GW1--07344_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD -
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Tlhis form can be used for single or multiple wells • For huern Il Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook A .lSrrE M s;
Well Contractor Name ._____ ,k''ROM TO DESCRIPTION
. ft. ft. -
2043 A _ _ __
ft, fL^�
NC Well Contractor Certification Number ' '"" " ' 1 1 -
;15rdi [a 4ASR (tor nlari=cigggeU'e)Y(�fixORER{if410 ab)e)^t ' ' „•7
Dennis Holland Well Drilling, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
Company Name __ _ _ - n
yl(1:6:INf4l✓, .f Ashy( tjiali,$IN.0.12,,a'aiecualla ed lli8 MO::; a it;:;:;<
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t lei A)+'=.'i:r ...
• FROM '1'0 DIAMETER' THICKNESS MATERIAL
2,Well Construction Permit#:, � T,-2_L[,6 t� 9_ 9..
Lin all applicable well penults(i.e.County,State, Variance,Injection,etc.) 1 ��? r ft //Q •• ft._�-/°II.• lto-��R`2! PVC
3.Well Use(cheek well use): •r ft 12a r h._/`` I� ;fn. fig. 5T 1�'
Water Supply Well: ....._ ---- -._ C `. i `:
FROM_TO DIAMF.TER IT�SLOT512F, THICKNESS •,MATERIAL.
DAgriculturn' UMunicipaVPublic - ft. ft. in.l
OGeothermal(Heating/Coolin Supply) °Residential Water Supply(single)
g pp y) ft. "Ct. io.'�
Olndustrial/Commercialt1' {�: tc '>• <a::
[e}lt$s dential•Water41.
Supply ..�- %)(shared) �i.1`.".�F:it:.�•X.:Cki. iii'�,- �i,�,.�i.�^'
� FROM.. .._.,�.7{0�: ::=�'.":'.-.._c�i��'�`C'�-..••`�L...._.�s.c�,..- �%''�'� ,.;'_�s:': ....,:
[7[rrigution ______, MATERIAL .,,,. EMPI,ACEMENCMETHOD;&AMOUNT
Nau-Water Supply Well: t`ft ct. i
OMonitoring 0Recovory ft r ft.
3 y/* ra6fyC o&-._tt.PC.41._--•-
Injection Well: .__-
fr, ft.
f.7Aquifer Recharge °Groundwater Remcdiation Tif9'SN•Nn%II:ks.'?R`OW(ite""ill '•e"` ,'•Ig
Recovery• OAquifer Storage and mom ___T(r _ MATERIAL, EMPLACEMENT METHOD
f7Sulhtity I3azrier
fr. -tr. i.- ,
OAquifer'fest oStormwatcr Drainage — - ! •
C°Experimental Technology °Subsidence Control ft. fr
2 ,3DRL 1 isn( atdnciitaddi lo"elt9o18 fi (c5eyZy ` ?t _ : ;': '°°OGeothenal(Closed Loop) ( 1'mccr FROM TO DESCRIPTION(colorzhardaess,soitlrock type,grain size,etc.)
, .OGeothermal(hleating/Coolinp Return) °Other(explain muter B21 Remarks) ft, ft. I,
4.Date Well(s)Completed: ( 3a Well 1DIl /U/A _-ft. ._T_..- ft. ___^_! _- _ ^� .
Sa.Well Location: _.._- -- •--- - G *" ,_-•:�
$/,.,/oSoh - ft. ft. z� r, s T :
-rAf v,FSTil.lE4/7S L4 _ _._._. __ - v- 2023-.._._
Facility/OwncrName Facility ___ ft. - — ft. Y--- —�' --
�� ✓f — T ft. �_-- ft. -�._I ...� I r!i;i'm•F,<i-'n ;1r_n_._.3:;- �L
/44 Woo H.4 vEN M_s'T ft. rL I, 5�. ,L �' d<:t
Physical Address,City,and Zip �5t` E
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7 /rs,h .2.s-2g- 37-.S7a.4< !a '..5- .eL aim �.�_L � €.-e ea- 1Ail_
County Parcel Identification No.(PIN) - _i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22,Certification:
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.9-5-43 2>'9 .77 N 8.3a 277 '6 1>i 7" _....w .. 'c r _. _•__. , ..ate ,Q�20,2.3
- _ Signature.ofCettifcd Well Contractor _-__ ________,Date
6.Is(arc)the well(s): Wmauent or °Tempor'ary
By signing this form,I hereby eolith,that the well(s)was(were)constructed in accordance.
with I SA NCAC 02C.0100 or I.SA NCAC 02C.0200 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or lo copy of this record has been provided to the well owner.
If this is a repair,fill out known wall construction information and explain the nature of the
repair under 12/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
S.Number of wells constructed: .construction details. You may also attach additional pages if necessary.
For nnrltiple injection or non-water supply wells ONLY with the same construction,you can •
submit one form. SI111MI'I"I'AI.iNSTIICTIONS 1
9.Total well depth below land surface: .505'-_ _____ (f(,) 24a. For All Wells: Submit this firm within 30 days of completion of well
l•'or multiple wells list all depths if different(example-3 c@200'and 2@/00') construction to the following: ! 1
1 _(ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 9
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If water level is above casing,use"•h-" 1617 Mail Service Center,Raleigh,NC 27699 1617
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11.Borehole diameter: 6u (in.) 24b.for Injection Wells ONLY: Inaddition to sending the form to the address in
Rotary • 24a above, also submit a copy of this?form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
^TT 1636 Mail Service Ceritei',Raleigh,NC 27699-1636
13a.Yield m O Air lift 24c.For Water Supply&Injection Wells:
(gp ) ._._____ __._ Method of test:-_,__._ .._
----- Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type:H &H __ Amount:Amount:_�2 oz._,__,__-___ well construction to the county health department of the county where
�- -----------7- constructed.
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Form GW-1 North Carolina Department of Environment and Nat sal Reso,trecs•-Division of Water Resources Revised August 2013
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fF Jackson County Department of Public Health
„, ��• i- ,- 538 Scotts Creek Road, Suite 100
i JACKSON SyIva, NC 28779 ��� Permit
t. COUNTY
:,r ItiVI„h` Phone: [phone] FAX: [phone]
Reference Number: Permit Number: 2023-24649-9-12757
PIN: 7528-37-5704 Application Date: 3/8/2023
• Owner: SIMPSON INVESTMENTS LLC City: CULLOWHEE NC
• Address: PO BOX 42 Zip Code: - , 28723
Lot Number: LT 14 WOODHAVEN EST
Service Type: IP/Well Permit Bedrooms: 3
Directions To Site: Lot 14 Wo..havcd states �!
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Fee: $680.0 r" / - elpt' I
EHS: • r Issue+ Date: .A, • _ • O 2`3
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El-iS — __ Approval Date: v.F -,
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Signature: Date:- <-ez
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