GW1--04708_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD — ---'- 6/. . ;
This form can be used for single or multiple wells • For Interntli Use ONLY:
1,Well Contractor Information:
Mitchell Dean Coo ....N"siizR.rargEstsk;.; 1:', ;:,wf :a:;j:04,;Q..0 a
FROMj , .___
TO DESCRIPTION
Well Contractor Name j . ft ft.
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2043 A NC Well Contractor Certitcation Number . c"tiw� ft 'I` 61ee i :".FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. - --ft. ��r in. SWAP-.2t / 'J
Company Name �-'"-' _ ""'- � _
6't1.,/l�1E _r• S o-r. te.,' sv.:;:Nt i,';:,.;.
. It i1,.11y('fUIt;TUgU!T.U`�(Redi}ieFiire P�101ted5:lOOP')isaf"r,!�"•. ;�ii�Yv;:: s'e,.-_i,.,;.a
.FROM_ TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 0 7.,, ,. 4�' -/ fa R. . iv.
List all applicable well permits(i.e.County,State, Parlance,Injection,etc.) —^�--^ -
3.Well Use(check wellrr• ft. in.
use): _. a
i. ,. r,,.. i-...s....S,;Iz7!f�GRF�FN'.:r %:i.,:` �'i4�:'�i:�..`',; .f�.•,lr:.•;nr 5.�,,,•^-:...�-^.-.^.r----
Water'Supply Well: .`. �i:_._ ; •:..�. :>r..:r».;-::-,.:,;s<a>:,.'. -:•: •:
,FROM TO •. .DIAMETER SLOT SIZE THICKNESS MATt:ii, .
ClAgricultural lJMunicipaVPublic ft. ft. in.
°Geothermal(Heating/Cooling Supply) t It dential Water Supply(single) ft, ft. in.
DIndustrial/Commercial -'t3;' :. 7'" ", _ ,.<-;• :<-, .::;1.;-:;,
ClResidential Water Supply(shared) _....__... :`.;.;,4>���`�..., . � :>�.::: <:�>�..,�•`'_'`'',:?;;:.:..:,:�s�;c:��r::..;a,.s.:,,,,.
FROM __TO^( MATERIAL, "EMPLACEMENTMETHOD&AMOUNT
❑Irri-anion ft. .-�fr.. ��Q�, � --1
Non-Water Supply Well: _ el . _ / -"`ate 1'c.-.../1'4
°Monitoring °Recove - ' 3..- ,ft,. O ft. -.- /
Injection Well: ry n�a �_'�`��5•` � �?
ft. ft.
(.7Aquifer Recharge OGrounriwater Remediation -=z kSAti ql,` pro;iP,AiC4Itt`i'+a` -x" "i< .I `zis .sr.
S�1<; I (f. E�aGleSr,.�� ?�'��'�;;< ..:��;:':„ :<-sir.+.:;;:,� ...
❑Aquifer Storage and Recovery llSulbtity Barrier FROM TO MATERIAL. EMPLACEMENTMETHOD~.
fr. ft.
°Aquifer Test CIStormwatcr Drainage ---- -.
CIF;xperimentalTechnologY • °Subsidence Control ft. �rt.
(Closed Loop) LO 5liRtEitTha t c): atiac}fikTilirionial.9fieedliYii eigii ,c5;,-
L�Geothermal :5..,. Rs Yyi'.`•�.Y�:aa:rs-'a�r°•..,..-
p) °'Tracer FROM TO DESCRIPTION rotor berdnem,soltlroektype,trainsize,etr.)' '
, °Geothermal Heatin.Cooling Return °Other ex lain wider 1121 Remarks) ft. rt.
4.Date Well(s)Completed: 07-/6T Well ID# /t/_ ✓/. - 3 _
----- ft. ft, t \ ^s'L
Se,Well Location: - ft.t. _ ft, �'"
A aJy y F.s g, e L.L. c a72 9, _2 -s ._._ ft._ JUL 2 4
Facility/Owner Name Facility IDi/(if applicable)^ — — _ _ __ _-__��.---...__.-..._,.20 _.__.
ft.� —fr.
�f1�Flfmayi sci pit+....`�. i
A/eAF �074 Ga/ci/ m•he. A"� it. - _ ft, _ _._. �i �r
Physical Address,City,and Zip r ::,:,a: .:; 1 -T-�,.• ac :, :":•:_s•:.;
s .zAis AK csa i.:<:.v . .. .. a;
AI colt 75/2 p s'reez_l 7 _ _
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:—
______
(if well field,ono latlloug is sufficient)
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3.5'o7QS" N r4'3 y 77 ' P/ i' W -3 r
Signature of Certified Well Contractor Date
6.Is(are)the well(s): (httfe manent or OTemporary
By signing this form, I hereby cent&that the well(s)was(were)constructed in accordance
wHh 15A NCAC 02C,0100-.or iSA NCAC 02C.0200 Well Construction Standards and that a •
7.Is this a repair to an existing well: °Yes or KNe^ copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Information and explain the nature of the
repair under 1121 remarks section or an the hack of this fonn, 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: consltuction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same consiruetion,you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface.: /dam$' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ell depths if different(example-3@200'and 2®100') construction to the following:
10.Static water level below top of casing:- - fd" M(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"E" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b, For Injection Wells ONLY: In addition to sending the form to the address in
Rotary
24a above, also submit a copy of this formwithin 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.sager,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: , 1636 Mail Service Center,Raleigh,NC 27699-1636
) :-�y•_ Air lift 24c.For Water SuLrply&Injection Wells:
(fiPm _13a.Yield ____. Method of test:____________ Also submit one copy of this faun within 30 days of completion of
136,Disinfection type:H& H , _ _ Amount: ____12 oz._,� __ well construction to the county health'department of the county where
' — .. constructed.
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Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

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QcoteC _ .i�� ��:' - _ -�a._.
d .� Macon County — NEW WELL CONSTRUCTION --
m Public Health' _ CONSTRUCTION AUTHORIZATION
°Jd , a5a . PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Baudry Estate LLC ' Y •= LOG# 072422-P OSWW# 0724224
INTENDED USE Single-Family Well,Residential P I D # 752858827 ACREAGE `24.73
LOCATION Near 9074 Gold Mine Rd - , _
DIRECTIONS "t '
Highlands Rd to R on Goldmine Rd,continue past 4074 and parcel is on your'right in a series of bends
li I
Permit Conditions Yr i' �{ 3
-'_=Well shall be constructed In compliance with all NCAC 2C Rules �• -.t r "+ +.
Maintain minimum setbacks as applicable,including 1001 fro-mseptic system components;and 25'from building`perimeters. 3:
—Diagram(Not to ScaleY
, - to4/2./\ r.. ......
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•r Type Vc Drip .. \- N/ b° `1500fh
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�M�16',Oak i4 s• ioo'Min ,::4;:
1,_ ,Zo _ ,
i:072422-S � •%/ fr.‘� �.•
:-
T _ 124 ' Permitted Well
r 15 — _ w Area*-F2 : ._
. ' " 'Permitted Well. =f/►�1 .
, ��
_ „.. Area#1 �� • -
I/I
I.
Big Rock
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Gold Mine Rd
- 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`meterieltcbagge 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 -
I' `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 OgjTHE WELL.IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP--INSTALLATION. ESTIONS?[phone]•
Issue Date: 9/2/2022 Jonathan Fouts,REHS 1979 11IPAut/zor/zec/State Agent
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