GW1-2022-07827_Well Construction - GW1_20220822

WELL CONS'CRUCTION KECORI) -- - -- -- - - �
This Ibrnr enn be used 1•er single or multiple wells Fur Intemat Use ONLY:
I.Well Contractor Infor•metion: _. �_�- __ _ _.� _„-^_ _•_�
Mitchell [dean Cook 14 wATFRr<miFs ^-
Well Contractor Name -_..w- .�..._._ _.._�..-- --- ..� _.T__.•._-_-___---- __-___-_.--- -
NC Well ConuaclorCenification Nmnber �[SIQIIT_PR(AS(YC(tor moth cesealiw'llla;<)It>Ia N it:" IicLbl r a:
PROM f0 -�Dennis Holland Well D-IAMF1FR TA ICKNEAS MATERIAL
Drilling, Inc. rt ,r ft �� f/
Company Nautr, -- - -T�-'^- -•`-'�� 16 TNN1cK(AS[N( OR- '11:1-B.-INC, 77.
eojharurul.'.Clo '`: 77
�/ FKOM 10 DIAMETFK- 'I-HICKNY.SS MATERIAL 2,Well Consn'ucti011 Permit 9: U j«1 /© _..-. -"-
In
Lis,all applirnble.well per,nns(i.e.Cutniry,,SK,/e, Vannnrr.,Injection,etr.f'_'-_._____---��• � _- ..._. _ _
T u,
3.Well Use(check well use): rt ft_ w
Water Supply WeII: _____-_'"___'"'_ "-"'�- FROM DIAMFTIR SLOT sim.. THICKNESS MATt:R1At1.
ClAgricultural C7MunicipaVPuhlic ft• - fr.^ io.
GQeothermal(I Ientinp/Cooling Su Clt�
pply) K-1-Identied Water Supply(single) R.
f]IndustriallComu)ercial 18 GRnUT - '��'
C:1Re5idential Water Supply(shared)
C]Ini anon PROM Ta_ ntATEK1AT�� EMr1A<EMF.YFMF.niun&nMot�rn^
_.._ - - " n. �!Nun Water Supply Well: _ - _ — - �� - 2�sr�1`
C1Monitorin r�f!^EIRecovery
J
Injection We'll: '_' -- -_._�__ __ fr• .- f'_
OAquifer Ilechargc FlOroundwater Rcmediation 19 4AND7C1tAVFk;PACK rfap licktile)
ClAqulfer Storage and Recover FROM TO MATERIAL EMPLAI E111F_MTME,TIIOD�
Y C7Sulinity Harrier -fr, fr.^
IJAquifer•test C:1`itornnvater Drainage
C)Experirncntal Technolo tr ft.
6Y (.7Subsidence Control
ClGcolhermal Closed Loop) 2U 1)1(fl`LING[UC�eHnch nddluonel'shecte tf n`etse �
.. ( l) [.1'l•raCC! FRUM - DFScmTION�eolor,berdoes2s eolUrockt7Pe>Jgrvnec_uyela)..-._
C7Gcothermal Teatin Ceolin Return) C70ther(ex)lain undCr t!l I Remarks)
ft.4.Date Well(s)Cunlpleted:Url well
rr. rt. b.., ..:� s ..
Su.Well Location:
fr. ft.
A- Y__� i_V�1_ �I-i �1_ _ ft. rt. _..._.._._._.._._.
Pacilit Owner Name Facility IDU(if applicable) -. _.__.._...___- -_........_------ -- ..-_._._._- t1
Physical Address,City,and'!•ip ;2! REM.AtiKSmm•_,��,-'-T�T�R�T_�__y_:^- ^-�--_-_
Comity Parcel Idr.mificntimt No.(PIN) -___ _ _.._.._...---____--- �_. —______ r ..____. -•--_ ___�n 1
St).Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22•Ccrtiticntion: _ T
(if well Geld,one IaUlong is i sli c.icnt)
�.
..3-=�--`- •--- --'"�------- N .-_._ �G3/._L._- W -....1 ,r -C- - -: - _�"!_..__:. c-_..._....-_ -----------
Sigmnhue ufCcnilicd Well Contractor � Untc
6.Is(arc)the well(s): rmanent or (7Teinportfiy
By signing This form, l hereby terrify that the wcll(s)was(were.)constructed in necurdanee
wish 1 SA NCAC WC.0/00 at,1.5A NCAC 02C.02.00 Well Construe/ion Smndm•ds nn(l drnl n
7.Is this a repair,to an existing well: OYes or 85NV""'_ copy ofthis record has been provided In the well awner.
/f thls is a repair,./ill our known wall cnnsn action information and explain the nnmrc of the
repair unde.)#21 remarks seclion or on the back oidtisionm 23.Site diugr•anl or additional well details:
You may use the buck of this pap,C to provide additional well site details or well
8.Number of wells constructed; _ consnuclion details. You may also attach additional pages ifnecessary.
For multiple injection or non-voter supply vr-llc ONLY will,the same caccrruedon,you con
subn,if aneJarn,. Sl11LM-irl'Al.[NSTUCTIONS
9.'[utal well depth below IRud surface: 249. For All Wells: Submit this torn within .10 (lays of completion of well
Nm multiple wells lost all depths i di erenr(example-00 and).rJ100' �- T^ ( ) Construction to the tbllowiti p p Ill ( v (� (. ) b
10.Stntic water level below top of casing; / (ft.) Division of Witter Rcsouiices,li formation Processing Unit,
If-alerlevel is above casing,use-+" 1617 Mail Service('crite.r,Raleigh,NC 27699-1617
11.Borehole dian)eler:_6 .�� (ill.) 24b. For_Inice(ign WcUs ONLY: Ir I addition to sending the form to the address in
Rotary 24a ahovo, also submit a copy of this tbim within 30 days of completion of wino
12,We'll co list[-itctino method: _ Y construction to the following:
(i.c.nugr.r,rolaiy,ca61c,dirccl push,cic.)
Division of Water Resources,UDderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,RRleigh,NC:27699-1636
1 Air lift 24c. For dater Si )Ly Rc ln'cl.ctiuu Wells:
Ian.Yield(gpm). j!�__..._._._.__.. Method of testr._._._..... _...._...____. Also submit one copy of this form Ivvithin 30 (lays ofcompletiunof
F�13b.Disinfection type: & Amount: oz.f"� well construction to the county health dcpartment of the county where
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Pone(iw-I North Otrolina Department of fmviroumcnt and Naaual Resources...Division of Water Resowres Reviscd August 2011

Qtotec.�
Macon County NEW WELL CONSTRUCTION
E Public Health� ,, CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
_.._ ------------------._....-_................... _._._._....__.
Lynn Wanner • 080122-P • N/A EFrom44
Sincle-Fam�Well, Residential • 7517050477101 Logg N Rd
_._._.1 N: L onto Coon Creek Rd left onto Loge N Rd; 2nd house on ri ht
----------- -- ---— ....------= --g..
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,
Diagram (Not to Scale)
f
Power
Pole Z
�i
—30' P\
Proposed well Sice
30'
0
—82 �
101 Lajg N d
19
Existing ST
N
d
J
qo
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: 8/5/2022 Charles Womack, REHS 1300 jj-62Mr _Authorized5tateAgent