GW1--04710_Well Construction - GW1_20230724

•
WELL CONSTRUCTION RECORD ••
For Internal Use ONLY:
This form can be used for single or multiple wells -
1,Well Contractor Information:
Mitchell Dean Cook • ��� A .rtl. - ...,::•:'�%r..t.a.- ,. ...>Wa.o,t:>.......,,t4..:yv...,.,.:�.,.
FROM TO DESCRIPTION
Well Contractor Name ,r*O'ft. /-/i ft. I ,
2043 A ft. auiY� . rt
NC Well Contractor Certification ?IS:`.O. �i R N '' �" r�` m;:. 'y:C};x+%::`
Number 11 E•$'GN,41PI `(fOlaaigiBi'd)ratiY.Of.IyI: ';lkt(Itil)jjilic File)].: >;,: ..::Vi .v:
FROM TO DIAMETER ' THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 0 • ft
70 r ft. �i� in. r�� 4 V c
Company is i J ', ,.,.
p ly Name '1" 11V1?7E�Zttt''•i1;Sii`I�r:(311;•`;!<tUg�V(r.. a�df a hiiil;'cl' <:z,.,�:,.t,.,. :::ts ':=:.
• .+" ?(>; if k o3iSd+I"o,�Op);'`„ueL:},l:ti�X:.^.�tf.i�:T'T�X:=n
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 6 57 1� 'P n. _ -- -
List all applicable well permits(i.e.County,State, Variance, ft. ft. . i
Injection,etc.) - _
ft ft. in.
3,Well Use(chec
k well use): +.j�t/,}p ,
=.110,.0REI F44 i t, [ei. ;i,?: : ;?.SO'l..i zCF,. %? ,,:
Water Supply Well: "�..1,;..�., =::;x..:::...t_,:;:''s
••—FROM TO DIAMETER .SLOT'SIZE THICKNESS MATERIAL,
°Agricult rat CDMunicipaVPublic ft. ft. in.
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
° ,ass .:r,• dx4'c 3., arias :n.
°Illdllatrl ��$�� .e%` a";�` � .
al/('Olnine %l._..�11n.1?�'`� :'i'i �r.> ,,,i•�=fe6��;'-
rciai �I'�2esidential Water Supply(shared) , :;. ........... :�Y<'�> %;�::,: �+z,,.:�::':<'.�ti'%%a.,..:..,ors,;:..:,;?is....<<.,:.. =
FROM • TO MATERIAL EMPLACEMENT METHOD4 AMOUNT
❑Irrigation
Non-Water Supply Well: - L3 • ft. 3 ' ft. Pa f7 'J . a /Rs3.,s' ,/6 m.�eJ,
°Monitoring ❑Recovery 3 ' ft. , o , ft. -,• i. f. -
Ae7s 2/ Ari
Injection Well: ft. ft. !�
°Aquifer Recharge OGroundwaterRemediation s,.19> AND%fit A•\E r'kticf`f'Fe 4'L .•4Y4�<F�§Jty _���!
• � , i P .(� prjd dii�e)i;'�;..-..,..^.Y.:-�.J11..? ti,.
• ❑Aquifer Storage and Recovery iJSalhtity 13arrier FROM TO MATERIAL, EMPLACEMENT METHOD
ft. ft.
DAquifer Test OStorntwater Drainage
ft ft.
°Experimental Technology (.7Subsidertce Control
ClGeothermal(Closed Loop) °T'racer ?`2Q•DRT14010.aa1 rittaci�aaliioni tsslit e;�n`geriiiti "r?arc:': 41:•. ; :_::
FROM TO DESCRIPTION feeler,hardness)soil/rock type,grain size,etc.)
•
, °Geothermal(Heating/Cooling Return) °Other(explain tinder 1121 Remarks) ft. ft.
ft. ft. Rg -•e+ ® F•1
4,Date Well(s)Completed:06-2/)---23 Well ID# 6_-�...^--±•� -.....>
ft. ft,
. Sa.Well Location: ft. ft. JUL 2 A 2(J2J
r J s L'o.,4' CCC-375)11;e4-)_ 15 0`�`44670 ft. ft.Pacific/Owner Name _ _ r,,.i�em?JR;I i�fP.:'- f, Utt Y crlity ID#(if applicable) AIM..• . ft. ft. Df M+
C3&f h&/ <-'4 y s- J _/r o/. _ ft. fa _.
Physical Address,City,and Zip T'i3'SRE1FhA1tIGx -`r'f'"^•` `i5'% ,. .sign Ai%:.....Ti.:v: i;.:< <ts:'• i•a't
Comely Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
Signature of Certified Well Contractor . Date
6.Is(are)the well(s): IZPiicnanent or °Temporary
By signing this form,!hereby rent fy that the well(s)was(were)constructed In accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or ( Ni copy of this record has been provided to the well owner.
if this is a repair,fill out knowtr well construction Information and explain the nature of the
repair under#21 remarks section or on the back of this form, 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: construction details. You ntny also attach additional pages if necessary.
For multiple.Injection or non-water supply tvells ONLY with the same construction,you can
submit one form. SUBMIT'TALINSTUCTIONS
9,Total well depth below land surface: 3,67.5- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: /el i (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•I-" . 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary - construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _75 Method of test:� Air lift 24c.For Water Supply&Injection Wells:
---------
Also submit one copy of this form jwitltin 30 days of completion of
13b.Disinfection type: H & H Amount: 2 OZ. __ well construction to the county health 'department of the county where
constructed.
Fomt OW-I North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013

?,4., Macon County
o' J
P blic Health NEW WELL CONSTRUCTION
.d..`.'s' CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OL"iiiER .CCJS,LLC LOG# 051723-P OSWW ':N/A
INTENDED USE >Shared.Well, Residential PID # 7504484670 ACREAGE
�3.76
LOCATION ;388 Bethel Church Rd
DIRECTIONS ":Highlands.Rd to L on to Bethel Church Rd,to 388 Bethel Church Rd
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.
Well shall serve no more than 14 connections,or 24 individuals.
Diagram(Not to Scale)
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This',unlit 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 QR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTION . 828)349-2490
Issue Date: 6/7/2023 Josh Wilson, REHSI 3227 AuthorizedStateAgent