GW1-2023-01070_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORI) For Intenral Use ONLY:
This form can he used for single or multiple wells
I.Well Contractor Information:
•'!
Mitchell Dean Cook ::1a WAT ERION ES?
FROM To DFSCRDMON _
Well Coutractor Name ft. ft.
2043 A ft. fL
NC Well Contractor Certification Number i`IS n. t[KRELASMC:forimulti chscdlwe "iU�2t1'iIN '?it1A`'' i'ca6le is ?'$;'-xis .:
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. p- fr. �� ft. 6„ ;in!. _ 2-1 w�
Company Name }l`6 iN-NVR`CASTty(r 0K1'P3J.I11N.Cy' edthe mt+Y.z[pled bmli.;.-
FROM TO I DIAMETER , I THICKNESS I MATERIAL
2.Well Construction Permit#: v o� 5 _ fa R. in.
List all applicable well permits(i.e.Coun%State, Variance,Injection,err.) CL PL in,
3.Well Use(check well use): :/ ;:r, - :..•.: ', `+; c, ::,a.:: >;:• <.: .
7'.:
Water Supply Well: FROM TO ;DIAMETER` -S��LOWSIZF, I'HICKNR9 „MATERIAL i
CiAgriculhtral rJMunicipaVPublic ft, ft. in.
QGeothennal(Heating/Cooling Supply) fe<sidential Water Supply(single)
ft. �ft. in.
❑Industrial/Commercial El Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMET)IOD&AMOUNT
Cllrri ation ft. 3 ft. d
Non-Water Supply Well: ft. , fr. �
0Monitoring ClRecovery W Jr
Injection Well: fr. ft.
QAquifer Recharge QGroundwater Remcdiation -1,9;sANn/. AYE)i?PAG1f'rf:e' lice d _.:-+ ,. _: ' v
FROM TO MATERIAL EMPLACEMENTME'I•HOD
[]Aquifer Storage and Recovery ❑Salbrity Barrier ft. fr.
QAquifer Test QStormwater Drainage `-`
ft. ft.
OExperimental Technology 03ubsidence Control ---L, c
„20 DAi1 f:YNi3sIi()(k.atfa¢hi§d'diltonelrsti'i ets rftnicc�ge ..
C1Gcothermal(Closed Loop) 01'racer @ROM TO DESCRIPTION color�ne soiu� urocktypK rainAze etc.)
[:)Geothermal(Heating/Cooling Return) ElOther(explain tuider#21 Remarks) tr, ft.
ft, rt.
4.Date Well(s)Completed: O1 Well ID#f� �, '-' "'- - -' --
ft.
5'a,Well Location:
Facility/OwnerNmue Facility 1Dll(ifapplicable) -"--�� �� r_i�•.__
�ft ft. IA AI 2
Physical Address,City,and Zip _ ,,....._,l.flsr, ,c'.art
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or-decimal degrees: 22,Certification:
(ifwell field,one ladioug is suf iicieut)
tt +
�.� signature ofCani6cd Well Contractor Date
6,Is(are)the well(s): fl1'ermauent or ❑Temporary By signing ihis form, i hereby certify thdl the weii(s)was(were)constructed in accordance.
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and Ilia/a
7.Is this a repair to an existing well: ClYes or W?44 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 under 921 remarks.seclion or on the 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
S.Number of wells constructed: cimstructi(»t details. You may also attach additional pages if necessary.
For multiple injection or non-waler.supply wells ONLY with the same construction.you can
submit one form. SLJIIMIT'fAl,INSTl1CTIONS
9.Total well depth below land surface: ' M _ (It,) 24a. For All Wells: Submit this form within 30 clays of completion of well
Far multiple wells list all depths if dierent(exaurple-3@200'and 2@100') construction to the following:
10.Static water level below top of casingi �Q , __ ____,(ft.) Division of Water Resour ees,Information Processing Unit,
1/water level is above casing,use."t" 1617 Mail Service Center,Raleigh,NC 27699-1617
6" 24b,For• Injecti n Wells ONLY: In addition to sending the form to the address in
I1,Borehole diameter: (iu.)
24a above, also submit a copy of this faun within 30 days of completion of well
12,Well construction method: Rotary construction to the following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,IJuderground Injection Control Prograru,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Sup &In ection�Well9:
13a.Yield(gpm)_• � Method o[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 lim tli department of the county where
-- constructed.
Forur GW-i North(:arolirre Department of Bnvuoumcnt and Natural Resources--Division of Water Rcsvitrces
Revised August 2013

KEM=LE
J Macon C o u n i y IMPROVEMENT PERMIT and 1 CONSTRUCTION AUTHORIZATION
,Public Health 0
d •' U 5 f-&Vl �.s o-n- 8a 3 SI9=G 4591 N SITE WASTEWATER
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ana •• O O 72-5 '• 0 0 22-p
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.. GPD
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IASTau�.x r�l�� Lon.3 X 36 w, k1B'.1S'�tepr n I(v(u�SaQ
j ah.� Sr dti ee.+k�ar Svv..Et., IY1n7.��w Sfo' ,� S�;le �lti b--Ii..r�wo�� Tre1/Ktws^S�..N /i�cY KA (,en(AR7'• ,
41^.• —Sr (d Laws
Dia ram Not to Scale
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''I K.+lv• Z S a to �n Type SoII.Depth: pn)Slope: O % LIAR: t3.s Saprollte:/ Type ea:
• . . ZO (tt� LIAR: 0,5 Saprolite:/
t�t7 Z on center V •ZV ^low side L r c ,'a I • I Iv ry p
The iSSUanCe of this penult by MCPH in no way guarantees the Issuance of other penults. The permit holder Is responsible for checkingwith appropriate
meeting their requirements. This permit is subject to revocation If the site plan,plat,site or Intended use changes. This governing hodlhs In
hX the NC Laws and Rules for Sewage Treatment and Disposal and to the mndltons of i penult. Cn ruGlonand IRstall�artiholn Rules�NCAC 950,a1952,itih959 provisionsi
.1956,.1957,.1958 and.1959 are Incorporated by reference Into this permit and shall be met
Lsstle Date:
•---,� /, ub7odzed 52�l�+Agent