GW1-2021-02217_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook FROM TO DESCRH'1'I r WTI
.FR - ON
Well Contractor Name .eft 46 ft
2043 A �r�r'ft g6't�i ft
-
NC �r .
NC WeII Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 0 , �, ft. .,4�5 in. 4�--X
.
Company Name 13 -
t e ecl 1.b. _
FROM TO DIAMETER THICKNESS MATERIAL
2.WeII Construction Permit#:-io 7,o20-2, /0 ft ft. in.
List all applicable well permits(I.e.County,State,Variance,Injection,eta) ft ft. in.
3.Well Use(check well use): s WOO u r � •;f�Water Supply Well: FROM TO DIAMETER', SLOT SIZE THi KNESS MATERIAL
ft. ft in"
OAgricultural OMunicipallPublic
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft In.
Olndustrial/Commercial OResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMETIiOD AMOUNT
OIrri ation ft. �9 ' ft. _
Non-Water Supply Well:
OMonitoring . ORecovery 3 ft ft
Injection Well: ft ft. i
❑Aquifer Recharge OGroundwater Rentediation ;1 Y "?1Y L.,` Ra d b b -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL EMPLACEMENI'METHODft. ft.
OAquifer Test OStormwater Drainage ft ft
OExperimental Technology OSubsidence Control
s +3f,D�;r! '� md.1' �h to f `;�''•'
OGeothermal(Closed Loop) OTraaer FROM TO DESCRn''I'ION Nolor hardyem solltreck type,araim size etc.
OGeothermal Ileatin Coolin Return OOther(explain under#21 Remarks ft. ft
` J ft ft
4,Date Well(s)Completed:O?j�17 Well ID# _/--y .. ft ft
So.Well Location: ft. ft
ft. ft
Facility/Owner Name Facility ID#(if spplicable)
ft ft.
ft ft lotorrr atlon prat;i=ssing t
Physical Address,City,and Zip _-f«r: �: h
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minu s/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 3
w h�.,, .,�'���1 � ram: ca 7-
Signature ofCertified Well Contractor Date
6.IS{are)the weli(s): immanent or OTemporary By signing this form,1 hereby cerio that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or AN copy ofthis 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 con0wcdan,you can
submit axe form. SUBMITTAL.iNSTUCTIONS
9.Total well depth below land surface: a.!9 f� (ft.) 24a. For Au Wells:' Submit this form within 30 days of completion of well
For multiple wells list all depths if dfferent(example-3(a)200'and 2@100') construction to the following:
10,Static water level below top of casing: (ft.) Divisioh•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.Eor Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 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: j
(i.o,auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -S Q 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 Department of f?nvironment and Natural Resources-Division of Water Resources Revised August 2013

Qjoteer,
�m Macon County NEW WELL CONSTRUCTION
C J Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Brian Jenson • 072020-p • 041121-s
Single-Family Well Residential 7513740163 1.5
• • Off Peaceful Cove Rd ^
' Highlands Rd to R on Peaceful Cove Rd to first L property on R
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Property lines were not marked between adjoining lots. The well area may or may not be on the same parcel as the camper.
Diagram (Not to Scale)
Fence/property line as per Brian Jenson 7/28/16 30'
..—..—..—..—. E"-_'.* Rebar
" —..—..—..—. — 5'min
well 20' 25'
Area 100, 75'
10, 25'rain Proposed 75 16 i Fence Well for Sawmill
IpO. RV Shed -air Area
Rep �E ' Over 100' `
75' i
Q ST ' _._.
PT Fence
Power Pole
147'
> N
0
Existing Well
XN
W
Existing Gravel Road
—� Cullasaja River —�
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: 4/26/2021 Justin Mintz, REHS 2177 /YG.,a" AC— Authorized State Agent