GW1--03458_Well Construction - GW1_20230518

r
WELL CONSTRUCTION RECO.IZI) -^—
'This forlu can Ire used for single or multiple walls For Intemtll Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook : a,WRF
1z<<I'NESst"T�A<:
FROM TO DF.SCRIP'InON
Well col actor Name ft. ft.
2043 A � ��. _'r-re.•
NC Well CoatmctarC i
vrt ficationNumber :'l.,St�n `P.N•Ri(,'";�YT{Cyi:forimul r�1 'f:) 1.iI. t if:'' f'c$61e•t�st'?;{}'.' '�=i;A.,�•'
,
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc, rt . - W"
Company Nalue - ---- _ _ i ft _ _ ---^ - / VG.
M1,, 1kTPl t}'i.1AsnY(r(il Tu)3pvG:.'a'oi o:oiel;ci5icazlo r-
FROM TO DIAMETER THICKNESS MATERIAL
2•Well Construction Permit#:_ _..Y� Olr ft. ft.
List all applicable well permirs(i.e..County,.Stare, Variance,Injection,rrc.J
•3,Well Use(check well use): ft. ft.
Water Su il Wcll: •-..-_----....�. i:IT/,5`C`RE.F }�-" ;;,.,::,-; .;; ,,�a_A.�.: >,�',.: x�;l, r-------... ,
PI Y FROM TO DIAAfETKR SLOT8IT.E THICKNESS hrATERIAt,
ClAgricultural OMIini''cipal/Public fL ft. in.
OGeothermal(Heating/Cooling Supply) tdrtcsidcntial Water Supply(single) �rt. in.
❑industrial/Cammerci
G]ResidentialWaterSupply(shurcc!) .^i'' ,..,;.�'%4i:<"wr .�,:�s.. ....<.,..:.,;:,..�azva,:,c�„r•,,,,,....,K,T, ;
IJ1CC1 irt1O11
FROM TO r MATERIAL F.MPLACEMENTMFTHO &ANOl1MI
^^"•
ft. rt. _
Non-Water Supply Well: _,_._
OMonitorill r ecovwy It. rr.� w
Ii1Jection Well: ft, ft.
DAquifer Recharge f_IGrouudwaterRemediation <1:9.''.i ' L)/,' i "'L ;; :•t:A.n„r •y if.` -1}-sue.--^
A`YET�.I`•.AC�I�?'i+a""Il�iill.g :::v.4... �};,.�;., .�s:',
DAq uifer Storage and Recovery IJSulhtity Barrier FROM TO MATERIAL. EMPLACE111FNTMETHOD____
ft. ft,
tJAquifer Test CJStormwater Drainage -
OExperimental Technolo
gY L7Subsidence Control
mat(Closed i'211;)liRttl.ttvr3?f';O'(t'at�ae adIt�oailis'ec'rs Iito` is "se..`•` ;,"' ...�A'
0(reother Loop) OTracer • l:``..;;..,::rs' ..:;•
, FROM _TO _ 11ESCRIP•I70N coloryherdne sofa�Uroek rye rein eize cic. _
lJGeothermal Heatiu Conlin Return) C70ther rx lain imderN2l [temarks) fr. ft
4.Date Well(s)Completed: C, -f¢ Well IDN_ _ _ __T.. _ --• - -•-----_. �_ —
Sn.Well Location: .Secmu� i-p.elJwmlq
,
ffrr, �i'a
Facilit
y Facility IDII(ifapplicable) -ft. _ Ct.
-2 ft. n. _ .--- rY t . • s. '' .
Physica�� �
Add css, lip
..-..[.�l.._._«� T7 571 Z �4I;;FIE A�ltl��,.u.......:.._....._......�._...i:j,...:�;`.•:.t.., '�,y-:,�"Lf� r:�: .,.�:�_,^ `''
a
Comlty Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:�
(if well field,one lat/long is sufficient)
J Signature of Certified Well Contractor Date
6.Is(arc)the well(s): rmanent or L71'emporary
0y signing this fora,!hereby r.P•rl fy that the we11(r)a-as(were)constructed in necordmrcr. -
with 15A NCAC 02C.0100 or LfA NCAC 02C.07.00 Well(.onstructlon Standards and tlmt a
7.is this a repair to an existing well: OYes or btlDle-- copy oj'this record has been provided to the well owner.
If this is a repair,fill out known well construction information and exploit the nature.of the.
repair under#21 retnarks section oron the backofrhisform• 23.Site diagra or additional well details:
You m may use the back of this page to provide additional wall site details or well
8,Number of wells constructed: construction details. You nay also attach udditional pages if necessary.
For multiple injection or non-,Pater supply wells ONLY with the same constrrction,you can
submit one form. SUBMITTAL INSTIICTIONS
9.Total well depth below land surface: -'5—Q_-5� _ _ (fL) 24a. Fqr All Wells:, Submit this ibrm within 30 days of completion of well
For multiply.wells list all depths ifdifferent(example-3@200'and 2L100') Construction to the following:
10.Static water level below top of casing:�74 ^_ _ ,(ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,rise."•1" 1617 Mail Service Center,Raleigh,NC 27699--1617
11,Borehole diameter: 24b.For Injeeti n Wcll. ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:-
(i.e.auger,rotary,cable,direct push,etc,).
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WF,LIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: Air lift _ 24c:,For Water Su r�l &Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H ••,•_ . Amount:12 oz• well construction to the county health department of the county where
'- constructed.
rams cW-1
North fountain Department oFlinvironmcnt and Natural Resources-Division of Water Rcsoruces Revised August 2013

Macon County
o � Public Health
n �-� -�� NEW WELL CONSTRUCTION
D (�t CONSTRUCTION AUTHORIZATION
C�/n f- co� PRIVATE DRINIQNG WATER WELL
Samuel and Deborah Mason T� • 121222-P • 122322-S
Single-Family Well Residential OWN 6568475974 5
• • 00 Clint Cole Rd Franklin NC 28734
' B son City Rd to L on Tellico Rd to L on Clint Cole Rd Veer left and go past house number.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from all septic system components.
--
IP P/L IP
130' 290'
51' 20'
9,min
P/L
Ex.Surveyed �� 9�min
;�. cemetery plot 1
A' �� W/ pins
s� 6 S/T 30'
103'
105, 2�
FprpBDRM
oosed
- - - - 154' Home--
120'
20 Soil road 39'
IP 5'
20' 20'
Permitted well
area
(20'x25') �
This permit is valid 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 INSTALLATION. QUESTIONS?[phone]
Issue Date: 1 20 2023 Jonathan Foyts, REHS 1979 / A (�flfn►1y� 5 AuthorizedStateAgent