GW1--03457_Well Construction - GW1_20230518

WELL CONSTRUCTION RECOItI) For lntcm4i Use ONLY:
Ibis form can be used for single or multiple wells
1.Well Contractor Information:
-
Mitchell Dean Cook as
FROM TO DESCREMON _
Well Contractor Name
2043 A �ft. �, �� ft. --
�zr ., ,
NC Well Contractor Certification Number15y.n1lTFlt GAS ..U;foY.mtiiltrchs`itl�✓¢ ;OfUUINEIT(f[i(cable -
FROM I TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. © : ft• r�—�—„' v� �—
Company Name 16: ; ,!`$CASIiy('tUltTC1U1NG edtharmtil,il"wedlo$
��n9LI� FROM !0� DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: U_J__ _ ft. � ft. � in.
List all applicable well perndts(i.e.C•ouuty ,Stare, Varlanee..injection,etc.) fL ft. in. ^T
3.Well Use(check well use): - z.
Water Supply Well: — ' FROM I TO DIAMETER ^SLOTsizE I 'nllCKNE5S I MATERIAL
CIAgricultural ❑MunicipaUPublic ft. rt. _
io.
CJCieotlferunal(Heating/Cooling Supply) Gl�idelrtial Water Supply(single) ft. ft.
O(ndustrial/Camtnercial C lie idential Water Supply(shared)
FROM TO _ MATERIAL, EMPLACFMENTMF,THOII&AMOUNT
[]Iffl�ltll(111 _ Q, ft. ft. , �
Non-Water Supply Well: fa � ft.
OMonitoring ORecovery --
Injection Well: ft. ft.
(.]Aquifer Recharge C]Ciroundwater Remcdiation 19� SA'Nb/GkAXF.i+i`AGK itieplihcabla� _
FROM TO .MATERIAL EMPLA(,EIIIENTAI I'HOD
[]Aquifer Storage and Recovery 03ulbiity Barrier ft. ft. '
[]Aquifer Test GStormwater Drainage
ft, ft.
OExperimental Technology []Subsidence Control
$0,llRlf I.iNf,f nG atta'ctf{iiddiii'fi ifi'eeYi"ifin 0,'36,y
0(reothermal(Closed Loop) C71'racer FROM _ TO DFSCRUMON color,hardness,sollfrock IyM,gram slue etc.
DGeothermal Fieatin Coolin Return)�1.10ther explain underN21 Remarks) ft, ^� ft.
ft.
4.Date Well(s)Completed: Well IDNf � j,
Sa.Well Location:
ft.
Facility/Owner Naitic Facility iD#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Z,ip .i'. 1 ,
21 sIiEMA1ZK _ ntrV.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
Signature.ofCetti6cd Well Contractor Date
6.Is(are)the well(s):,.Fffler—mauenf • or C.7Tompor•aty ' By signing this form, /Whereby certify that the well(.)was(were)constructed in accordance.
with/SA NCAC 02C.0I00 at-15A NCAC 02C.0200 Well Construction Standards and that o
7.Is this a repair to an existing well: LlYes or alwir— copy ofthis record has been provided m the well owner.
If this is a repair,fill out known well construction information and explain the nature gl'the
repair under921 remarks section or on the back gfthisform. 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: consiruction details. You may also attach additional pages if necessary.
For muhiple injection or nun-water supply wells ONLY with the sane construction,you can
submit one form. SMIMITTAI.,fNSTUC:TIONS
9.Total well depth below land surface:_ 1_ �___ _ (ft•) 24e, for All_Wells: Submit this fgnn within 30 days of completion Of well
For nudtiple.wells list all depths ifdifferent(example-3 r@200'and 2@100') construction to the following:
10.Static water level below top of casing: _ ,�'Q _ _,(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"F„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11,f3orelrole.diameter:
6„ 24b, For, Inice ign Wells ONLY: In addition to sending the form to ill(,,address in
(iu.)
24a above, also submit a copy of this f(rrm within 30 clays of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.ouger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEI.I S ONLY: �~ 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Suppi &Injection Wells:
13n,Yield(gpm).-_- --_-...._._._._._. Method of 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 health department of the county where
_ ---- constructed.
Fornr Gw-1 North Ctrrolam Department of Environment and Nanual Rosources--Division of Water Resources Revised August 2011

Q�oce��
•m Macon County NEW WELL CONSTRUCTION
E Public Health CONSTRUCTION AUTHORIZATION
''d • a' 'PRIVATE DRINKING WATER WELL
WMichael Wagner • 120921-P • 092022 S
Single-Family Well Only setbacks Residential _ _ _ 7459840864 0.29 —
• • Highlands Road to 4800 Horse Cove Road-.Highlands
— — —
Hic�hla_nds Road,to 4800 Horse Cove Road-Hig hlands
----------— --... ............................
— -- ....--_---—
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. .
Maintain minimum setbacks as applicable, including 50'minimum from septic tankage and 25'minimum from building perimeters.
Diagram (Not to Scale)
LZ
4�V
Approved
_ Well Area
(10'x 6') I.
120921-P
6• (25'Nlin)
r ,
fr
r r
_ c F:•
r -
r• .
- — -- — - (30'from C/L)
This permit is vapid for a period of five years except that it may be 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 MCPH 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'NSTALLATION. QUESTIONS?[phone]
Issue Date: 10/7/2022 Jonathan Fouts, REHS 1979 —_AuthorizedStateAgent