GW1--03506_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD .—____
11tis form Call be used for single or multiple wells - For Internal Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook 14.WATER,%ONES__ ---
FROM RTO DiiSCRIPTION ""
Well Contractor Manic //D, rt. //J r
ft-
2Q43 A '
2�a •ft.�//, ft.
NC Well CootractatCcnification Number IS.OUTER CASING.Sfor multi-cased wells)OR,LINEµsif ap livable),—--
FROM TO DIAMETER THICKNESS MATERIAL.
Dennis Holland Well Drilling, Inc. - A d ft, ' , ft. ,„ in,
-- o�.z I •vc
Company Name 16:INN ,ASING OR:TUB G(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permitft .• _ fr it. in.
—
List all applicable well permits(i.e.County,,Stare, Variance,Injection,etc.)T ' •'! _..__.— _ _
rt. ft. in. —
3.Well Use(check well use): ----------------4.:
17.SCREEN T
Wafer Supply Well: _^ •FROM TO DIAMETER SLOT SIZE TIICKNESS MATERIAL
DA ricultural ft. ft. in. ' '
8 l7Mltniaipal/Plrblic ____
°Geothermal(Heating/Cooling Supply) idcntial Water Supply(single) ft. --ft.', in. - �'�'Y --"
°Industrial/Commercial DResidential Water Supply(shared) 18.GROUT____ "�^_—"�'
FROM L IA I.TO MATER EMPLACEMENT METIHOD&AMOUNT
Non-Water Supply Well: _, t.I • fa8.24p_±ii ft. ft.
°Aquifer Recharge OGroundwater Remediation 19,SAND/GRAVEL PACK ifs lipcablc
°Aquifer Storage and Recovery 1]SRllmlty Barrier ",,_FROM TO MATERIAL EMPLACEMENT METHOD/__i�
ft. ft.
°Aquifer Test 1]Stornrwatcr Drainage --- --
ft. ft.
()Experimental Technology ()Subsidence Control
20.DRILLING LOG(attach additional sheets if necesaa��_
(J(iP.OIIIC[Illal(Closed Loop) LlTracet FROM _..__._ TO DE:SCRIPTIONScolor,hardnesssailfrock i pe,train size,etch__
[]Geothermal(HcatinWCooling Return) °Other(explain under N21 Remarks) ft. ft.
4. Date Well(s)Completed: e:05- i Vell IDH /V A ___�_ ' ft. ____ ft, _ - ,
Sa.Well Location: O. fa _ E-"� _ e L., e/ C Li
P —Z ...__....._-._
n.
ft•
Facility/Owner Name _ ,___-....._....._._..__.___AIN.1_21YZT..._......._
,�t�Y Facility Ifni(if applicable) ft, ft.
._.L.I[_ksd_as H G-y4'-rq �.._�1' �7 ....__._�.ft. f6 '----- --IfAfi'.~n'A:71 r•-!r3f'w;.�y ifT,i'--
Physical Address,City,and Zip -------------
2L
g REMARKS
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) ,, /
3.,5' o_ '-5* ' . . 1.S " W' t '�G�E: /)
l� L ,—JIL2._ Cad — c)S_�Z,p — �..0.LS.t
Signature ofCertified Well Contractor• Date
6.is(arc)the well(s): I111efmanent or ()Temporary
fly signing this form,I hereby cern&that the we/I(s)was(were)constructed in accordance
with 15,4 NCAC 02C.0/00 or!SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: (7Yes or RN-Cr copy of this record has been provided to the well owner.
If this is a repot,fill out known well construction 00rnration and espial,'the nature of the
repair under p21 remarks section or on the hack of this forth, 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: 1 construction details. You may also attach additional pages if necessary.
-----
For multiple injection or non-water supply wells ONLY with the same construction,you ran
submit one form. SUBMITTAL.INSTUcTIONS
9.Total well depth below land surface: SO.5 ' (ft.) 24a. For AEI Wells: Submit this fool within 30 days of completion of well
Fur multiple wells list all depths if different(example.3 tt 200'and 24)/00') construction to the following:
10.Static water level below top of casing: �O ',__ .^,__-__,(ft.) Division of Water Resources,Information Processing Unit,
//wirer le el is above casing,use"�" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6' (in.) 24b. F E InieMoo Wells ONLY: In addition to sending the form to the address in
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:
(t c auger,mtary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WAFER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gP ) � Air lift 24c.For Water Supply&lnjection Wells:
13a.Yield m Method of test:___-._____.____....._.._._
- - --- Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,I-I&,_M._.__._... well construction to the county health department of the county where
Amount:. _Q_•,._.....___..___-" constructed.
Revised August 2013
Form(, -I North Carolina Department of Environment and Natural Resources..Division of-Water Resources
W

Q oteor
•m M a C O n C o u n t 1830 Lakeside Dr
y Franklin,NC 28734
o •
J Public Health (828)349—2490(Office)
° � j (828)349—4136(Fax)
a'
WELL CONSTRUCTION AUTHORIZATION
Owner CCJS LLC WEL 041024-1 SEP 042724-1-043124-1
Location 1674 Mashburn Branch Rd(Lot#4) PID 7503574206 ACREAGE 0.93
Directions Take Wells Grove Rd to R onto Mashburn Branch Rd to property on L
Design Shared Well • Permit Type New Construction Expiration Valid for 60 Months
' 4
•
Nail c�+
4154 Stream
See Se•tic , ipropo�` 4 (35')
Log#043124-1 104' ► it-B se- 2S'Min
I edroo I.`
100'r�
® in i 100 Permitted
Min well SAot
•
' Lot#4
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. (Including maintaining 100'Min to all Septic Permits surrounding area.)
3) When well and pump are completed, and home is ready for CO, contact MCPH for inspection.
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.
May 1, 2024
Issue Date Chaz E Si 3258