GW1--03090_Well Construction - GW1_20230428

WELL CONSTRUCTION ItECORI)
'1Lis loran cen be used Ibr single or multiple wells For Intemttl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
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14e11 Couhactor Name- -----•---- FROM TO_ DESCRIPT70N '-"'
NC Well ConUactor Ccrtifcatinn Nu mbar 1S''C)lJii12tC�AS71I. f!i0.JX..,,_ .{oiilmuliiac�Yc�21fwC is"()fi IalN.: +,'i:C';�p]Icg6•c"c ;: '
Dennis Holland Well Drilling `�°"' TO �=� `
Inc. fL -- ft _DIAM _ TA1CK1vESS
•-_ETF'R MATERIAL
Company Name �� �_ Jul
ti1:67;1)h!) Hl`.C;ASf1!jiV >LIJTIIG:' fti`altrlWtlt 8 ;'tir;: ::.: :•:::;.^rT
2.Well Construction Permit N: 4J J(;-
4 FROM„�. Tp DIAMF;TF:R 'ITIICKNESS MATF.RIAL,�lS
LIV all applicable well peraills(i.e.Comity.Starr, Variance,lnjec.Non,etc.) ----
3.Well Use(check wall trse): yJC -C(. �• , f(, y� in. _
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_ _ UTAP7STKR ,V.S17._F. Ttl(CKNFM I71ATFRIAL
F'We"s"llplywell..
1Agrieidtural l:lMunicipaVPublir, ft. - Tft. In. '�
DGeothennal(Heating/Coolii)g Supply) F
,,3<9idontial Water Supply(single) �- ft. ^ft. --'io:
I7lndustrial/Colntnercial
(:]Residential Water SupPly(shurai)
, ri?a _ ,,>: ,•.::j,�, :..,::•.r.,:,.
�Irfl (rI1011 FROM TO_~ ... ..,••' -.a.`T:i��::�,: r::`'cr.'fii�'e?`ttr;:::::•'aa�'.. :
MATBHIAI~ - ;EMPLACEMENTM, 0 &AMOl1NT�F
C1Monitoring n,
C7R(covury
Injection Well: -- ------
(.7Aquifer Recharge ft ft.
f_7Groundwater Rrnlcdiation •'i�
i -...-+��P/.,' :A4!Fi,�'I �IC�1fia'.`�t3b e ux_:.: .�:;-?;;-,...-.:-•z-:-•---T
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[]Aquifer Storage and Rucove FROM _ To _,ry 08albilty Barrier .." MATF,RIAI.T�_! EMPLACEA7tsTtTME'ITIO
(]Aquifer Test ft• -ft.
C:lStormwatcr i�tainage -�... ..._._._,.,..._ ,�.••_
CIF..xperitnental'rechnology (:]Subsidence Control ft. T rL^
(:)Geothermal(Closed Loop) C.:)'fracer s20?llAti 1s1N(3[O:(?(aNach 61tl[torialJstieo'`s:i'ftn
I�Geothennal Hearin Conlin Rctum C)Other(explain tinder#21 Remarks FROM TO �)ESCRIPIION roloryhardoe solUrockt ea„tu etc.ft
4.Date We11(s)Climpleted:4) ,3 Well ID1l_ i(J }. ». _ �_ � d_
LL._ _.__ .- if
ft._.. ft. _ �.4 _.
sa,Well Location: __... T., ._r._._. ......__ ._ __ �_,q-�p �p • q
ft.
.•L�'.Lls:.�.C??._.�/%-�.y,.,/?..l-F� /I�/i�+.�...,a CL � -ft. _______. ..... .._..
Facility/Owner Name Facility ID#(if applicable) ----- —. _._ -�.� fifiu_�Sd�II• l uf C�G•;�'vCc iPr�Vt l
...Zld l ink jTcf
Physical Address,City,and Zip - - ft. ft.
2'1I;EIA'FtllSl. � r:r^-^ C S, -�•<n--
County
Parcel Identification No.(PfN) � +� -
sb,Latitude find Longitude In degrees/minutes/seconds of-det tint degrees: 1� '� ���'/_�_ ✓"- � - -""--- "� _.._._._
Orwell field,one tat/long is sufficient) 22,Certification:
o
Signahtre ofCcrtiGcd Wcll C,;outractor Date
6.Is(are)the well(s): lit maucnt or f.7Tcmporety
0y signing this form,1 Hereby ret•t fy that the well(r)was(ware)ronsliueted in accordaner.
wish 15A NCAC 02C.0100 ur l.tA NCAC 02C.07.00 Well Construction Smndards mad that u
7,is this a repair to an existing well• OYes or 6UNo copy aj /
This record has been provided to the well owner.
/f rhls is a repair,fill inn known well e:mtsnvmion it jormallan and explain the nature.of the.
repair under#21 remarks section a),on the back gfthisjortn. 21 Site diagram or additional welt details:
You may use the brick of this page to provide additional well site details or well
8.Number of wells constructed: _ conshuction details. You may also attach udditional pages if necessary.
Fur mulliple injection or nun-waler supply wells ONL Y trill,the same construction,you can
submit one form, SMIMITT_AI.,INSTl1_C_TIONS
9:'I'otal well depth below land surface:.•fie):5- -�T- �__(ft.) 24a, ,fe x II Weill: Submitttthis Ihnn within 30 clays of completion of well
1•'ornuuldple wells lisl all depths ifdiifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: �� Di
s ^ (ft) vision of Water Resources,Information Processing Unit,
1/waler level is above casing,Ilse"•�" �'� 1617 Mnil Service.Center,:Raleigh,NC 27699-1617
11,lioteholediemeter: 6.
_ __� .(in.) 24b, )or lnjec it2u Walls ONLY: In addition to sending the form to the address in
.Well construction method: Rotary conshuction to the following:Rota 24a Rbovt:, also submit a copy of this form within 30 clays of completion of well
(i.e.uugrr,rolaiy,cable,diroct push,etc.) '•""'-'��"-"'-"-'^"-_'--""- ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SIlPI'LY WE:I,IS ONLY: _ �_ 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm) Method of test: Air lift 24c..Far Water Supl&&Injection Welli:
--'- —`- -"'- Also submit one copy of this form witliin 30 days of completion of
13b:Disinfection type: H Amount:,�2 OZ. well construction to the county hcalthl di pnrtrnent of the county where
_T constructed.
i
Folnt CW-I Notth Carolina Ueparttnent of 1?nviruuutonl auii Notural Rcsotuces--Division of Water Resources Revised August 20)3

Q<°teet
0 �m Macon County NEW WELL CONSTRUCTION
s Public Health ,`'3 ��`'
` CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
William Urquhart • 301623-P • Exist
— ing
Single-Family_WeII,.Residential ......
............._........_...__...._......_. Existing
' 64802239h3 1.38 _
101 Little Mountain Rd
1i441 S to R on Coweeta Lab Rd, R onto Little Mountain Rd; #101 is around bend.
Pennit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. `
Proposed well permitted for owner's preference. Consult MCEH if site is unsuitable/may not produce; permit can be amended.
Diagram (Not to Scale)
A
0
101
' Little Mountain v%--
Driveway ,1M
2Is
®�Norx;sw Well
t �3$Dry Well15'
Little Mountain Rd 1P0
< V
This permit is valid for a period of five years except that it may he 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 hICPH 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: 3/29/2023 Jeremy Pless, REHSI 3157 _ -- l/�-�_ Authorized State Agent