GW1--01382_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For Intcmal Use ONLY: '
This form can be used for single or multiple wells ' l
1.Well Contractor Information:
`i14..W,ATER%ONES: I.'.!
Mitchell Dean Cook FROM TO DESCRIPTION
,+ ft. ft.
Well Contractor Name •
2043 A - ft. . ft.
15.OUTERCASING.(or.multi-cased:wellss)ORLINER:(if'applcable)..•
NC Well Contractor Certification Number FROM TO DIAMETER MATERIAL
ft. ft. { in. ✓ty
Dennis Holland Well Drilling, Inc. U ' r�.' ,r:, ITHICKNESS
'`�i . •
16:`INNER CASiNG�OR;TUBINC(geothermal d=close loop) .
Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:„La/8'"
%3a 3.5--9'J.3�'`' ' ft. ft. in.
—
List all applicable well permits(i.e.County,State,Variance,injection,etc) ft. {t, in.
3.Well Use(check well use): 12.SCREEN v
FROM 'fO DIAMETER SLOT SIZETHICKNESS MATERIAL
Water Supply Well: ft, • ft. in„
❑Agricultural °Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) aRgrential Water Supply(single) 1s:GROUT _
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL. EMPLACEMENT• ,• ME7710D&AMOUNT
Non-Water
ft• ft• a �xi30A�d�n /
Non-Water Supply Well: •• ft. J .�+�y,, ��
LiRecovery S f t '2° l'�� l;).. / -
❑Monitol'ing ft. ft.
Injection Well:
❑Aquifer Recharge
°Groundwater Remediation •-19.SAND/GRAVEL PACK.(if:applicable)... EMP•:- • -.
• FROM -TO MATERIAL METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
❑Aquifer Test ❑Stonuwater Drainage ft, ft.
❑Experimental Technology °Subsidence Control 20:DRILLING LOG(attach additional sheets it ueces'sary)`
❑Tracer FROM . TO DESCRIPTION(color,hardness,soitirock type,grain size,etc.)
❑Geothermal(Closed Loop) ft. tt.
' °Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
t
4.Date Well(s)Completed:c ..1�,/W ell ID# /Y../A. ft. ft. ;
S p
ft. ft. ��;�.�1 f� Sr!<r^i.f
So.Well Location: • ft.
ft.
044A15,�n1✓JJILoic.SWGrt'v fit/: /4 . T �___ ----A W
Facility/Owner Name Facility iD#(if applicable) {t ft. � ` ' 2O2y
f
Physical Address,City,and Zip 21.REMARKS - `
•County Parcel Identification No.(PIN) Wg/1 AP7rtJ J0.5-•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(it well field,one lat/loug is sufficient) r,,,,GG,,/
N Signature of Certified Well Contractor Date
G.Is(arc)the well(s): 121K7manent or °Temporary By signing this form,I hereby cert 'that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: cs or [allo
copy of this record has been provided to the well owner.
If this is a repair,fill out known well constntction information and exjtlain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed: 1
For multiple injection or non-water supply wells ONLY with the same construction,you can S- I PAL iNSTLiCTIONS.
submit one form.
y0 Cf ' - .(ft.) 24a. F A lls: Submit this form within 30 days of completion of well
9.Total well depth below land surface: construction to the following:
For multiple wells list all depths if different(rxainple-.L@200'and and 2@i00') Division of Water Resources,Information Processing Unit,
If0. terlev iswater level below top of casing:
-______AL. (ft.) 1 Mail Service Center,Raleigh,NC 27699-1617
water level is above casing,use"+"
6„ 24b. For Injection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter. (1°') 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,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Air lift 24c.For Water Su l Rc In'ection Wells:
13a.Yield(gpm).____, -- Method of test:________ Also submit one copy of this,form within 30 days of completion
of
well construction to the countyhealth department of the county
H & H Amount: 2�C)Z• constructed.
