GW1-2022-09159_Well Construction - GW1_20220930

W.II:LI.CUNSTRUCTIUN RECO:RI) -----�--_
This form can be wed for single or multiple.wells For Internifl Use ONLY:
I.Well Contractor Informatioll:
Mitchell Dean Cook 14�YiAtFR7QNr:S
1
Well Contractor Name FROM TO _DF SCRM ION
2043 A 5G�� `rr. � ,ft.
NC Well Contractor Certification Nwaber 1S,n.UT.NR(}AS'IM( for mWh eLsgdtcvlle ft°O
Dennis Holland Well Drilling Inc, PROM r0 - DIAMsTF•R TFII(KNES,S MATERIAL T
Company Nantc
16 11�IVE1(C AS(lYr bR Tll$ING eiihapmnl'cl'`cd ltid
2.Well Construction Permit 14: FROM 70 _ DIAMF7"F:R "I'H(CKNB. ATt;RfAL
List all applicable well perndts(i.r.Cou�,S'trage�r� I l(ect�ete.) - m� -T fr. (t. in.
3.Well Use(check well use); ft. ft. -;n, —
Water Supply Well; L2 S(.)213fiN a . .
_ ^.
FROM_ r0 _� DIAMErFR �;SLOTSIZF. T7fICKNFSS • MATERIAL
C1Agriculhtral fJMunicipaVPublic ft. ft. in.
00cothennal(Henting/Cooling Supply) 144t6sidential Water Supply(single) - ft.. ft. in.
Olndustrinl/Conunercial OResidential Water Supply(:shared) "Ig CsROUT
❑Irrl�atj-plh' Ohl Tn _ -A JAL, EMPIA(F,MF;NTME771UD'&AMOUNT
Nov-Water Supply Well: ri• _ fr.
C3Monitaring D. 3 tr. /6*
/ - �
❑Recovery J'' !� f?i�i / Ogc _L��iJ
Injection Well: -- ft. - R. "
nAquifer Recharge (;1 Ground water Remcdiation 19 S DI.0 AVF PAGtC:'tf a t1lc'g6 e' "
-
ClAquifer Storage and Recove
ry f7Salinity Barrier ADM TO _MATERIAL ., EMPLACEMENTMETIlOD
f�Aquifcr'fest ft. -- .-_
C1Stor iwater Drainage —�-
❑'.xperiniental'leclulolo ^ft• - ft.
BY CJSubsidence Control
ClGeothermal(Closed i.00 2U 1)KrhIIN( [O( etfac8thd'dtttonel:ah`edts Ihn"`esse r
p) (.17•ri1CCr F7iOm TO DESCRIP ION color herd°e eoiUrock t -
CJ(icothermal Lleatin Conlin Return) OOther(ex lain under N21 Remarks)
- ft. fr.
ft. fr.
4.Date
Well(s)Completed:Ct 9 D9 ? Well[D!t �l/� _ — b~°. i _.e ,^s 4P "T6."'
ft. ft.
Su.Well
/Location:
ft.Al // A—_ fL—
Facility/Owner Name ft. 'f.. -v=.�? (itiii
F•ncility lDN(if applicable)
—ft.
Physical Address,City,and Zip
2I. EMA1tK1:
("O°°ty Parcel Identification No,(PIN) �-�
51).Latitude and Longitude In degrees/minutes/seconds or decimal degrees: n
(ifwcll field,one lat/long is sufficient) 22.Certification:
a�
� Signature ofCcrlificd Well Contractor Detc
G.is(are)the well(,): f�rmaneut or []Temporary
By signing this form,/hereby certify that the well(,)was(were)constructed in accordance
with 1 SA NCAC•02C.0100 at-1.rA NCAC 02C•.0200 Well Cunstrucuon Standards and that a
7.Is this a repair to an existing well: CIYes or WNO copy r/this record has bean provided to the well owner.
1f thIS is a repair,fll our known well construction information and explain the nature of the
repair under k11 remarks section or on the back of utisfonn. 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 of wells constructed: construction details. you cony also attach additional pages if accessary.
h'or multiple injection or nun-trntrr supply wells UN/.Y with the same construction,You cull
submit one form. SUBMITTAL,INS'I'(_1C_TIONS
9.'rotai well depth below land surface: e6i a.S r _ —�(ft.) 24n. For All Wells: Submit this titan within 30 (lays of completion of well
/•ar multiple wells list all depths ifdifjercnt(exnn+ple-3@100'and 2(rJ/00') constnrction to the following: ,
r
10.Static water level below top of casing:____41 S (ft) Division of Water Resources,Informatioo Processing(Jolt,
/)water level is above casing,use"+" - 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter:_6 (iu.) 24b.)or InjectirZn Wells ONLY: In addition to sending the form to the address in
Rota 24lt above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary Constntction to the following:
C.auger,rotary,cable,(fireci push,etc.)
Division of Water Resources,(Jnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,iRelefgh,NC 27699-1636
1311.yield Method of test. Air lift 24c.For Water Supply&Injection Wells:
__.___.-.-._____..._.. Also submit one copy of this form within 30 days of completion of
131).Disinfection type: H $c H Amount: 12 oz. well construction to the county health (h partinent of the county where
— p- -- - constructed.
I
Forur CiW-I North Cuolinn Department of Bnvironmcut and Nanual Resources--Division of Water Rcsour cs Revised August 2013

Q�o�ecr
Macon County NEW WELL CONSTRUCTION
o� �a Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
EGo
Isidro&Renee Vargas • 081622 P • N/A
--...._._............ _Sin le-Fames Well Residential ' 6488944499 1 1672j__frysa Rd: Otto, NC toA state line to L on Lamb Rd.te._L on S. T ryphosa Rd to 6th driveway on L(up the hill --.-.-.-.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
a
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
\\ Une Proposed Well Location
081622-P
.._............_..._-. — -...................---
nritc
Fence near property line
Tree �rarnfie/d ``�
>100,
Tree (
Tree ❑
b
�p Electric Box
ti
E
fln,.
,E,
Sitr,
P/-
o11ej
N
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]
8 30 202.2 Charles Womack, REHS 1300 _ 1(�0�4uthorized State Agent
Issue Date: / / - -