GW1-2022-10380_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORll —
11us form can be used for single or multiple wells For Intern;tl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook 14 1YAT)12'I:ttiP7ES _:',
FROM TO rLDM'5CRUMON
Well Contractor Name -
2043 A
rt.
rt.
NC Well Contractor Certification Number IS OU1 F R;(;AS1NU for multi cnse111,1 16 OR UINF if?a icab]e
FROM T TO D1AMF.TF;R THICKNESS MATERIAL
ALIT^�-
Dennis Holland Well Drilling, Inc. . rt. � i'r
Company Name 43
....
16: Esli CASINQ01Y 1U$INb` 'eothermal closed'1'o.0` ��
FROM 70. DIAMETER THICKNESS MATERIAL
CJ r•
2.Well Construction Permit ft. ft --tt. in.
List all applicable well pernnits fl.e.County State, nr 'er Injection,etc)
3.Well Ilse(check well use): ft. in.
Watet'Supidy WcIL -�" !--" T' -FROM-_ TO DIAMETER StOTSIZE THICKNESS MATERIAL
g ^
[DAriculhrral l:7MunicipaVPub]ic _ --
0(ieothennal(Heating/Coo)ing Supply) t0lT csidcntial Water Supply(single) rr. TRTtt. in.
❑hidustrial/Commercial EIRcsidential Water Supply,(shured) lt3;CyR'Ol7T -
FROM TO MATEKIAL F,MPI"ACE"MF.IVT MFTHUD,&AMO[1NT
IDIfII at1011 -•-
NOn-Water Supply Well:__ .�'" _ o•-r`/v '
CJMonitorin ft• rr• /
g C.]Recovery 5 _G' ��`�� %s L-/X�^ < ?'�
Injection Well ft. _
[.]Aquifer Recharge nOroundwaterRemediation 19 S :NI)/C1tAYEI.P,AC�IC rCa '(iraryl�� .
OAquifer Storage and Recove FROM TO MATERIAL. EMPLACEMENTME•rHOD�
Recovery L`1Salirrity Barrier fr --tr
[.]Aquifer Test 08torn)watcr Drainage - --
L1Experimental'I'eclmologY []Subsidence Control ft. fL
Z0 1).RTLLIN(y h<)( attactiiGdditronal`dhacta rf n ce 4a
13(leethermal(Closed Loop) C.TI'mcer —( �- -= --
FROM TO _ fIESCRD''TION colorL6ardocs�aoiU_ roc�ro �aiu�lzelclr�
IDGeothermal Hcatin Coolie Return) [:)Other(explain under#21 Remarks) ft. ft,
ff-
4.Date Well(s)Completed: Well IDH ft. f D "�r r� ___
Se.Well Location:. -� ft. ft.
F L�
tr, ft. aAiibTr3�'+Za�[ "L.cllit;S._ .r_ __
Facility/Owner Namc Facility IDN(ifapplir"able)
ft. ft. DANO OG
Physical Address,City,and Zip 21,«11E74IAR1G5 - .r:.,
County Parcel Identification No.(Pi I)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:��
(i(well field,one ladlong is sufficient) 1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 01'ermanent or nTemporaty
By signing this form, l hereby certify the/the well(r)was fwrreJ constructed in ocrurdnnr.•r.
wiih 1 SA NC:AC OX.0100 or 15A NCAC 02C.07.00 Well Construction Standards and flint a
7.Is this a repair-to an existing well: ClYes or lrINO copy of this record has been provided to the well owner.
1f this is a repair,ill out known arll construction information and explain the nature of the
repair under#21 remarks section or on the back q/thisfornr. 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 ityection or non-water.supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9,Total well depth below land surface: C) ____(ft.) 24a. For All Weil,,: Submit this f'or n within 30 days of completion of well.
Fat•multiple wells list all depths ifdifferew(example.-3@200'and 2(a;100') construction to the following:
10.Static water level below top of casing: S - TM (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service.Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b. For In'ec ONLY: In addition to sending the form to the address in
Rotary 24aabove, also Submit a copy of this form within 30 (lays of completion of well
12.Well construction method: constnrction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONI.,Y: �- 1636 Mail Service Center,Raleigh,NC 27699-1636
(gP ) Air lift _ __ 24c.For Water Sriuf,l &I tion Wells:
13n Yield m �_ Method of test:
`�- Also submit one ropy 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
- _ constructed.
1701111 GW-I North CaroGrua Dcpartmctu of F,nviroumeut and Natural Resources-Division of Water Resources Revised August 2013

iA a c o n County NEW WELL CONSTRUCTION
1 „
j10 3 k Iea-d r " CONSTRUCTION AUTHORIZATION
�.� PRIVATE DRINKING WATER WELL
Sf1'1 tt�tl rt+n�(la ` Bonnie S wyer t� hai Imo n 3oh son ,t 0 j 042322-P —^ ® N/A
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;�i�4 '111 ,r1�f Sincle_Fa_,.AV_Well, R iden.tial s c * 6555792372_ . ' ' ' 33.79 _
�_._.._
�, Au}iti olwr, ui.h minctowri ! lls Rr . pasi paint where Rd turns to left.The property is on left ber'ore you get to the bee boxes
'' •�' � r r :' cl; i2t`i. There is z loc!<ecJ chain ate across the driveGva on the left.
0
or1,>,, -,;: ;.....,.., .:,.. II !CAC 2C iules a. In f:Gl';: .uc.i....l :i:r1 c S.
,ch.Aing 100'from septic systems.
Diagram (Not to Scale)
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it ! House Pad
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House Pad
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,E , ,except th t it may be revoked at any time if it Is determined that there has been a material change In any fact or
CI CUrn$t, l.y)1' - ,(.r,n,_ :;i__.,.,. �,r:nt••: _.e.aaar, Ind protertlen^urst rne;�t state regulations.The well shall be inspected and approved by Macon County
P;iblic HeaD:n bein-:: ';ou, ,a_. 'i'Y,:a;c,;;r,:.•: rh v;,-;': n16::atod!)v ktC.Pri i5 to p cvide protection from possihie sources of contamination. Flow volume(well yield)Is NOT
goaranteo--i at a
A.\WEL±,i ,:CN MIS" BEFORE FINAL POWER I4 GRANTED 0_R THE WELL IS PLACED:INTO
SE=RV1; r- rt = h „,-P „ I r,•.<r,:-rji- Ai?ER P!!MP INSTALLATION. QUESTIONS (828)349 24t90
slue t aru: i;: u : Jonathan 1=outs, REHS 1979 ��3hi�� Authorized State Agent