GW1--01944_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORI. For Internal Use ONLY: •
. This form can be used for single or multiple wells
1.Well Contractor Information: •
Mitchell Dean Cook 14.'WATERZONES_.. . . . . . " , '
FROM TO DESCRIPTION
Well Contractor Name /3..It. l36'ft
2043 A ft. ft. .
NC Well Contractor CertificationNtunber 15:`OUTER-CASING'(formulti-cased.wells),OR'LINER(ifap.licable ` -
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. Fa: ft. • ft. in. .5ao/f'.-.21 _ Oi.i
Company Name ,16.INNER'CASING OR-TUBING(geothermal,closed-loop):-
FROM. _TO DIAMETER THICKNESS MATERIAL
• 2.Well Construction Permit#: O t I.5.4. T / ft. ft. in. _
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) - -----•Y
- ft. ft: in.
3.Well Use(check well use): 17.SCREEN �~^ w ��
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft ft. in.
['Geothermal(Heating/Cooling Supply) lt'kPCesidential Water Supply ft. ft. in.
( g/ g PP Y) (p y(single)
❑Industrial/Commercial ['Residential Water Supply(shared) '.18.-GROUT.. ;- . .i` -.: :.;; .
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
['Irrigation a ft. ft. t1
Non-Water Supply Well: es3pf/QsY-J�"Z � y /�" 7��2,
❑Monitoring ❑Recovery 3 i ft .26 t ft- /_�yA, - j� s s!) . J
Injection Well: �� •
ft. ft. f7 ! •�` 1>`J
❑Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if.applicable).. '
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test DStormwater Drainage ft. ft. •
❑Experimental Technology ❑Subsidence Control
-20.-DRILLING LOG(attach additional sheets-if-necessary)-. •
❑Geothermal(Closed Loop) E1Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,Rrain size,etc.) ..
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft
ft. ft.
4.Date Well(s)Completed: a.2..2gr.24Vell ID# At 71:1 • ft. ft.
5a.Well Location: . ' ft. ft -
iliit.e✓/O ei,/e ,u.-5G? <✓. /i6r r ft. ft. u' T < + , ,+r. .•. .
Facility/Owner Name Facility 1011(if applicable) -- --- -- u ��'t,��=L 1 "` l —-
ft _ft. A
• 2
�Zfr e;� y/u v /ed.. ft. ft.
'
�� 20(4
Physical Address,City,and Zip / / ,.21.REMARKS.:. :. , _, - . . l ir;---- h 1., �,',-::,t,;_ un
44 AiO G 4:7 7 S o 7 1 yC/ 2SO _ i.J�'J Q1'.`J)G
County 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): immanent or D'fcmporary By fy )
signing this f ono,I herebyecru that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 infbrntation and explain the stature of the
repair under 1121 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 may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: / S S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list oil depths if different(example-3@200'and 2@l00') construction to the following:
10.Static-water level below top of casing: -z O (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 sendingthe 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: ry• construction to the following: I
(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) YAlf li 24c.For Water Supply&Injection'Wells:
.�0 . Method of test: ft —
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:H & H ,�-_, Amount: 12 oz. __—�_, well construction to the county (health department of the county where
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

11otec.r •
a, ` .m M a c o.'n County 1830 Lakeside Dr
o Franklin,NC 28734
r Public Health (828)349—2490(Office)
°'d a�J (828)349—4136(Fax)
WELL CONSTRUCTION AUTHORIZATION
Owner Melodie Ruse WEL 011524-1 SEP N/A
Location 846 Gregory Rd PID 7506741750 ACREAGE 28.54
Directions 846 Gregory Rd
Design Single-Family Well Permit Type New Construction Expiration Valid for 60 Months
Well Driller Cert# .
.. Y
r I 'I
aid %I
-- -- .___ _ -�5-- - ' ' . - -- - - ----- - - - -- --
Q 7`j /
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d„ y___ _ _
5;.
:1411 a.`c9
Well Area fT7 / 102' .
(10'x5') 10' e
(1170 Fkistni /� t
o
`. Huse I FA/sting r
3
' �`. I Septic I
/
\ /
•
Pond
/ .
. b
Diagram not to scale —_,
Permit Conditions
1) Well shall be constructed in compliance with all NCAC 2C Rules.
2) Maintain minimum setbacks as applicable. Including but not limited to 25' Minimum to Stream and building
foundations, 50'Minimum to Pond and all components of Septic System.
The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking with appropriate governing
bodies in meeting their requirements.This permit is subject to revocation if the site plan,plat,site,or intended use changes.All rules in 15A NCAC 02C Well Construction
Standards are incorporated by reference into this document,including any subsequent amendments to those rules,and shall be adhered to.Please contact MCPH for
inspection when well head and pump installation are completed and you are ready to apply for connection to power.
Any person abandoning a well must submit to MCPH Form GW-30 upon completion.
January 29, 2024
. Issue Date Chaz Allen,R HSi 3258
- IN Li—LIZ 6-2- 2