GW1-2022-08907_Well Construction - GW1_20220912

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WELL CONSTRUCTION REC().RD
71iis form can he abed for single or multiple wells For Interniti Use ONLY:
L Well Contractor Information:
Mitchell Dean Cook
Well Contractor Name FROM TO DESCRD'TION•ft. 4/�fL I ,
2043 A 335't. ft. i
NC Well Contractor Certification Nmnber 75`n1) :N 12
PROM r0 DG1 :R THICKNESS I MATERIAL
fr.
Dennis Holland Well Drilling, Inc. o fr. 6, in.
Company Namev., _ r
Sliy(f:t) B. ($" 00,'i6"inayicliiJcli ifiB .�.,.'•.:..
2.Well Construction Permit#:
FROM TO DIAMETER THICKNESS MATERIAL
U�f ��J _ fa ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): ft. ft. tl in.
Water'$Ilpply Welt: FROM TO DIAMETER SLOT SIZE, THICKNESS e+ MATERIAL
DAgricultural UMunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
01ndustrial/Commercial sidential Water Supply(shared)
Olrri at1011 FROM TO MATERIAL EMPhACEMENTMF.THOD&AMOUNT
ft. ft.
Non-Water Supply Well:
OMonitoring ORecovery ra fL J 04
Injection Well: ft. fr.
OAquifer Recharge OGroundwater Remc i i ;i d at on '.';1)/Gt);A\!Eil:tF11C f+a U�•...g.:< '> ,:,.a s t?;:r5..:r. t;5;.r.;r-
OAquifer Storage and Recovery OSalinity Barrier PROM TO MATERIAL EMPLACEMENThIETHOD
OAquifer Test OStormwater Drainage
❑Ex erimentai Teclmolo f4 ft.
p gY L7Subsidencc Control
OGcothermal p) Cf'1•raCer(Closed Loop) 20 vRfi[INf i[U'(s'attar ffid'd.rironal itti'ects rfen`e99e ;i.;;±+' " t
FROM TO DESCR�•1'lON color hardae eolUrock rdtia size etc.)
DGeothermal Heatin Coolin Return GGther(explain under 921 Remarks) ft. ft.
fr. fa
4.Date Well(s)Completed:per Zee-,2;2 Well ID#� /►/, A ,
ft. ft.
SR.Well Location:
Facility/Owner Name Facility 1D#(ifapplicable) _ ___� _�•
ft ft. SE P 1 2 2022
Physical Address,City,and Zip
County Parcel identification No.(PIN)
5b,Latitude and Longitude In degrees/minutes/seconds of-decimal degrees:
(ifwell field,one latllong is sufficient) 22,Certification:
��� Signature ofCcitified Well Contractor Date
6.is(are)the well(s): iAK"Imancut or OTcmporary
By signing this form,l hereby certify that the well(.)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or LfA NC'AC 02C.07.00 Well Construction Standards and that a
7,is this a repair to an existing well: OYes or R WT— copy of this record has been provided to the well owner.
1fdds is a repair,fill out known well consuwctlon information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this )age to provide additional well site details or well
8.Number of wells constructed: conshuction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (� (ft,) 24a. K2L_&0 Wells: Submit this tbrrn within 30 clays of completion of well
Far multiple wells list all depths Jd fferent(example-3@200'and 2L100') construction to the following:
10.Static water level below top of casing: 7,Q (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.E3orehotediameter: 6" (iu.) 24b,)pr In*ecti,Qu Wells ONLY:I In addition to sending the foal 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: Rotary construction to the following:
(i.e.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(gprn)._�(� _ Method of test:Air lift 24c.For Water SuRply&In'ecti I Wells:
"--"— --� Also submit one copy of this form within 30 days of completion of
136.Disinfection type: H 8t H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW I North Carolina Department of ruvironment and Natural Resources-Division of Water Resources Revised August 201.1

Qtote�F
Macon County NEW WELL CONSTRUCTION
E = d Public Health CONSTRUCTION AUTHORIZATION
EMAtLED PRIVATE DRINKING WATER WELL
Bernd Holler • 081721-P 085221-S
110721-S
Shared Well iff,6.08
Residential • 7524481503
• • Tract 4 Three Hundred Acre Wood Sites 1 and 2.
' • Ellijay Road to R on Rocky Branch Road to property. Will need to follow someone in to find this property.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale
Proposed
Cabin
Site 2
_Top Fill Bank
rn
a
Stream/ 41' �
68' -
80' 65
rD
,-- ig
80,
ro
LDP 10 Repair Area 20'
>100'
60'
Propo ed Well 10
: ' .
t--15---"
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 orthe 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: 11/19/2021 Charles Womack, REHS 1300 AuthorizedStateAgent
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