GW1-2022-07059_Well Construction - GW1_20220722

WELL C0NqT12'rJrrrT
`71 RECORD
-
This form 01100 used lbr single or multiple wells For hiter,141 Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook •
Well Contractor Name FROM TO DESCREPTION
At,o'ft. f ft.
2043 A 6W
NC Well Contractor Certification Niunbor MR i*tv's,. I .i A"*
TO DIAMETER THICKNESS MATERIAL ---------
Dennis Holland Well Drilling, Inc. e ft ft. /41 In,
...... ....
Company Nall.
2.Well Construction Permit FROM T ft. DIAM TER,'.In. THICKNESS MATERUL
List all applicable well permlis(i.e.County,S arl Vanrenjoton,a Itate, 6 1 10 ft.
1 -
ft. ft. :in.
3.Well(Ise(check well use): k-
........... f Apt, Z'.
. ............
Water ply Well:
FROM TO DIANIFTER SLOLTSIZF THICKNESS I MATERIAL
0 Agricultural 0MunicipaUPublic ft• ft. in.
VK
DGeothermal(Heating/Cooling Supply) -li-d1ritial Water Supply(single) ft. ft. In.
Dindustrial/Commercial EIResidential Water Supply(shared)
t, FROM MATERIAL I EMPIACEMENTMETHOD4, AMOJINT
2".L
No t;,Supply Well:
0monitovB ORecovery ft. 6,
Injection n Well:
DAquifer Recharge CJGroundwater Remediation
DAquifer Storage and Recovery OSalinity Barrier FEt0M TO hUX W ERIAL EMPLACEMEMETHOD
ft. ft.
0AquiforTest 08tormwater Drainage
OExperimentalTeelinology IJSubsidence Control fa ft.
iffiNk
00cothermal(Closed Loop) 01'racer - I
FROM TO ALWRIFT]ION color herdae sofUro, ck rain size,etc.)
110coth-,rmat(lieatinpjCool ing Return) rJOther(explain under#21 Remarks) ft• ft..
ft. I ft.
4.Date Well(s)Completed:,0-7Z14 Well IDN
ft. N FN L-_ka V=V
SR.Well Location:
ft.
JUL 2022
ft. ft. 2 2
racility/OwncrName Facility ID#(if applicable)
n Pr0cW4*1MM—
OG
z4AZ ft, ft.
UL
Physical Address,City,and Zip
MIR
&r,
Comity Parcel Identification No.(PIN)
5b.Latitude Had Longitude In degreeslininutes/seconds or decimal degrees: 22.Certification:
(if%vell field,one[at/long is sufficient)
Mf N RSA 12 ',613 2 4Z-mga.2.,z
Signature ofCcitified Well Contractor Date
6.Is(are)the weII(s):11rmancnt or LJTcmporary By signing this form,I hereby reri(fy that the well(T)was(were)constructed In accordance
wflh IJA lVCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or copy of this record has been provided to the well owner.
If this Is a repair,fill out known well construction inforntatlon and explain the nature"of the
repair under#21 remarks section or.on the bark ofthisform. 23,Site diagram or additional well details:
1 . You may use the back of this page to provide additional well site details or well
8,Number of wells constructed: conshuction details. You nay also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL,JNSTIJCTIONS
9.Total well depth below land surface: (ft,) 24a. For AM Well : Submit this form within 30 clays of completion of well
For muldple wells list all depths if&fferent(example.3@200'and 2@101) construction to the following:
10.Static water level below top of casing; (ft.) Division of Water Resourceh,Information Processing Unit,
lfwa(er level is above casing,use 11,11 1617 Mail Service Center,Raleigh,NC 27699-1617
. I
11.Borehole diameter: 24b. For Injection Wells ONLY: In tl idi tion 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 pttsh,etc.)
Division of Water Resources,I[Jnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1311.Yield(gpill). of test., Air lift 24c.For Water Supply&Injection Wells.,
Method
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H well construction to the county health department of the county where
Amount:Iz-o Z.— constructed.
Form GW-I North Carolina Department of Environment and Natival Resources-Division of Water Rcsolurol Revised August 2013

Q�Otecr
�/ �•, Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
t Alex Fairfax • 061822-P • On File
Single-Family Well Only setbacks Residential 7517056544 4.25
• ` • 241 Archie Point
' 241 Archie Point
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 50'from septic system and pond and 25'minimum from building perimeters.
Diagram (Not to Scale)
PAL 1Permitted
10'Well Area
(061822-P)
16'to
_ Pond )5p r Cat.
8
53'
45 `ep holnt
88, P�
P/L- . vrv�tr�j
>8o 4r�h e2p¢o 4t Task ptic
46'
35'
s
k.60,`��^
r„
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: 7/7/2022 Jonathan Fouts, REHS 1979 f_d S Authorized State Agent