GW1-2021-02496_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD For IntemOl use ONLY:
Ibis form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook i�a;� ;MIX :ft r�.,<-ic�t.:rci3y1��,. �..��t1::
FROM TO DESCRIPTION '
Well Contractor Name "', ft
2043 A ft ft
NC Well Contractor Certification Number ii1 ,010 •Bran r fbiliii � Q il' et( !s,rn�.','��!>;
FROM TO =DIAMETERTHICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. rt. 1 fts� �Company Name
FROM TO DIAMETER THICKNESS MATERIAL{
2.Well Construction Permit#: !/D��f— fr. ft. . 'in.
List all applicable well permits(i.e.County,State, variance,Injection,etc.)
3.Well Use(check well use): fa ft. !..
Water Supply Well: R P.TA;: to >s rt'•':iK;''v``.J'•r .< sus s3 tl u is�' .2< .., t., 1
pp y DIAMETER 1SLOTSIZE :THICHMS MATERIAL '
ft. ft. In.
❑Agt9culhtral 13MutiicipaUPublic
OGeothermal(Heating/Cooling Supply) I ential Water Supply(single) f, ft. In.
Olndustrial/Commercial. : tl .. ..s . ..w? ti ifi)�"v`>[r\°`. •s>?:iK.:' "'iYi.iLt Y' a :`•t A:.
pResidential Water Supply(shared) FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑hri at'on ft. 3 ft. `�
;NOD-Water Supply Well:
OMonitoring ORecove ry ga ft. M
Infection Well: ft ft.
OAquifer Recharge DGroundwater Remediation ii. " / ?tL? A a` 8 €; z,'-'v ++_': MV"1 L
7 y' ;,s_„y,,n 1�A' ,V .) lam'.-zs�if
OAquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage
tt tt
❑Experimental Technology DSubsidence Control
$; 9Ky1R ALr )Is{)...........t1' w;�:•,.`�." w� _:s`':'.,
DGeothermal(Closed Loop) OTracer FROM TO DLSCRrMON color,haWaM solurock type,train slue etc.
DGeothermal (Heating/Cooling Return ❑Other(explain wider#21 RemarkJsJ ft. fr.
fr. ft.
4,Date Well(s)Completed: Q9—l5t-a/Well ID# ft ft
So.Well Location: ft to
,.» ft. ft SEP
Facility/Owner Name Facility lD#(if applicable) 01"
ft. ft. � CBssing
L2,2L 66 Z C-- ft. it { i I. h��secr',o
Physical Address,City,and Zip
iA ifi�'^q�'t�..\•�i,�l' 4ftYt�ii�ANi.GY'..�HJ'. :iE+t3A.�>3�M�7tJi1:`.>s'r?�li�.al''�J :fi.'�Y::''•.1
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/ininutes/seconds or decimal degrees: 22 Certification:
'
(if well field,one lat/long is suflicien .t) j
N !2�72/ � t5 Jam. -20
Signature/�i of Certified Well Contractor Date
6.Is(are)the well(s): MP&Fmauent or ❑Temporary
By signing this form,!hereby cerlO that the well(s)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: E3Yes or WN1 -� copy of this record has been provided to the well owner.
If this Is a repair,f ll 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: ��S (tt) 24a. for AD'Wells-:'Submit'this form within.30 days of completion of well
Far multiple wells list all depths lfdiiferent(example-3@200'and 2 tJ100') construction to the f011
10.Static water level below top of casing: J�2"i (ft) Division of Water Resources,Information Processing1Uiiif;
lfwaterlevelis above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (ln.) 24b.For Infec(ion Welft ONLY: In addition 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:
(ix.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)_ �� Method of test: Air lift 24c.For Water SuPely&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 Environment and Natural Resources-Division of Water Resources Revised August 2013

Macon County 3t)36�e NEW WELL CONSI�RuCTION
Pub, rc Health corusrRUCrION AlJTt •� ON
Pi2I11Ai"E[ Rli�ltiiVG"11f =r ` VIIEI:L
Tom P.Sarris ildul9_p * 6_I3-S
it. ie-FAmii.Well Residential "6564178849
fol.�w;tO tO:. take loft.6t-, -lAters cctI .s_ecotl <iot.on left
Pennft Condidons .
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain Minimum setbacks as applicable.
301 ROW on all subdivision roads. Do not drill well in ROW.
Diagram(Not to Scale)
Property tine Forest Service Monument
c
a �
Well Area 87' c G�,r
80, �0ay
Proposed Iron Rebar
100, 3 6R
House6s'
c N
60'
t �
a
1 40' a
ti
2 pro -------�-�
0
Iron Rebar
t0 Property Line a`r!en.4ila�v
This,permrt`is valid fora ped6d of five years exceptithat it may be revoked at any time If it Is determined that there has been a material bhangeln any factor
dreamstance upon which the permit is issued. well ipplion,installation,:and protection must meet state regulations.The well shbh.be inspe�d and 3ppfoved�by�Ia n,Ci3bnty
Public Adalth befb&-Wis.put info use."The location of.the will iildlcated;iry MCPH is to provide protection from possible sources of c6litaminatlon: Fiohr-vdffifo AT:#14 l9'NO i
guaranteed at�any.'site by MCPH.
A MUM&b COMPLrE"J'IQIV INSPECTION ,ST BE APPROVED BEFORE FINAL POWER IS GRANT_ T{1E WELL;I5 P*"'k INTO
SERVId. PLEASE S615DtlLE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. UE NO 2490
Issue bate: 12/13/2019 Kyle Jennings;REHS 2142 Authorized State Agent