GW1-2022-07060_Well Construction - GW1_20220722

WELL C0N.RTDTJ1"TTr'hXT RECORD
I 111b U11-1111 can be Used for single or aill1liple w--1k For Internal Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook
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Well Contractor Name
2043 A
NC Well Contractor Cullification Number
-mig
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Dennis Holland well Drilling, Inc. DIAMETER THICKNESS MAD,'RIAL DIAMETER.
Company Name in
2.Well Construction Permit FROM D1 ETER MATERIAL
I a.
,01inly.State, Variance,Injection,etc)
List Oflapplicable wellpennits(i.e.C
3,Well Use(check well use.): sm IF11
water filli y 1101offl:
ClAgricultural -jt�(ML TO D ER SLOTSI-ZE 1(:KNFZSS
ft.
00cothernial(Huting/Coolilig Supply) Cj,� rdentia'l Water Supply(single) ft• ft. in.
01ndustri'll/Cumniercial
Elikesidential Water Supply(shared)
'Dirr, fition FROM EMPI FMEIN J METHOULA AMOJJNT
Non
-W
�t—er Supply Well: • ft
".01litoring ft.
ORecovery
DAquifer Recharge IJ Grou ndwater Renic(liation
T,
OAquifer Storage and Recovery ElSalillity Barrier FROM TO KATERLAL
EMPLA(:FJ%lFNTNlET1[QD
DAclififes-Test ft. ft
O.Storniwater Drainage
DExperimental'reclillology U18tibsidence Control fL ft.
RU!"Uff ..... ....... 16?
ElGeOthertnal(Closed Loop) E)Tracer a
00cothermal(HeatinW 'JO��Lxpj�� of TODESCRIPTION—J Q!!k
Cooling Return) I el L n utider421 Remarks) [:I
4.Date%11(s)Completed: Q-,_I
N—AL41A-- ft.
5R.Well Location:
ft. -um
ft. ft. DWWOG
Facility/Owner Name Fricility,ID#(if applicable)
C/
ft. ft.
Physical Address,City,and Zip
Gamr
County Parcel identification No.(PIN)
51),Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if%yell C101d,0110 18010118 is StfffiCiOlit) 22.Certification:
N W
Signature ofCcnificd Wcll Contractor Date
6.Is(arc)the veell(s): wr rr.-lient Or [TI,cuiporary
By slgalng this form, hereby rerto that the well(v)was(were)constructed-in-accordance
with 15A NCelC 02C.0100 or IJA NCAC 02C.0200 Well Construction,Standards and that a
7.Is this a repair to an existing well: ClYes or [qKo- copy of this record has been provided to the well owner.
If this is a repairfill inti knowl,well construction infortnation and explain the nature of the
repair tender#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.Number of wells constructed: You may use the buck of this page to provide additional well site details or well
collstl'uctioll details. You may also alta6h additional pages if necessary.
For multiple hijection or non-water supply wells ONLY with the same construction,you call
submit one futon.
SUBMITTAL rNSTUCTIONS I
9.'rotai well depth below land surface: qS _(ft.) 24a. For All Wells: Submit this fijiniwilhin :30 (lays of completion of well
Pormultiple wells list all depths ifdi&rcnt(example-3@200'and 2@10F) construction to the rollowilig: I
10.Static water level below top of casing: (ft.) Division of Water Resource.v,'Information Processing Unit,
ff water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter;
24b. For—1nkr_tiQn_Wc1Ij ONLY: Ln addition to sending Use form to the address in
12.Well construction method: Rotary 24a above, also submit a copy of thinfor-in within 30 days of completion of well
constniction to the following:
(i-c-litigar,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR NVATER SUPPLY WELIS ONLY: 1636 Mail Service Center',Raleigh,NC 27699-1636
His.Yield .... .. Method of test: Air lift 24c,For Water Supp-!X&Inlection We I I 1.11:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:_H & H---- Amount:.1-2oz. Well construction to the, county health!dcpartment of the county where
constructed.
l'onn G W-I North Carolfint Department of rtivirotimont and Natural Resources-Division of Writer Resources
I Revised August 2013

d �,� Macon County I NEW WELL CONSTRUCTION
EA, Public Health �IC61NSTRUCTIONAUTHORIZATION
L i PRIVATE DRINIQNG WATER WELL
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Valerie Call • 071022-P • Ex.
Single-Family Well Only Residential 7,'5i7059935 EM 1.59
• • 295 Jim Cochran Road '
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295 Jim Cochran Road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 50'minimum from septic system.
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jDiagram (Not to Scale)
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` Permitted
Well Location
(071022-P)
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Property Line
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Its 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]
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Issue Date: 7/12/2022 Jonathan Fouts, REHS 1979 AuthonzedStateAgent
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