GW1--04264_Well Construction - GW1_20240719

W E:LL CONSTRUCTION RECORD For lntem01 11sc ONLY:
ihis no can be rued for stugle or multiple wells
I.Well Contractor information:
Mitchell Dean Cook 14.WATER-ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 'zo�ft.
2043 A
NC WeII G,atraclot Certification Number _15.OUTER CASING. for muiti-cased walls OR;LINE it a^ !cable
S P L._.._..._ .._
FROM Tq DIAMETER THICKNESS MATERUt.
Dennis Holland Well Drilling, Inc, ft. I ft,
16,INNER LASING OR.TUB G" cothsrmal.closed-ion
FROM_ TU DIAMF.'rF:R '1'HI(:KNESS MATERIAL. _
2,Well Construction Permit N: „2 SL-� _ ^� ft. _ _ ft.
14m all applicable well per,wis(i,e.County,Stale, Variance.,Injection,ete) --- - - —- ---
ft, ft. to,
3.Well Use(check well use.):
Water Supply Well: FROM I Jo I DIAMETER SLOT.4I'LC THICKNESS MATERIAL
OAgricultural 01vitwicipal/Public tr. ft, -_ in. - —
rlGeother lin
nat(Heatinp/Coog Su 7pply) ,sidential Wntcr Supply(single) ft, "�ft. in.
��� T_
Uhuhtstnul/Commercial UResidential Water Supply(sharc(I) 18.GROUTUT
FROMM A'rER1AlL, EMPLACEMENT METHODAAMOUNT
rllrrl t1h011__
ft. •- ft.
Non-Water Supply Well: —^ �' 0 __ �Q!��q�+� ►�S -rY�P
/ ft.L7Nlonitoring fr.
_ ter+ c•„-,.�
I:JRecovcry ._.___ r �^I&et�.tl`>r :.�:;,,�.�-. ✓� �'
Injection WrlRechal: ft.
C)Aquifer rge aGroundwater R.emediation .k9.SA_ND/GRAYER,PACK(if.ap lip ca61e)�
�.
(]Aquifer Storage and Recovery l.7 FROM TO MATERIAL EMPLACEMENT METHODSalinity Barrier tr, fr.
OAquifer'rest 05tornrwater Drainage fr --
l]Fxperintental're.chnology (:)Subsidence Control
20;DRIIJANt.LOG attach additional shcc�s iif ncces3!aj_
DOeothennal(Closed Loop) L)Tracer FROM TO _ DF,SCRIPTION(color by irdor�s s fYroek rlpr ain siu�etc�,__
r)Cieothennal Heaton (.00hn Return) UOther(explain under N21 Rr:nlmks) tt. fr.
ft, fr.
4,Date Wells)Completed: IDN , /
ft. ft. - t
$a.Well Location: ft. ft. S Z.
' _ ft, ft.
Facilily/Owner Name Pncdity ITV(if applirablc)
A.
Physical Address,City,and Zip 21.REMARKS.
County Plural Identification No.(PIN)
Sb.Latitude and I,00gitudc in degrees/roinutes/seconds or decimal degrees: 22.Certification: T~�
(irwell field,one lal/long is sufficiont)
Signature,of fortified Well Contractor , Date
G.Is(arc)the well(s): Vf P maocnt or' L'Temporary fly signing this form, /hereby rertify ilia!the,eel/(s)n•or(were)consovcled ur accordance
with 1 SA NCAC 02C.0I00 or 1 SA NCAC 02C.0200 Well Construction Standards and Mal a
T is this a repair to as existing well: (]Yes or W1'6__ copy ojdris record has been provided to the well owner.
if this a n repuu;fill our known well eonsmicoon it for•ination and exploits the naturr o/the
repun under e;ll rerno•kt.terlion nr on the back of this jorin. you
Site diagram or additionalthis well details:
You may use the hack of this page to provide additional well site:details or well
g.Number of wells constructed: l __ construction details. You may ulso attach additional pages if necessary.
For mtibiple injection or nWa•waier supply wells ONLY wilh the sage construcdnn,yet'roll SURMiTTAL,INSTUCTiONS
•-
9,Total well depth below land surface:•,_�QQS_ �_ (ft.) 24a• nr jV__W'01l3: Submit this form within 30 days of completion of well
roll nudtiple wells list all depths ijrlii ferent(example-.1 a 200'and 2@100') constnlction to the followingj:
10.Static water level below to of easing: O'— �_ _ _(ft.) Division of Water Resources,information Processing Unit,
P g' --- - 1611 Mail Service(',enter,Raleigh,N(:27699 1617
//weer level it above easing,use. "+"
6" ?.d 24b. F�LID&tion Y-013. ONI,Y: In addition to srnding the form to the address in
11.Borehole diameter; (in.)
----""' aabme, also submit a copy of this limn within 30 day-s of completion Of we:
11
Rotary construction to the following:
12.Well construction mrfhod:
(i.c.auger,mtaty,cable,direct push,ale.) i)ivisiou of Water Resources,Underground Injection Control Program,
- 1636 Mail Service.Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Alf lift 24c.6'or Water Su 1 &ly njection Wt�ls:
13a,Yield(gpm) Method of Also submit one copy of this form within 30 days of coltlplclion Of
13b.Disinfection ty e:,E�, (,.M_......_..._.. Anlnuttt:. 2 Viz•
well construction to the county health department of the county whcrc
p .... _....__......___._...._._. constructed.
- Revised August LQIJ
form OW-I North Caroluta 0e10111"POrot of I?n m vironcot and NaUual Rwsourees Divisirnt of Water Resolutes

Q�OteCr er /( cAr (_3 ii ivr
m Macon County
1830 Lakeside Dr
o -'7 Franklin, NC 28734
E d Public Health / [phone]
o� of A 4& C)(�D(:� 0 [e-mail]
d . &1Oi,
WELL CONSTRUCTION AUTHORIZATION
• Lucina L. Hernandez 061024-1 061424-1
Lots 12-17 Cedar Hills 6582431117 18
GA Rd to R onto Addington Bridge Rd to R onto Skennah Rd property is the on Right
• Shared Well New Construction Valid for 60 Months
15'
eC�� ,• S6,
Permitted
Well
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� W
Ex
Rd No Cur , a
Bank)
Q� Z °
Q �oa
i .i,
(
QQ ptic ti O
1 S
,
..` Repair urea ��` ' ,' % �0 ;
`.,41 i 4 m
X.
Well o �N
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, 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.
June 20, 2024 G r7" N v'
Issue Date Chaz Allen,REHS 3258