GW1-2022-01866_Well Construction - GW1_20220216

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemal Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cookr
4� �0.:... i -�L h�1�4:{•r 5£ f Y.- 'tF'ii,,'.7
FROM TO DESCRIPTION
Well Contractor Name A ft, Q .ft.
2043 A FEB 1 G 2n22 ft. ft.
NC Well Contractor Certification Nwnber t:; i r-3 ..1 e'iu .^+� 1.7ti'. 015::01-%11 t' -foy,mi55tt
�SsMr'i317t'� FROM TO DIAMETER THIC[NESS MATERIAL -
Dennis Holland Well Drilling, Inc. a . fr. 99. ft, 6„ -2 f G
Company Name - _
'F1' I;1ZG�AS _fY`c� 's= .
FROM TO DIAMF.TF.R THICKNESS MATERIAL
2.Well Construction Permit#: / //_7 fa ft.
List all applicable well permits(i.e.Counry,State,Variance,injection,etc.)
f0. ft in
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT 3IZE I THICKNESS I MATERIAI,
❑Agricultural OMunicipal/Public tt. f, In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fa in. i
<-
i
❑ ustrial/Commercial 011re—sidential Water Supply(shared) '•1$�013'❑1171 atlOn �.€
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
O . 3,
Non-Water Supply Well: ft. ft. r .3• .5 ir,
❑Monitoring ORecovery ft. fL , 4h,
Injection Well:
OAquifer Recharge OGroundwaterRemediation >1 r 7PJiCo1F.1, i e: _v% @,,•s`",^%`.r.r 4t.: f'
OAquifer Storage and Recovery ❑Salinity Barrier FROM -TO- MATERIAL I EMPLACEDtENTMETHOD
fr. fr.
OAquifer Test OStomtwater Drainage
erimental Technology ft ft,
OEx
p gY OSubsidence Control _
OGeothermal(Closed Loop) ❑Tracer 2Qi: R xLrfl. ?Y h a '"c .a ii l"a`als7reo'ts'f iii"'"` ;;;i YY;�y,:cYd frl:'.C+sj�:.:
FROM TO DB,SCRIP'r[ON color Garda aofUrock rain a'ae etc.
❑Geothermal Heaiin Coolin Return ❑Other(explaintmder#21 Remarks) ft, ft.
rt. ft.
4.Date Well(s)Completed:G1.2 02-aa Well ID# IV,IA.
rL ft.
Sa.Well Location:
to fa
ft. ft,
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Gl FF ,-'IVOGte IV,ZZ t� fL IL
Physical Address,City,and Zip
Cowuy Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one lat/long is sufficient)
70 ,3 7 7 N —�3 e1V o5.3 56 w i t
` Signature ofCortified Well Contractor Date
6.Is(are)the well(s): "I ;manent or ❑Temporary
By signing this form,1 hereby cart fy that the well(i)was(were)constructed in accordance
with 15A NCAC 02C.0100 ar ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or copy ofthis record has been provided to the well owner.
If dtls 1s h repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks section or on the backofthisform, 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: $d (ft,) 24a. For AR Wells: Submit this form',within 30 days of completion of well
For multiple wells list all depths tf&Ifferenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing; d ' (ft.) Division of Water Resources,'Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service.Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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,Raleigh,NC 27699-1636
13a.Yield(gpm)_R D Method of test: Air lift 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 2 OZ• well construction jo the county health department of the county where
constructed.
Forst GW-I North Carolina Department of Euviroumeut and Natival Resources—Division of Water Resowrosl' Revised August 2013
i

Qroce�r
Macon County NEW WELL CONSTRUCTION','
E d P CONSTRUCt'ION AUTHORIZATION''
EMAILED PRIVATE DRINKING WATER WELL
CCIS,LLC • 121121-P • 122221-5
Shared Well, Residential ' 6588428384MM 11.27
• • Off Snow Hill Road
F
' • 28 N to R on Cowee Creek Rd. to L on Snow Hill Rd. to L on new gravel drive just past old white church to site on L.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well to be drilled on property.
Well is to maintain at least 100'to any part of the proposed septic systems or will invalidate permit as a shared well.
Any questions call MCPH.
Diagram (Not to Scale)
PL
IP
40
Proposed
Well Area 3'
51 x
y
n,
m
100'from
Proposed
0SWW
Area
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. TIONS?(82 349-2490
Issue Date: 1/4/2022 Tanner Stamey, REHS 712 Authorized State Agent