GW1--03316_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD For Intentgl Use ONLY: - -- --
This form can be used for single or multiple wells
1.Well Contractor Information: _ "- _._.._"
14.WATER ZON1$ ^.._. • .._� _
Mitchell Dean Cook FROM __To ' -"oEsclt�ngn _ ___
Well Contractor Name �� C1; ft. 76' ft.2043 A / rt i�t: ___ _
fzYL .,,iki! _
NC Well Cootractor Certification Number 15,OUTER CASING Sformulti-easedwe11s).OR LINPR(if ap licabtel_ ,,,,-_�„
FROM tie DIAMETER THICKNESS ATER IAL
Dennis_M_olland Well [drilling, Inc. �- M ii rt. AM.,. in. 6�4, 2? i _/4, ,_
Company Name ___. -- � •16:INNER CASING OR'TUBMEgeothermal closed-loo
FROM- TO - DIAIAMF.'ft:R THICKNESS MATERIAL. - 7 i
/ r in.
2.Well Construction Permit N:9r.F/,? �./ __ _ a ' ft ft' �• ' _ �.�d fl �__ ____
List all npplicnble well permits(i.e.County,Mare, Variance.Injection,roc.) ft.- ft. in /O
3.Well Use(check well use): 17,Sf tREN _..._^ . ._';
Water Supply Well: T - '^ FROM TO____.... -DIAMITEER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
°Agricultural 17Municipal/Riblic _�� ---_----- ---
_
❑Geothermal(ltcating/Coohng Supply) 7 ft. ft in.
idential Water Supply(single) __--_... -.____--_.-.T�
Olntlustrial/Commercial ❑Residential Water Supply(shared) 18.GRUUT
FROM TO _ Tail A_rERIAL� EMPLACF.M ENT MET1140 b AM(WMr
Lllrrl•atioll fl :a ff rGl C �>�• -J- ic c /-� lRl:
Non-Water Supply Well: - •_±, + R.
°Monitoring °Recovery t. - -� :r '� r,� -
_ _ - ft ft.
Injection Well:
°Aquifer Recharge °Groundwater R.emediation 19.SAND/GRAVEL.PACK(if applicable)
` FROM TO DIATERIAIL EMPLACEMENTMFTHODT
(JAquifer Storage and Recovery IjSalinity Barrier ft. ft _-
0 Aquifer'1•est OStormwater Drainage ft. _._.__ ft.
[JP.xperimental'Technology l.7Subsidcncc Control 20:DRILLING LOG:letach additional sheets if nccesaag)_ __
°Geotherlmal(Closed Loop) ❑Tracer FROM __ TO ^DESCRIPTIONjcolor,hsrdoesstsoiVnck If.,gnin size,ets „-_
°Geothermal(Heating/Cooling Return) °Other(explain under 821 Remarks) ft ft.
_� -___ _ --�,.�__^__ _ -�_- -- •--
/) ft. ft,
4,Date Well(s)Completed: t.45 jell IDN__/V1 ur. __ _. ,`ft ft.
.�-- `` k.
�___ 4 ..�♦ _,..t lr _ o
Sa.Well Location: ft. ft. I,r f;��
/ /l - J it I 1 V _-iTErt•_.__�_-_.-.--_..-
C1Zar/c'am�t tl .yam �_T __
Facility/Owner Name Facility IDS(ii applicable) It. ft. iir�v _.` r---. 4:- Unit
,per I'( J _- r „S ,_„_ ___
Physical Address,City,and Zip 21,REMARKS •,• _ -_ _. _._._..__
l t�/ Si e evL _.. y •
County Parcel Identification No.(PM) -___ �/I/ wc' __cubs?� __„____•_.__-
5b.latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce-r-•h-fic�atio�n-:
(if well field,one lat/long is sufficient)
3.,5< / ' ‘ U2'' :=f'S" .2% -�_,4 _ w 1A/i i t6:A. /1__1)L !klei__C:,:6'-- Date
"` Siimature of Certified Well Contractor
6.Is(are)the well(s): pc manent or °Tcmporaty By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 01C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Wes or 84115-.
copy of this record has been provided to the well owner.
If this is a repair,ill out known well construction injo•+nation and explain the nature oldie 23.Site diagram or additional well details:
repair under#21 remarks section ar on the hack of this form. You may use the back 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:
For multiple injection or non-water supply wells ONLY with the same construction.you can 5U13MLTTAL.INS"1'IICTIONS_
submit one form. rUl t
9.Total well depth below land surface:
ft. 24a. Mgr We118: Submit this form within 30 days of completion of well
,��.....-.__..__.--•--------•--( ) cnnstluction to the following:
multiple wells list all depths ifs (rxantple-?rr 200'and 2CI00')
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:__••-7O ___(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use
246. For Iniection Wells ONLY: In addition to sending the form to the address in
I1.Borehole diameter. 6„ _ (in.) 24a above, also submit a copy of this form within 30 days of completion of well
Rotary
12.Well construction method: __ consuuction to the h>Ilowing:
_-.• __ -- ------^•-"
(i.c.auger,misty,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 SuD&di injection Wells:
13a.Yield(gpnl)_,_ O ____.._....._ Method of test:-_._..._____._.___.__-.•_.._._ Also submit one copy of this farm within 30 days of completion of
I &
13b.Disinfection type:.____ .._
. ..
12 oZ• well construction to the, county health department of the county where
-_-__-
. _.::....._..._...._...._-. constructed.
_ . Amount:
'-' Revised August 20I1
Form OW-I Notth Carolina Department of Enviromnenl and Natural Resources--Division of Water Resources

,11111111111111.11.11.1.11
1830 Lakeside Dr
Q�oteor.
( m Macon County
Franklin,NC28734
� � (828)349 (Office)
° ,m Public Health (82H)349- -2490 4136(Fax)
WELL CONSTRUCTION AUTHORIZATION
WEL b - SEP • L -
owner WE •
LL PID f, '�; : ACREAGE o 3�
Location �.
Directions .r�, t2k �W , i Expiration Valid for 60 Months
Design :4 , ire I.1'n.�.Lt;.1} •ermit T .e New Construction
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Pit-
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Text Box
Diagram not to scale
Permit Conditions
1) Well shall be constructed in compliance with all 15A NCAC 2C rules.
2) Maintain all minimum setbacks, were applicable. /
3) When well and pump are completed, and home is ready for CO, contact MCPH for inspection. 4, <4 'lif
. f 4
The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking with appro ri 1 .elq ng
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 NC,A.Q,2 1 .al?
ra_
Standards are incorporated by reference into this document,including any subsequent amendments to those rules,and shall be adhered to,Pf i r , I _ .I r-
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. te.•' t r47 *'''
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