GW1-2023-01748_Well Construction - GW1_20230223

WELL CONSTRUCTION RtCORD or multiple ForInterim Usu ONLY:
'This fonn cen be used for single walls "
I
1.Well Contractor Informatiou:
Mitchell Dean Gook
_ _F _ROM TO `DESCRIPTION
Well Contractor Name, t •fG y ft,
2043 A
—rr. rt.
NC Well Contracror Ccnificetion Number E15oOU7`NRf(ti'`tiYIVCr.,fbYrmulfi5c38ed_{_ S
FROM TO DIAMRTF:R TFIICKNESS MATERIAh, ''�--
Dennis Holland Well Drilling, Inc. •rt 'ETE _ — --
Company Name
�1'.6•INN�ItY,r�S'iNli,��.f,'BIJCiIIV�:.(ge'of�e•mel'clo�icd�lii� 'i`;"ref
FitOM_ TO-� DIAMETER THICKNESS MATF.RfAL_ _
2.Well Construction Yerufit N: CS.;2�•'� � 0 ___ r If. r ft, �r in.
List all applicable well pernn0s(i.e..County,State. Variance,injection.etc) �_.._._ ._ _. __v_ -1 ^— / Loy-' T
Use c ): ) I ft. tt11 4 s ft.
3.Well (check well used
Water Su tl Wc1P — — ( EifVi- _ �::..•,;;::...:.:: _.:: >
PI Y FF7OM _ TO _ D1AN1 ETt:R _SLnT 417.E THICKNKSSMATERIAL•_
I'_lAgnctdtural C]Municipal/Public
❑Geothermal(lieating/Cooling Supply) Uh169fidential Water Supply(single) ft.���—ft. _ in.:
❑Industrial/Cot `1...`"
nmcrcial �.sRhU.Ts''•
["IReside:ntiul Water Supply(Shared) •� :�:>' "`Lss•:.:a.':`��r .... ...:::...e:. .:.:::: is>f_;;::;;:.,�.:'-:;:,=<
_FROM_ TO_,. MATERIAL F.MPLACEMF,NTMF,THO�t &Afv10UNT
F0Aqui'i'fvr
er Supply Well: d_ ____ - �2`dr! -,�cr-e.�. �f
(:JRecovcryWell:Recharge ❑Groundwater Remediation :1:4z SANIS%GkAVFi,`?PpGlf:if+e"i"
ClAquifer Storage and RecoveryFROM — TO ---�� MATERIA I._ � —EMPLACEMENT MET1101)
❑Sultrily Barrier fr. _ �^fr. _
IJAquifer`Vast 08tormwater Dnuinago
ClExperimentul'I'ech»ology
❑Subsidence Control
mat(Closed r+2Q,3llRt(�,��'IJYtyllsn:(' k 1_ .diillibgelrsli'eof'e'i n:'e:95a ; 'r _
00cother FROM _ T ( f1 iy t•rs'<::'. :.:%:r:' �._:'
' L,OOP) ❑'1'rnccr 0 UF:,tiCRIP'TION�oloherdara�soWrockinnrain sin cto y.,
(GGothermal Hearin Cooling Rclunt) C)Other(<:x)Iain.tmdci Remarks ft. ft.
4.Date Well(s)Completed:,d 3 Well lI)H� _.._.__.—
_
Sa.Well Location: ft •__— -_ft
^_�Z���d .GL�.._...•._-...._.. Vl+rtrbr'S� _.. __ T ft. —....__._.ft. ....... .. �._,n di
Facility/( nrorNarne Facility ID#(ifopplicable) --__rr_.^__.__,_.__ft.
j_LrTt _..__
vfr:r�f'A t^
Physical Address,City,anti Zip
i'r2i:i1LE�INA'1Z12 �._..._�a-rF,: -�•:-..,--•-• �-r--;-^t-••-•..^r•.,.--_.�.�._..
Cotmty Pnrccl identification No.(PM)
5b,Latitude nod Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification
(il'svell Geld,one latlorrg is sufficient)
N _K' c G aC ..ASS �1�� -- =1�`�_-I a 3
Sigunttre ofCeniGed Well contractor Date
G.is(are)the wcll(s): Qlmauent or• C71'empor'ary
0y signing dds form, I hereby rectify that the well(s)erns(were)constructed in acrurdnncr.
with 15A NCAC 02C.0100 or IJA NCAC 02C.07.00 Well Construction Standards and tint a
7.Is this a repair to an existing well: CJYcs or XXT copy oj'this record has been provided to toe.well owner.
If flits is a repair,fill out known svrll construction information and explain the nana•e.of the.
repair under#21 remarks.reetion or air the back gfrhisform. 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: consliurtion details. You may also attach additional pages if necessary.
For multiple injection or non-u'amr supply wells ONi.P with fire sanre constriction,you can
subunit one form. SUBMITTAI,fNSTUC:TIONS
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9.Total well depth helow land surfare: 'G� ___(ft.) 24a. I+or All !Veils: Submit this)iota within 30 days 01'completion of well
Fo•multiple wells list all depths tf(iifferent(example-3@200'arrd 2@100') construction to the following:
10.Static water level below top of easillg:T, 1 „____ _•(ft.) Division of Water Resources,luformation Processing Unit,
lfsvaterlevel is above rasing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.BoreholeBoreholediameter: 6„ 24b. for Lljecljgn Wells ONLY: Ini addition to sanding the Form t0 the address in
Rotary 24a above., also submit a copy of'thi's fonn within 30 (lays of completion of well
12.Well construetiou method: __T _— construction to life following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,junderground Injection Control Program,
FOR WATER SUPPLY WELT S ONLY: —�-- 1636 Mail Service(.enter,Raleigh,NC 27699-1636
13a.Yield(gpm). Me
r. Air lift 24c.For Water Sit )ly Rc Injection Wells:
/...=�.._.___._._—. thod of test:-__•__•,_•__�._._.___
Also submit one copy of this fonn within 30 days of completion of
13b.Disinfection type: H & H Amouut:.. 2 OZ. well construction to the: county hei lth department of the county where
constructed.
Forst CiW-I Noilh Carolina Deparlment ofl?nviromnent anti Natural Resources-•Division of Water R'osourcos Revised August 2013

Macon County
Public Health
NEVVVVELL CONSTRUCTION
PRIVATE DRINKING WATER WELL
Potmil Conditions
MallItaill M111111111,1111 setbacks as applicable.
` . Oia0rmn (Not hoScale)
-- — —_
Pk
This permit Is valid for a period of five years 111"It It In.,)y bil fovokixj at:nly"11111a If It 1�,de"armilwo(Nitthoro haf,,:een a materlo,cnanov,in any ract or
orcunittance upon wmcii wo permit I!,,ltz;ued, weii lo<ation,im,.talkidon,Lind prot,.,cuor,fntj!.t rnect"Ahtf.rej)(011tiowi.71111 yk!ll thlill IY,-InspMed and approved by macen cotinty
Put)!Ic Health bef*e It is plit Into t1se. 111,2 location of the wall in(PaIN'd by N011 I,.,to pivvldo p.,oto-von from pozibio sources oecontamination. t-*icAv yownw.(well yield)Is NOT
A WELLHEAD COMPLETION INSPECTION MUST OE APPROVED BEFORE FINAL POWER {SGRANTEDp_OTHE WELL lS PLACED lNlD
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP lNSm ION. QUESTIONS?[phone]
Issue Date: 2��_ -- ` ' 5nta/go�/