GW1--03507_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD �' 5
This form can be turd for single or multiple wells ___ For Intenud Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook ii4.wATBR r'OIVES __
• _FROM TO DESCRDTION
Well Contractor Name �fglite. ,y ,f' ----
2043 A ft. o4l�,/- ft.
-- - -
NC Well Contractor Ccnification Number 15.(A TER CA3UVG.Sror multi eased wells'OR.LINE—if a llwble ------
FROM TO DIAMETER THICKNESS T MATERAL.
Dennis Holland Well Drilling, Inc. /Jd D, 7.,ft. �., in. /� �I QQ�/
Company Name _'" e;�'.2/ y
16:INNER CASING 012;TUBMIG,(Reorherm_aLclosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: • ft. in. — "-
tt.ian T._.
List all applicable well permits(i.e.County,State, Variance,Injection,air)
_... - -- .. -— - _... __ �_^-
3.Well Use(check well use): - __,__x y
17.SCREEN - -
Water Supply Well: ._PROM f0 DIAMETER SLOT SIZE -THICKNESS MATERIAL
°Agricultural LOMtmicipal/Public -- ft. ft. in.
rlGeothermal(Heating/Cooling Supply) 7 sidential Water Supply(single) ri. (t._4__ in. '—
Oln<htstrial/Conunercial LT Residential Water Supply(shared) 18.GROUT _ _.___-_FROM TO
MATERIA EMPLACEMENT METHOD&AMOUNT
fltrrigadon — 1 L �
Non-Water Supply Well: ft. , ft. iFiV e7j�, .�`aih/-
❑Monitnring DRecovery 3.t fr^ v i ft. 1,I.Y ? _ ' ,
Injection Well: -""— ft. rt.
[]Aquifer Recharge DGroundwatcr Remediation _ 19.SAND/GRAVEL PACK(if ap halide
['Aquifer Storage and Recovery (:]Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD_.
It. T ft.
0Aquifer Test DStormwater Drainage
fe. ft.
OExperimental Technology DSubsidence Control
20;DRILI.(NC LOG[attach additional sheets if necessary)
()Geothermal((Nosed Loop) ❑Tracer FROM TO DESCR IPTIONscolor,hardoraa,aoiVrock type,grain slue n
C°Geothermal(Heating/Cooling Return) bother(explain trader N2I Remarks) ft. ft.
4.Dote Well(s)Completed: --- - e"
9:41 Well IDN /li j<< , ELi
Sa.Well Location: —___
ft. ft. r - - --
N _ _ft._ __ _ _. JUN 14-2021
Facility/Owner N me ._ Facility 111W(if applicable) _.- _----._._.. _._.._.....__
rt. I.. lrAAGr A:L.Y:^.i: ,71'n r.loNe',a+�Um*
t _ _ __
Physical Address,City,and Z.ip 21,REMARKS _
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one Iet/long is sufficient) /
Se 4 2,_�' ,f'4 j-�- 5 S‘ __ 53 / 9Le e .� " 1�l �_/�ell rM._ d =2.9--2aA54
Signature of Certified Well Contractor- Date
6.is(are)the well(s): I(IPancnt or [''temporary
fly signing this form,l hereby certifil that the well(s)was(were)constructed in accordance
��...�^ with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or vitro— copy of this record has been provided to the well owner.
If this is a ropan;fill out known well construction it formation and explain the nature of the -
repair under#2/remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the hack 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 inlrction or non-water supply wells ONLY with the same construction,you ran
.submit one form SUBMITTAI..INSTLICI.IONS
9.Total well depth below land surface:p a,Jr (ft.) 24a. For.j111 Wells: Submit this form within 30 days of completion of well
For maduple wells list all depths if different(exontple• t tc 200'and 1)100') conatlliclion to the following:
10.Static water level below top of casing: 6.0 7. (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.) 24h. For Iniecalon Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: rY _ _______,__ construction to the following:
(i a auger.misty,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
t/ • Air lift 24c.For Water Supply&Injection Wells:
13a,Yield(gpm)....,_ ,I.2,.______, .._ Method of test:----•-----.__--.`..._.._._
Also submit one copy of this form within 30 days of completion of
1-1 & H well construction to the county health department of the county where
13b.Disinfection type:•_-_...... Amount:,12 OZ.
p constructed.
Revised August 2011
Form GW-I Noah Carolina Department of Environment and Natural Resources-Division of Water Resources

Qiotec�
�� rm Macon County NEW WELL CONSTRUCTION
O
a/; �d Public Health CONSTRUCTION AUTHORIZATION
'd PRIVATE DRINKING WATER WELL
APPLICANT/OWNER HM Squared Investments LLC LOG# WEL-041524-1 OSWW# EOP
INTENDED USE Shared Well, Residential PID # 7540583057 ACREAGE 2.62
LOCATION Off Hicks Road
DIRECTIONS Left onto Mirror Lake Rd., right onto Hicks Rd., property on right just past 1029.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks.as applicable& Honor EOP approved permit.
Diagram (Not to Scale)
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v,'pg./F7 Tree li ,: .
New Permitted - age :IieSi. •
i
Well Location o w , E
VP P c ed i
�• .-a. Z___
\,FOP - :it' ? �/
eOtiO {' /
^b k Al'1a C/r . 1 ro,:: Lune Fhllnw.
NN (.'enlcrlirw•aI Small Orono,
2 --- - - - !In,..f'u.,.'•I.I.0
_.........._____ _______ _/____,..'"-s.,:-/..._-I. , /
This permit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change in any fact or
circumstance upon which the permit is issued. Well location, installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. Flow volume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS? [phone]
Issue Date: 4/25/2024 Jonathan Fouts, REHS 1979 S"•krAl `""'' 1' 1 Authorized State Agent