GW1--03455_Well Construction - GW1_20230518

WELL CONSTRUCTION R C0 .111)
71_,�i;­IU can he used lot single or multiple wells or linernTo Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook "a
77.
Well COUtractor Name _R�VS(PJ
2043 A
ft. ft.
NC Well 26e f I
Contractor Certification Nunibcr
ab ii)i
Ohl 0 Tn[CKNE&S_ I MATFRIAL
Dennis Holland Well Drilling, Inc. -E'76� si�Ff`!!--4
cornPany Nalue Z,ft, 1n"1<_0_x,- I lovc
T&I W­URTIV
2.Well Construction Permit 9: FROM---_R_ DIAMETER_ 774ICKNESS MATERIALList at/applicable well permits(i.e.(�, ft. ft. in.
01"11Y,Store, Variance.hVecflon,e.jr)
3.Well Ilse(check well use): ft. rr. in.
.7-
�o M M
Mm DIAM TER�yA ff.RIAI.
ClAgricultur, C)Mullicipalillublic ff. in. AtA
DGeotherinal(Heating/Cooliog Supply)
14R-es'idontial Water-Supply(single)
7.7 Supply(shared)C)Residential Water
L
;THODA,l lim, ERIAL
ft
Supply
well..
j1W ollilo,-ing CIlRecovery
fir. fit.
O.Aquifer Recharge
013roundwater 1kcinediatioll Is
.ElAquifer8torage find Recovery m TO MATFRIAI 08alinity Barrier EMIFLAcEmm
IJAquifer Test ft,08tormwater Oininago
013xperimentalTeel-foology (Aubsideme Control ft. Tt.-
"DRIL lJOcothery-nal((losed Loop) ElTim cer ..................................... ......
MSCRiyrm coloELhmdrfts!l 3DII/rock ly e,grrain siu,eic.)
LGeotherm n tuidcr#21 Remarks
4.Date Wel
ls)Completed: as-4if5a�Well IDN 1A
ft.- ..3
Sn.Well Location:
ft. ft.
_Ttpj f 0-2-5.2 _f IVIAY-
fL
Fficitily/Omier Nanic Facility ID11(iffiPPlicable) . .....•
ft ft.
J
ft. rt.
Physical Address,('ity,and Zil)
Parcel Identification No.(PrN)
.9b,Latitude nod Longitude In degrees/minutes/seconds or decimal degr-cis:
(if well Field,one hit/long is sufficient) 22.Certification:
0 9
N
Signative ofCcilified Well Contractor Y Date
6.Is(are)the well(s): 01'ermauent of-
By signing this,forni, I hereby rerqjy ihni,tho wil(c).was(wrrc)constructed it;accurdo,ice
with 15A HCACO2C.0100 or IJA NCAC 02C.0200 Well Construction Siandards ond that a
7.Is this a repair to an exisdug well: OYes or 69 copy qfthis record has been provided to the well owner.
If this is-7 repair,fiti vid kninvir Nell construction it and explain the nature oj'the.
repair under 921 remarks section or on the back qfthisform. 23.Site(diagram or additional well details:
8.Number of wells constr-octed: 1 You may list,,the.back of this page to provide additional well site details or well
For multiale infection or non-tvaterstipply-wells ONLY with the-saitreconsir'uction,you can consimclion deluils. You cony also alto.ch additional pages if necessary.
submit one form. SUBmn"rAL INS,rucTIONS
9.Total well depth helow land surface: _5 (ft,) 24a. For All wells: Submit this loan within 30 days of Completion of well
1•bralulfipte welts list ale depths ifc1ifferant(example- construction to the following:
10.,Static water level below top of casing; (ft.) Division of Water Rcsourllesi Information Processing Unit,
ffuwer 1"el is above casing,use 1617 Mali Service Center,Raleigh,NC27699-1617
I I.Borehole.diameter; 6. 24b. For In addition to sell ding the fort to t r s i
011.) L I nj g�gj Lip n NKv I Is 0 N 1,Y: 1i the a I I es 11
24a above, also submit a copy of this form within 30 (lays Of Completion of well
12.Well construction method: Rotary construction to the following:
(i.e.imser,rowy,cable,direct push,etc.)
Division of Water Resources, Underground Injection Control Program,
FOR 'ATER SUPPLY WFIAS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Method of test: Air lift 24c.For Water So &Supply Injection Wells:
...... Also submit one Copy of this form within 30 (lays of completion Of
13b.Disinfection type:-H & Fi Ainouut:.12 oz. well Construction to tile, County health�department of the county where
--,:j constructed.
Porn GW-I Nonli Carolina DeParliriont ofFrivirotiment and Natural Resources--Division of Water Resources Revised August 2013

Qiote�r
dip•m Macon County NEW WELL CONgMUCTION
�a PUbIIC Health CONSTRUCTION AUTHORIZATION
.d PRIVATE DRINKING WATER WELL
Permit Conditions
Well shall he constnictecl in c.mmrilianrP with all Nf"Af 3iC PiIlnc,
Maintain minimum setbacks as applicable. o
Diagram (Not to Scale) ----- --- —
SST �-1------
YJ
JJ `i
This permit is valid for a period-of exo!pl that it may be(evoked at any ume it it is deterininc(i that were has been a material change In any fact or
nrcumstance upon which the permit is issued. Well location,Installation,and protection must meet stale regulations.The%cell shall be inspected ana approved by Flacon Counby
put)l+c Health before it is put Into use. The location of the vier:indicated by MCPH i_.to provide protection from possible sources of contarnination. Flux volume kw ll vieldl is NOT
guaranteed at any sae by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANT. OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTA"110N. QUEONP?,t.1328)349-2490
J� ' '4u ii-ed State Agent
Issue Date: v _ _ ;�`� 9
14