GW1-2022-01869_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD
7111s form can be used for single or multiple wells For Internal Use ONLY:
1,Well Contractor Informal'
oD: n "< j
Mitchell Dean Cook " `'� 9}WAFR2OIYES
r l r
FROM TO DESCRD'TION
Well Contractor Name r-110 1 ra V-1__ ft.
2043 A �., ,
Inic aL � : �:� t r,Ur�i> rr tr
NC Well Contractor Certification Number t 'Q/iy�G
CY. 15 Q[1 .+R +hSTNiG fo�,milti cksdl�, Ue Q�t SINE
FROM TO DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. a ft. o ft ,n
Company Name / G
'-1r1, !sR`CA51Nf;bit>Ttllf G'`a'dt`hertria ZI'.�13o r, .:._.
FROM TO
2.Well Construction Permit#: DIAMETER, THICIQVESS MATERIAL
O 9D 7,2_L/d tr.
List all applicable well permits(i.e.County,•State, Variance,Injection,etc.) ft. in.
ft.
3.Well Use(check well use): ft. in.
is [ '
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIIICKNEss MATERIAL
❑Agricultural ❑Municipal/Public ft• fr.
DGeothenmal(Heating/Cooling Supply) DResidential Water Supply(single) tt. ft. in.
Dindustrial/Commercial EIR6ssidential Water Supply(shared) 18.t R4Ut .+., :rL.< .;,i➢,.,. "^,. ;?,.
❑irri atietl FROM TO 1 MATERIALS EMPI.ACEMENTMETIIOD&AMOUNT'.
Non-Water Supply Well:
.S 4
❑Monitoring GRecovery to ft.
Injection Well: ft, fr.
OAquifer Recharge OGroundwater Remediation +pri�lC'if n Ilea a,Y
DAquifer Storage and Recovery CSulinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. fr.
OAquifer Test DStornuwatcr Drainage
to
DExperimental TechnologytL
L�Subsidence Control
DGeothermal(Closed Loop) C11'racer Z0;Wit L>�N.t h(`r'attecW1 art 6*
FROM TO DE,SCRD'rTION color Endo soiVrock nln eiu etc. '
DGeothermal Heatin Coolin Return ClOther(explain under#21 Remarks) rt. to
tr.4.Date Well fr.
s)Completed: p .z Well[D#_ ,
fr. ft.
SR.Well Location:
ft. ft,
/r_ A/,4. ft. ft.
Facility/Owner Name Facility ID#(if applicable)
�fl, ft.
yr o r.i/ wpQ�.s n FF ,S k�>e yA�• r,. rL
Physical Address,City,and Zip
lL1 a ccth �5 7�'�9500
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
i
3S" >a/9
Signature of Certified Well Contractor Date
6.is(are)the well(s): f�manent or OTcmporRry
By signing this form,!hereby cart fy that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYcs Or t f'Qo 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 this form. 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 some construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9,Total well depth below land surface: 1z'O5 (ft.) 24a. For All Wells: Submit this fbrm'l,,within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3 td 200'and 2@100') construction to the following:
10.Static water level below top of casing: at'od (fL Division of Water Resources;Information Processing Unit,
If water level is above rasing,use"+" ) 1617 Mail Service Center,`Raleigh,NC 27699-1617
11.Borehole.diameter: 6" (iu.) 24b.For Infection Wells ONLY: in adiiition 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: ry construction to the following:
Ge.nuger,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
13.9.Yield(gpm) 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.
F'orni GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resoturcos Revised August 2013

i !
M a c o,n County "C REQUIREMENTS FOR FINAL INSPECTION
e Public Health FEB 1 5 2O22 PRIVATE DRINKING WATER
Lr`r ENVIRONMENTAL HEALTH
�j1°a�rx i 1830 LAKESIDE DRIVE"FRANKLIN,NC 28734
PHONE l8281 349-2489 FAX[phone]
APPLICANT/ r T�OWNER PDWW# iQ-/0 Z/ /
LOCATION PI N laS77 Z3S 95C��.
DIRECTIONS ��� �� Ad
WELL DRILLER CFRTIFI TION#
WELL DESIGN %OEW ❑ REPAIR ❑VARIANCE FACILITY: ❑SINGLE FAMILY MULTI FAMILY ❑ NON-RESIDENTIAL
i
• • ' • The Macon County Environmental Health Department has conducted a grout inspection for this Private
Drinking Water Well and finds that the following items(checked items)are necessary requirements before
final inspection (well head inspection)can be conducted. The property owner or representative should
contact this office when these items are completed. If any questions,please contact us:[phone].
{ House and Driveway Placement L OSWW System Location
Well Construction Report GW-1 / \ Water Sample
❑ Well Abandonment Report GW-30 ❑
Well Head Completion ❑
Original Notice:
%DELIVERED TO: El FAXED TO: ❑CALLED: El PICKED UP AT OFFICE:. ❑(E)MAILED T0:
❑ Owner ❑'Representative A Driller
Casing Depth: L '(7 ��� GPSCoordinates• 35° Ins Lki DICIS- '1
Comments: 83°02(0 'l- 1113 (D
Date: / Z,s ,E (Authorized State Agent)
11 - • 1 9 At the time of the well he ion (fina(i ction)t o owing items(checked items)were
missing or incomplete and must be completed before a certificate of completion can be issued.
When items are completed or if any questions,please contact us: [phone].
❑ Well Plate ❑ ❑
❑ Pump Plate ❑ ❑
❑ DELIVERED TO: ❑FAXED TO: []CALLED: ❑PICKED UP AT OFFICE: ❑(E)MAILED TO:
❑ Owner 0 Representative ❑ Driller
Comments:
k
Date: (Authorized State Agent)
Well Head Date of Compliance: EHS Initials:
f
Water Sample Collected (D/T): / To Local Lab(D/T):, /
Released to State Courier(D/T): / EHS Signature: