GW1-2022-10379_Well Construction - GW1_20221115

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WELL CONSTRUCTION RECO.RI)
'Ttis form can be used for single or multiple wells For Internal Use ONLY:
L Well Contractor Information:
Mitchell Dean Cook ;FRO
Well Contractor Name ft.
TO �.. DRSCRIP710N
2043 A fr. fL
NC Well Contractor Certification Number ( SIPI{y`formii7ti cu�Y S` c i i' 'T '
'#$:^nU N•R A 's•..,;;�,,•
FROM TO DIAMETER I THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. U . ft , ft, G„ in, ��•�I vG
Company NameG�AStT1lrDIZTUl3gVCs,.'eoli® hral:i 1Wixa�Ioii"it 1 J4.; : '
ems,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t�5/ ��/J _ ft ft in
List all applicable well permlis(i.e.Coun%Stare,Variance,Injection,err..)
3.Well Ilse(check well use): ft, ft.
Water'S»pl)Iy WCII: FROM TO- DIAMETER SLOTSIZF. I THICKNESS MATERIAL
❑Agricultural 1J�MunicipaVPublic ft. ft. in.
❑Geotllerinai(Heating/Coolillg Supply) G7Rc'sidential Water Supply(single) ft. ft. in.
❑hidustrial/Commer "g':r S,::r.; „1.a ,:,r..;T+;. ;"r =:;:n>::.:,r•::.
C]ResidentialWaterSupply(shared) '�_'«<.. ':i�',��•= :`�;,..-.�.:............. Ia-:..- .
❑Irri anon
FROM TO MATERIAL EMPLACEMENTMETHOB&AMOl1NT
� , i.._fr.
Non-Water Supply Well: fr. -
❑Monitoring ❑Recovery ft. QQ ft. `
4
Injection Well: ft. ft.
❑Aquifer Recharge ❑G A PAG
roundwater Remediation :,iI9?i "•ND/,b E +
12 Is. 1F tf
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test 08tormwater Drainage
ft rt
❑Experimental'Tectulology []Subsidence Control
a
R?b1zIkl ilv aiichluaait on�l,slieois±ltia ces�a"; t ei•''{ 3`'y'l:.tf ;'i.)•.:'
❑Geothermal(Closed Loop) ❑'Tracer FROM TO
TO DESCRIPTION color haraoe solUrock I rain size,etc.
❑Geothermal Heatin Coolie Return). EJOther(explain tmder421 Remarks) rt. rt.
ft. ft.
4,Date Well(s)Completed: 1/-r5 � Well IDOL—" ft. f7
,
Sa.Well Location: fr.
Jtevi .trti i s /V. ft. ft NOV 2 5; 202Z
Facility/OwnerNmne, Facility ID9(ifapplicable) - - -
fL ft.
U� t D h /Y��-N• —f
Physical Address,City,and Zip dvRlQmOG
Cotulty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/iong is sufficient)
���/' Signature of Certifie ell Contractor Date
6.Is(are)the well(s): �ili'ermanent or ❑Temporary
By signing Phis jonn,I hereby rerl fy that the we11(,$)was(were)cottslrucled in nccutdnncr.
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or �ki� copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the.
repair tinder#21 retnarks.section or onlhe back of thisform, 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 mtiftiple Injection or non-water.snpply wells ONLY with the same construction,yott can
submit one form. SUBMITTAL,INSTUCTIONS
9,Total well depth below land surface: J'- _ (ff.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: a00 (ft-) Division of Water Resources,Information Processing Unit,
Ifwaler level Is above casing,use"F" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b.Eor In'ecti n Weil. 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,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(gp m)_ _ Air lift 24c.For Water Su &Injection Wells:
Method of test:1
--• "-'�--"— Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount:12 oz. well construction to the county health department of the county where
-` - constructed.
Fomt GW-1 Noiih Carolina Department of}i'._04 i fineni and Natural Resources—Division of Water Resources Revised August 2013

4tote�P t� _ 7
�o��� Macon County ((JJ� f NEW WELL CONSTRUCTION
�' Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Kevin&Martha Hopkins • 051422-P • 012319-S
Single-Family Well Residential ' • • 7515289618 4.02
INo • Onion Mtn Rd
Sol[
From Cat Creek Rd: L onto Rabbit Creek Rd R onto Onion Mtn Rd on right just past BerryCove Rd
EMM
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
o�
Primary Site 7r
,.s
Ridge
Shallow to Rock
.•� c O
0 7•
- %d
--- --- - -- --` ' ----��ePa area----.•.�-�'a - ----— - -- ��--a---- - - -----
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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
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: 7/25/2022 Jonathan Fouts, REHS 1979 s 60— Authorized State Agent