GW1-2022-09872_Well Construction - GW1_20221028

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WELL CONSTRUCTION RECORD
71ris form can be used for single or multiple wells For Intemgl Use ONLY:
I.Well Contractor InformatioD:
Mitchell Dean Cook 14 wATFRlOIYES�. s
bROM T0_ D6SCRUMONt
14e1t ConhactorNamc ft.
2043 A
NC Well Contractor Certification Number 15 OUTNR l gSYI!IG;"foY.mir7ti cns'cd? 0 :,O12iIsINF !rf i' lfcablc;r.:
FROM TO'- DIAMI:TF;R TAICRNES,S MATERIAL,
Dennis* Holland_Well Drilling, InG: r1. y - ft.
Company Name
16 I1(tI]FSRtCASIIVIrURTPUBING
FROM TO DIAMETER THICKNESS MATERIAL -�
2.Well C'onstructiou Permit#: C����J�--1 _ __ _ --
_ _ __ _ ft. Tft. in.
List all applicable weft pern+lts(i.e.County,,State, Variance.Injection, -TM�
3 ft.
ft, in,
.Well Ilse(check well use): - ��-
S I 1 111 Well:
1I y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
` •..
THICKNESS MAT ERIAI,
❑Agricultural ❑Municipal/Public ft. fr. in.
❑Geothermal(Heating/Cooling Supply) UR gtdential Water Supply(single) ft. re. in. "-
❑Industrial/Commercial lg Cr1tOUf r
[.-]Residtntial Water Supply(shored) • . > ...:-.: ,�' ,,,., ' ..,.,,;.
FROM TO _ _ MATERIAL, EMPLACEMENT METHOD.&AMOUNT,•
❑ICIi+atlOrl - � � '� � - - •- �, ft. •� TfL-
Nou-Water Supply Well: m'
❑Monitoring URecove �ft .Zu : ft. J-
Injection Well: ft. fr.
DAquifer Recharge I7Groundwater Remediation rI2AY.$T�T!AGi
❑Aquifer Storage and RecoveryFROM TO MATERIAL. EMPLACEMENT METHOD
L�Srtlutity Barrier fr. ft.
UAquifer Test ❑Stormwater Drainage
fr
C1F.•.xperimental 1'eehrtology ' C1Subsidence Control ft.
❑Geothermal(Closed Loop) i 20.:vR11 1}INCy GC)(> atfactiihddthonal9hxfe`rfinecevSarg ''-,;ter, ;
01`racer FROM TO DESCRIPTION color.bardae so+u� Vrack lypc ram n+zc c1c.
❑Geothermal Heatin L Coolin Return) C:10ther(explain wider t#21 Remarks) ft, ft.
4.Date Well(s)Completed:% z -Well ID# /t!- ✓T• —
Sa.Well Location: _ ft.
Facility/Owner Narue Facility ID#(if applicable) W ft. "ft.
Y ..&,5p- i!^% ft. rt. IS�SL.fY�:r.9v�;,, ! rt ;Diav�,
Physical Address,City,and Z.ip
uGv�, ice' 97 53�, -
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/niinules/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient)
_ I /
Siguaurr.ufCertificd Well Contractor Date
6.Is(are)the well(s): fAPc manent or r7Temporary
By signing.rhis form, 1 hereby rer+ijy that the well(s)was(wrre)constructed in accurdaner.
�� isirh 15A NCAC 02C.0100 or 15A NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or L+JIVO copy afthis record has been provided to the well owner.
If this is a repair,frlf out known well construction information and explain the nature of the
repair under#21 remarks suction or on the back of this form. 23.Site 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface.:��J_ _ _ .(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example.3@200'and 2@100') construction to the following:
10.Static water level below top of casing: d.�O (ft.) Division of Water Resources,Information Processing Unit,
lfwarer level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6H�_ _ (iu.) 24b. For Inigettign Wells ONLY: In addition.to sunding the form to the address in
Rota 24a above, also submit a copy of this foot within 30 days of completion of well
12.Well construction method: Rotary _ construction to the following:
(i.e.nuger•,rotary,cable,direct push,ctc.) _
Division_of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: -T 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a,Yield m ' Air lift 24c.For Water Su rt &Injection Wells:
(gp ) ll Method of test:__•__-��
—""'-'—`— Also submit one copy of this form within 30 days of completion of
13b.Disinfection type.: H & H Amount:-1-2 oz. well construction to the county health department of the county where
T constructed.
Form GW-I North Cnrolura Department of I?nvironmcnt and Nanral Resources-Division of Water Resources Revised August 2013

i
M a con Co u n t y NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINIQNG WATER WELL
APPLICANTIOWNER Lawrence and Theresa Stenger T • fill 060322- 4 • Existing
4_14.94 _
Sinqle-Familv Well Residential_ 7514797553 6.78
• 310 JennyLee Lane
' !'"OR Ellijay Rd.,to L on Jenny.Lee Lane,to L at address sign 310 to end.
Permit Conditions , o
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
— Diagram (Not to Scale) - - - --- -- ---
/-� Orel
Existing Power Pole
PL
10,'� s
PP XY=35 11'
a/t 83 17j3`3„W o y, 60'
S'/. �l Existing Septic tank
S t r
___`__--
2 /,'A �" >100'
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]
Issue Date: 8/10/2022 Charles Womack, RE:HS 1300 &IM—a—AlIthof izeo'State A_qent