GW1-2022-07302_Well Construction - GW1_20220809

W. CQNSTRUCTION RECORI) ---------
This torn can be uscd for single or multiple wells I'm Intern4l Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook ------
well Contractor Name
FROM TO DESCRIPTION
fit. �
2043 A y -r' ,ft
NC Well Contractor Cotificetion Nmobcr 15 QUTN (A`SIIYG`.for mulhtbswdllbUd-
Dennis Holland Well Drilling, Inc, FROM PO DIAMETER TnICKNESS MATF:RUI, T __
o " A. fit. ��
Company Natnc in. G
16'11�(NFRFCASIIy(r()It^7'111 G' eof 6...
FROM 70 `-""'2,Well Construction Permit 0: 2�j �, DIAMETER THICKNESS MATERIAL
Lis(all applicable well permits Ar..County,,State, Variance,Injection,etc.) fit' fit. in.
3.Well Use(check well use): fit• _ fit.41.
ti
Watel'$tlpinly WCII: T T F7(0M11 — TO DIAM T R SLOT SIZE Tlll(KNFS MAT
ERIAL
AT1R1A1—
❑Agricultural UMunicipaMiblic R. ft. in.
00cothermal(Hcating/Cooling Supply) t(es dential Water Supply(single)rt. -
l']Industrial/Commercial C)Residential Water Supply(shured)
❑Irri atioll FROM To MATERIAL. EMPI ACEMENT METHOD&AMOUNT
NoD-Water Supply Well: �j"tt' ft.
rOAquifer
onitoring [)Recovery ft. ft. _
ection Well: ft.
quifer Recharge 00roundwater Remcdiation =19 s D/C1tAY!PACK:tfroi Ildel a '
Storage and Recovery (JSnlinity,Barrier FROM _ TO* MATERU1. EMPLAGFJmFNTM1fET110D
UAyuifcr'('est ft. fit. _ -
C1Stormwater Drainage
OExperimcntal'1'cclmolo ft. ft.
BY C7Subsidence Control
Cl(i(othennal(Closed Loop) 20..DKtfLIN( L(Y( attach:mdtlflrogal:�hec(e.dioecessery
l) C1Tracer FROh1 TO _ DESCR�TION color,hudae solUrockt
yp OG----cothermal(H fit.
cating/Cooling Return) UOther ux>lain under N21 Remarks) _ ( 1--'' ` r.;a etrR ctt,�'
- ft.
.,e
4.Date Well(s)Completed:Q IDH ft. ft.
__ �1A--� •---- -
A. _ _ft.
-Sit.Well Location: _ _ ^�T h'.'J" p• 0
1 / fit.
Facility/Owner Nmoc i�(iti�F01
Facility ID#(if applicable) —_ ._. T __ ----------JL
ft.
Physical Address,City,and"Lip
"21 RBfY1Al(KS-
County Parcel Idcntiftcation No.(PfN)
i
51).Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latlloug is sufficient) 22.Certificaliou:
CP
35°
Signn Uete
G.Is(are)the well(s): ([ 'erTnanent or f.7Tcmporary mrc of(.c1u tc Wcil(:ontractor
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.02.00 Well Construction Standards and than a
7.Is this a repair to an existing well: ClYes or copy of this record has been provided to the well owner.
If this is a repair,fill out kr1oN'n we/I construction information and explain the nature of the
repair under Il21 remarks section or at,the hark 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
F Number wells constructed: conshuction(details. You may also attach additional pages ifnecessary.
For muluplr.injection or non-water supply wells ONLY with the smrre construction,you can
submit ane juror. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: .5 5 _
�.,,— 4 _ •-(fL) 24a. For All Wells: Submit this font within :)0 days of completion of well
1'a rnuhiple wells list all depths ifd erenr(example-3i a,200'and 2(R 100')— eetlStttrCt1011(0 llte f0110w1ttg:
10.Static water level below to)of casing: ) Division o esf Water Resourc Information Processing Unit,
//water level is above rosin "+" l�`,
b use 1617 Mail Service Center,Raleigh,NC 27699••1617
11,Borehole diameter:_6" (in.) 24b. For lniec_ Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this torn within 30 days of completion of well
.Well construction method: ry - construction to the following:
(i.c.nugm•,rotary,cable,direct push,etc.) "-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27099-1636
13n.Yield(gpun).__..._ � Method of test: Air lift 24c,For Water Supply&Injection Wells:
H & H Also submit one copy of this font 1within 30 days of completion of
lab.Disinfection type: Amount:•�2 oz. well construction to the county health department of the county where
_._.__ constructed.
Donn(iW-I North Carolina Department of l3nvironmart and Natural Resources -Division of Water Resoluces Revised August 2011
I

NEW WELL CONSTRUCTION
'ubk Health
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
CAN
Ronald and Wanda Webb
15,
751705
Fit.,
3)9 'im Cochran Rd.
Creek Rd., L.onto Jim Cochran Rd., 329 on R.
PennK
^ :n constructed in compliance with all NCAC2CRules. ~-
p ' x`.`knum setbacks asapplicable. ~ "
Diagram (Not to Scale)
Neighboring Septic .,"^
88,
L Wt�l Area]
105,
es
Drain Lin
Carport
Coch
Septic Tank
Yhis pc-,,-t-nit is valid for a period of five years('xcel)t that it may be revoked at any time if it is cle.termined that there has been a material change in any fact or
ci,curnsta i'i`r!upon which the permit is issued. Well location, intallation,and protection must meet state requIaLions.The well shall be inspected and approved by Macon County
Pi:blic Heas,tl before it is put into use. The location of the weil indicated by McPfi is to provide protection fro.ni possible sources of contamination. Flow volump(well yield)Is NOT
gt:arantee,,j at any site by MCPH.
AVVELLH�ADCOMPLETION lN5PE[rD}N MUST BE APPROVED BEFORE FINAL. POWER[S GRAN-FED�Q THE VVELL23 PLACED INTO
SERVD� ��^5E SCHEDULE AVVELLHFADlNSpF[TIOw AFTER PUMP lN6TALLAT�/N. QWESTlON��(W28) 349'2490
issue Date: 7/21/2022 Jonathan Fouts, REMS 1979 xYxorzef�a&`/�a