13b.Disinfection type:.- ---_ ___ — "-�
Revised August 2013
Form OW-1 Noah Carolina Department of Environment and Natural Resources--Division of W uer Resources

r� 3
JACKSON
COUNTY
UepplrtmcM or
•
The Jackson County Department of Public Health
538 Scotts Creek Rd.Suite 100 * Sylva, NC 28779
Tel: [phone] * FAX: [phone]
• :: €:
lley DIRECTOR ,. )
gag- ?' -CO ~ 2 l/
O
Well Permit
Reference Number: Permit Number: 2018-13035-9-13566
PIN: 7534-92-7900 Application Date: 2/14/2024
' Owner: DENISSOV, ALEKSANDR City: CASHIERS NC
Address: PO BOX 168 Zip Code: 28717 1,t
• Lot Number: LT C1-A SR 1163 _ _ _
Service Type: Well Permit Bedrooms: 0
Directions To Site: 107N; left on Pine Creek; rt towards Walnut Gap on left; HOUSE#439 on rt
across from Tlmoshaw near tree field.
•
•
Well Depth: - -
' Case Depth: , , -
Grout
• Yield:
• Contractor:
Driller: .
Weil Type:
Well Size:
Stay 25' from any building perimeter, Stay 100' from any,septic system and repair area. Stay 25' from
•
creek, stream or river. Stay within property lines. Well shall be cased to a minimum of 20' below ground
• surface. Attached drawing not to scale. Stay out of power line right of way, Stay out of any road right of
way.
THIS PERMIT EXPIRES ON: 2/15/2029
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL, THIS
DOCUMENT DOES NOT GUARANTEE YIELD-OF WELL OR POTABILITY OF WATER.
Remarks: - --— -- -- - - -- .-.. -
ATTACHED WITH YOUR WELL PERMIT IS A SCREENING REPORT WHICH SHOWS ANY KNOWN SOURCE
OF RELEASE OF CONTAMINATION THAT IS LOCATED WITHIN A 1000 FT RADIUS OF YOUR PROPOSED
WELL SITE. THIS IS A GENERAL LOCATION WHICH ONLY INCLUDES SITES THAT ARE IN DEQ'S SITE
INVENTORIES, AND IN NO WAY REPRESENTS THE EXTENT OF THE SITES KNOWN OR SUSPECTED
CONTAMINATION, THERE MAY BE OTHER SITES THAT ARE NOT COVERED BY DEQ'S AUTHORITY THAT
COUNTY HEALTH DEPARTMENTS WILL WANT TO CONSIDER. DIRECT ANY QUESTIONS TO YOUR LOCAL
COUNTY ENVIRONMENTAL HEALTH SPECIALIST REGARDING SPECIFIC KNOWN RELEASES OR ANY
FURTHER WATER SAMP G THAT BE RECOMMENDED.
Fee: $32 Receipt: //
EH Z f 7 1 Issue Date: z(is/vl
EHS: ARproval Date:
Signature: Date:

. td-11
. ... . .
Jackson County Department of Public Health
538 Scotts Creel( Road, Suite 100
JACKSON Weil Permit
COUNTY SyIva, NC 28779
; 'MVP:Ur Phone: [phone] FAX: [phone] ,
Reference Number: Permit Number: 2018-13035-9-13566
PIN: 7534-92-7900 Application Date: 2/14/2024
Owner: DENISSOV, ALEKSANDR City: i CASHIERS NC
Address: PO BOX 168 ,
Zip Code: i- , 28717
Lot Number: LT C1-A SR 1163
Service Type:- Well Permit Bedrooms: • 0
i
Directions To Site: 107N; left on Pine Creek; rt towards Walnut Gap on leq;1HOUSE#439 on rt
across from Timoshaw near tree field, i
L 1.2 i C&I•Ce.
40 temd r't
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Fee: $,11.e0 Receipt:
EH110117, il 1
issue Date: ZitaZy
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,
,
EHS: Approval Date:
!
Signature: Date:
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