GW1--01389_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For Internal Use ONLY:
'Phis form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 14_wATER-ZONES `�; .: -
FROM TO DESCRIPTION
Well Contractor Name ,2/„.'ft �/ r ft. I '
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2043 A CC�� ft ft. 1 j
NC Well Contractor Certification Number .15:-OUTER,CASING:(for mtilti-cased!.wells)'OR.LINER(if.ap lcable)..
FROM TO DIAMETER THICKNESS MATERIAL ,
Dennis Holland Well Drilling, Inc. v • ft 38' ft 6' in.
cI7R 21 101i4_
Company Name 16.INNERCASIWORTUBING'(geotheeutalclosed-loop):; -,- . -.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:;15023-�5-557-,-/.31.fJ41- ft ft I' ,in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
IL ft. I, in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft rn'I
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft Jul
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation D . ft ..? , ft
Non-Water Supply Well: ,�
DMonitoring 0 Recovery - ft ft. del,•
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation ;'19.SAND/GRAVEL.PACK(it applicable) . =- . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
H. ft
❑Experimental Technology ❑Subsidence Control '
120:DRILLING'LOG(attach additional`sheets if necessary) •: '
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiilrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft.
ft ft. •
4.Date Well(s)Completed:(Q_J9-„74jl Well ID# N./A. ft ft
5a.Well Location: ft ft -�, f.
/L)cacabs, NI.J4 jia /- 4S/,/A . ft. ft I.:,a C L t V L L)
Facility/Owner Name Facility IDik(if applicable)
ft. ft. MAR a h 20Z4
NG 10 7 So c+ 1- ft. ft
Physical Address,City,and Zip - (igt31itno t'+b Pa-.;;;..,rtby+ utcot
�21.<REMARKS; -. �
,_7-?gce ) • Iv,A. L 9t ir:LJln
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I .
(if well field,one lat/long is sufficient)
30 471 7 " N P 3'o d P ' / " w .z -y�=..°Z- � a ex 2.--/9-•2474 .
Signature of Certified Well Contractor I Datc
6.Is(are)the well(s): le .Yermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
,
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
❑ fila?7.Is this a repair to an existing well: Yes or ' 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 on the back of this forin. 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 may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL L NSTUCTIONS
t
9.Total well depth below land surface: S 0 5 00 24a. For All Wells: Submit thi I form within 30 days of completion of well
For multiple wells list all depths ifdferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: j 1 2_ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.)
24b.For IniectioD Wclis ONLY:I In addition to sending the form to the address in
Rota 24a above, also submit a copy ofl 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Air lift 24c.For Water Supply&Injection W
ti Method of test: ells:
Also submit one copy of this form i within 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water i Resources Revised August 2013

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Jackson County Department of Public Health •
_ JAGKSpN 538 Scotts Creek Road, Suite 100 ;
COUNTY Sylwi, NC: 28779i Weil Permit
D;,;;;l',; .Phone: [phone] FAX: [phone]. I
Reference Number: " . Permit Number: 2023•-25557-9.13184
PIN: 7568-45-6896 Application Date: 8/28/2023
Owner: HOOPER, MALCOLM M JR City: Sylva NC
Address: PO Box 909 Zip Code: 28779
Lot Number: NC 107 '
Service Type: IP / CA / OP/ Well Permit Bedrooms:
Directions To Site: 107 South to 7981 I
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Fee: $800,0Q
Receipt: ._
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CFi$: ; /,Q., L9S2 �L Pa„+ Issue ©attar 34�,//2-3____.
FF-9, : _______ ..... _____. Approval ®ate: ______
Signature: _ -_.._.__..w • Dal
doudapp.mktech.neWacksonPermits/Envidea llllPermiUWellPermilDrawirta.asox?EnvHealthPnrmil=1F4r,7 .,PI

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8/31/23,7:17 AM ENV Health Permit I 421
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The Jackson County Department of Public Health
538 Scotts Creek Rd.Suite 10() * Sylva, NC 28779
Tel: [phone] * FAX: [phone]
Shelley Carraway
• DIRECTOR
Shelley Carraway
Well Permit: 14
Reference Number: Permit Number: 2023-25557-9-13184
PT.N: 7568-45-6896 Application Date: 8/28/202.3
Owner: HOOPER, MALCOLM M JR . City: Sylva NC
Address: PO Box 909 Zip Code: 28779
Lot Number: NC 107
Service Type: IP/CA/OP/Well Permit Bedrooms:
Directions To Site: 107 South to 7981
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Well hepthi
Case Depth:
Grout:
Yield:
Contractor:
Driller:
Well 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. 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 8/31/28
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 1000FT- 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 SAMPLING THAT MAY BE
. RECOMMENDED.
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Fee: $800,00 Receipt:
HO' rrsv� Pnln�±r ;issue Date: J311 2-3._.
EIiS;• -- ApProva!!)ate:
Signature: Date: