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Home My WebLink AboutGW1--04017_Well Construction - GW1_20240708 WELL.( ONSTRUCTION RE CORD Iltis form can be tncd for single of multiple wells For Internal Use ONLY:T Y -!I.Well Contractor Information: _ Mitchell Dean Cook 14.w TER zFliS _ FROM TO - DESCRD�T70N -- Well Contractor Niue "' _ ft. — ..,.,,-...,__ i ft. 2043 A ft. ,dl�ft. NC Well Contractor Certification Number IS,OUTER CASING. for:multi,cased wells OR,LINE if a teable • FROM TO 5 - .�.S.-...P IAL7.-._.._...-._ Dennis_Holland Well Drilling Inc, —• DIAMETER THICKNESS MATERIAL. _ ft. ,•'rt. Company Namr. TT-T__—' •1.6.INNER CASING OR::I`UB G c urns:closed-too . w� FROM TO .F- 2,Well Construction Permit N: „D)AMF.rF:R MATERIAL (.ist all applicable well permits(i.e.County,State, Variance,�Injection.eta,) „.-"-_—...-_,... ft, ft y- in. —`-" 3.Well Use(check well use): 1Z SCREEN'_ ____.—.-._--., — __________________ _ Wafer Supply Well: -"— FROM rO DIAMETER SLOT SIZE THICKNESS MATERIAL. °Agricultural l7MtmicipaVPublic ft. ft, in, f:)Geothennal(Heating/Cooling Supply) 7 •sidential Water Supply(single) ft. ft,-�Y'�in.-- "` �- Ulndustrial(C:rnnmercial Ig,G_ROU7°Re '�---'—""'-- sidcntial Water Supply(shared) C1 IRl.ahnn FROM «.,,_ hrATIRIAL. rEa1PLACEM ENT METH/D h AMOUNT Non-Water Supply Well ^T -R - ------- --- u rt. ) ft. r_ _3 f�''''4'.V1 _, .ss �,7/_. . °Monitoring . ft, t^ ft.°Recovery _ (4,w4..!'>, •" / =,Q, �v-,,-1 Injecti 0Well: ----_._ ._,r„-_—.--.._' --._ ------.-- .---R. ft. °Aquifer Recharge D(iroundwater Remediation 19.SAND/GRAVEL PACK if a licuble — — (]Aquifer Storage and Recove . FROM TO afATER1AI. EMPLACEMENTMETHOD....T ry °Salinity Barrier ft. ft. _ _ ...._..... ,_, 0 Aquifer'I'est L')Stonnwatcr Drainage — ____ _ --_ .._� UF.xperimen !3Y OSubsidence Control tal'fcclnullo ft. ft, �_ UCieothermal((Nosed L.00 20;DRILLIN(:LOC.(attaetxadditional sheets if aseesita) • P) OTracef FROM TO DESCRIPTION(clot,ho door,son/reek impale size,eq.,. °Geothermal(Heating/Cooling Retum)._ °Other(explain under 821 Remnrks) ft. ft. 4. Date Well(s)Completed: r. ecl6-;, (Well IDN_ /V �� _-_ —_ ft. ft. r_ . 5a.Well Location: -- -.�—,-�,R--' ' /A 7 A 20i.k.InG ..crc.,,4 . LJL1.Ll, — , Facility/Owner Name Facility ION(if applicable) —••_._.___._..,,,_.,__.______._._..._...._..... � �. 2 J.7 eT.rt2, ,8N.-y-y R4?4,,,r�, -_.-..--fr. —_—ft,--------Uii fl:7Crtw:fsl .,,yam,,;_$ -._..---- Physical Address,City,and Zip 2L REM ARKS ---'—�'�� i f Comity Pairv.l Identification No (PIN) --- - `- -T__ T._ __ __.. Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ______ (if well field,one IaVlong is sufficient) . ,5°: a-..6.F•F i 4C3 _6' w 11-e.;:ii..E LL_. .rla.._Cee-if._. 061�.5_• �:�s4 Signature of Certified Well Contractor• Date (t. Is(are)the well(s): tilPefinanent or °Temporary ay signing this form, l hereby cent that the u•ell(s)was(were)constructed in accordance with ISA NCAC 02C.0/00 or ISA NCAC OW.0200;Veil Construction Standards and that a 7.Is this a repair to an existingJ� .well: ID Yes nr, lam- copy of this recur)ha:bum:p.^ovidad to the well owner. If this is a repair,fill out known well construction'affirmation and explain the nanar of repair under flat remarks section or on the hack of this forte. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well A.Number of wells constructed: 1 — construction details. You may also attach additional pages if necessary. For multiple injection or nun-water supply wells ONLY with the same construction,you ran submit One form. SUBMITTAL•INSTUC"190NS 9.Total well depth below land surface:, _2414.-' (ft.) 24a. &LAJ Wells: Submit this form within 30 clays of completion of well For multiple wells list all depths if different(example-3 a 100'and 2C3a l00') construction to the following: 10.Static water level below top of casing:.__-$4, _, _,_-,_,-_al.) Division of Water Resources,Information Processing Unit, //tears level is above casing,use"." 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6" (in.) 24b. Fob lnjretion Wells ONLY: In addition to sending the form to the address in Rota 2'la above, also submit a copy of this fin t within 30 days of completion of well 12.Well construction method:_ ry _ _ .._-____-.____._._ consrction to the following: (Lc.auger,inlaiy,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 J�Q Air lift 24c.Fur Water Supply&Injection Welts: (gpm)_._ Method of test:__,_,._•_.-_.___. ____ _ Also submit one copy of this form within 30 days of completion of 13b.Disinfection type:,I-I,&.M.- Amount:.12 oz well construction to the county health department of the county where T__ constructed. Recited nu[usi zn I i Forums UW-t Notth Carolina Department of Environment and Natural Resources•-Division of Water Resources \� Macon County q11 ...,,I`� 1830 Lakeside Dr Fr 0 anklin,NC 28734 a• tjPubIIc Health (828)349-2490(Office) o d a' 1 0 li-21 li-57 Id (828)349-4136(Fax) WELL CONSTRUCTION AUTHORIZATION Owner Raymond&Peggy Dills WEL 031124-1 SEP 034024-1 Location 1262 Jim Berry Road Franklin PID 6596567274 ACREAGE 12,45 Directions Sylva Rd, L onto Lake Emory Rd, R onto Jim Berry Rd, Property next to #1176. Design Single-Family Well. Permit Type New Construction Expiration Valid for 60 Months • 40' *b„ 128' Shed p�o�o5ed33p�M p. king Proposed Well i►,n Ory 0\tct` 25' 70'Pink • 19 pt,osedSePt�c /1-13' 14' 1ank25, 70'Blu• 10111—� 0. G 25' 9' 70'Pi . _ i. co ---- ---------- t^ 1 IIB(25%Red)Repair Area t 35' t -----►t (70'x35') t 15'Min.toI Dry Ditch i___ -_------ 70' \i' 155' to Spring Diagram not to scale Permit Conditions 1) Well shall be constructed in compliance with all 1.5A 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. 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 place well into service. Any person abandoning a well must submit to MCPH Form GW-30 upon completion. AI 19 2024 Issue Date T• vor Justice, REHSi 3294