr(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3,0 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 InieEfion Wells ONLY: In ti'ddition 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 Witter Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n,Yield(gpm)_ 25 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: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Dep artmont of Environment and Natural Resources-Division of Water Rosourcas Revised August 2013

i r -
QtoteC-r
a� Macon County NEW WELL CONSTRUCTION
�d Public Health CONSTRUCTION AUTHORIZATION
�y a' PRIVATE DRINKING WATER WELL
-------..........._...........------ - ...
i Robert Wooten • 110120-p • 110220-s
Single-Family Well Only Residential • 6585492630 11.38
• • Off Misty.Morning Drive
' • 28N to L on Lee Talent Rd to L on Mist_ Mornin Dr cross branch site on L
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale)
80'
------------------
-r
r Drive
25' � r
Repair Area r
A Large proposed 3 BR
Maple
r-- -----�
65'
ST
93' Ex. Fill
O Large Maple 25'
1
'
Drive ` �� 30'
kOver50' 60' 40'
50,
1
` 90'
Stream
Culvert
i
This permit is Valid for a period of five years except that it may be revoked at any time if it is determined that ikere has been a material change in any fad or
circumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.The well sha16e 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.
f
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]
7 Issue Date: 12/17/2020 Justin•M'intz, REHS 2177 Authorized State Agent
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