GW1-2022-09158_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD
'lris forty can be treed for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Mitchell Dean Coo s'. aY<'`7' .ES;«: s%<d:it:i '<'
FROM TO DESCREMON .
Well Contractor Name m�qd'T4.
2043 A rr. ft.
NC Well Contractor Certification Nwnber 'a,multt�cbiN1H`d "�Q .'1N FFIRRIt Iftwif
FROM TO DIAMETER THICKNESS MA .RIAL
Dennis Holland Well Drilling, Inc. �o rt. 54 rt. -
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Company Name A
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. -,16 .>+ ASItYSr: R•>..�.$741V. eof a ma;Ztat Flli$ :+_..�
2.Well Construction Permit#:
FROM TO DIAMETER THICKN&SS MATERIAL
7� y���� -P rG ft, in.
fr
—E—H
List all applicable well penrrlrs(i.e.County,.Store, Variance,lnJertion,ercetc) fG in
3.Well Use(check well use): r
Watel'SIIppIy WCII: 7-ROM Tor DIAMETER I SLOTSIZF, I TffiCKNFSS '`MATERIAL
❑Agricultural OMunicipaVPublic tt. ft. in.
fJGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ►°.
l7lndustrial/CommerciaWater '` '
U:T='s•t�dentt l aSupply(shared)
❑Irri at" v FROM TO I MATERIAL EMPLACEMENT MF.THOD&AMOUNT
ft. fr.
Non-Water Supply Well:
OMonitoring ORecovery ft. ft.
Injection Well: h. fr.
0Aquifer Recharge OGroundwater Remediation i9r ti%b ".'XEk;q6 Ift-191hiflagrA.
OAquifer Storage and Recovery (]Salinity Barrier FROM TO MATERIAL. EMPLACFAIFNT619THOD
DAquifer'fest 08tormwater Drainage
fG fG
OExperimental'IeclutologY USubsidenceControl
0Geothermal(Closed Loop) OTracer t O-M TO xL1N L<)'(s;aifaC iG`d do
FRO
R!R(UM T D&SCRUII'[ON color hard°e solUroek rain size,etc.
OGeothermal Heatin Coolin Return OOther ex lain under#21 Remarks) h. fr.
ft. ft. P
4.Date Well(s)Completed:CJq J���Well ID#—AL-IA , _
So.Well Location: ft. ft. F O
2077
vL/e �a13lr A D 7es'az ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) — — �— --
ol
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ii�s1 id f�7- r pom JF•t!t h. ft.
Physical Address,City,and Zip
s'q D Pv�
County Parcel Identification No.(PrN) ,
S_' �t
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Geld,arc latllong is sufficient)
N W / �/�a4C :r��
Signature of Ceetified ell Contractor Date
6.Is(are)the well(s): ermaneut or OTemporary
By signing this jonn,!hereby rerr fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ElDl>r' copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform, 23.Sitc diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: conshuction details. You mny also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTI.ICTIONS
9.Total well depth below land surface:—!,,2 C.; � (ft.) 24a. For AT Well : Submit this for in within 30 (lays of completion of well
Fat-multiple wells list all depths ifdiifferenr(example-)(a 200'and 2@100') construction to the following:
10.Static water level below top of casing: RIO (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6" 011.) 24b. for Injecliqu Well. ONLY: In!addition to sending the form 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,(6rect 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(gpnl)•_/D Method of test: Air Ilft 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type: H & H Amount:. 2 oz. well construction to the county health'department of the county where
constructed.
Fomr GW-I North Carolina Department of Environment and Natural Resources--Division of Water Resorts Revised August 2013

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d �� Macon County NEW WELL CONSTRUCTION
° Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
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Permit Conditions t ((
�►tl �e a St�tc�.rcc� W�
Well shall be construct4d in compliance with all NCAC 2C Rules. I
Maintain minimum setbacks as applicable.
ScPhti AM_ Diagram(Not to Scale)
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�Vn on_ _t. - t . . _ ryclbl�tPriyE.
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or Bafl, of �tovsa
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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 i
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POVJ R IS GRANT HE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTAL ON. E ?[phone] i
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Issue Date: Author/zed State Agent
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