GW1--04947_Well Construction - GW1_20240816

V►/E .4L CONSTRUCTION RFCORD
This can he ed for siugle or muliil,lc wells mi
For Inteyj Use ONLY:
• r^I.Well Contractor Information:
Mitchell Dean Cook _ ---iiTivAiliFiiii4ET�..:.-- .__
Well Contractor NMIe FRROM TQ- ----DESCRIPTION RE77DN -"'"'" - ^' - ^
n.
ft.
NC Well CoatractotCertification Number IS.OUTER G ASINC. tor:multi-eeaed wells QR;WNE kap Iwble - -
Dennis Holland Well Drilling, ROM r PTO DIAMETER THICKNESS
Inc.lac MATBRUL,
Company NUM: ��_�
I. ft, ia.
t6':1 Nra :ASING(7R.:TUBigf;"*o.thtrmal.closed,loo 2.Wall construction Permif li: FROM mTt? DIAMETER—. THICKNESS MATERIAL
Us(all applicable well permits(l,e.Cumrry,Score, Vrrritrnces, V"I' _..___.,_... ft. ft. io.
3.Well Use(checkfLT _ ft- - _ •
io,^ —-_--
well use):
Water Su —""_' -17.SSCR.EN;N_-. •-'__.__._.__...,,,..-N
PPIY Well: �T PRUM •YO -'_DIAMt:TK SIZE THICKNESS R SLOT SI - ' atk .RIAh
()Agricultural 17Mwsicipal/Public rt. ft• in.
f:ICieothennnl(Heating/Cooling Supply) 7 .sidcntial Water Supply(single) ft. �^ft.- '- in,_- '- "
C ----.----- -Uln(ustrill/Connercial LR sidential Water Supply(shared) Ig. ;RUUT"o -�• -
-
Tr -n:anon aoi f MA'IERIA .I EaIP1ACEMEIYT MCTgDZAMOUN
ft.-- - iV f.Nou-Water Supply Well:
()Monitoring
I:Recovery fr.
Injection Welt; --_.__-__ _ _ ._ __ _ ,'T—_ft1. w
ft.
°Aquifer Recharge OGroundwater Rentediation .19.SAND/GRA'VEL PACK
' Aa "caD lr)
--. - .-—_
FROM TO MATERIAL EMPLACEMENT
()Aquifer Storage and Recovery 1:]Salinity Barrier I. ft.
()Aquifer
C3Slonnwate.r Drainage __
°Experimental Technology 173ubsidence Control fly ft. __M
QCieolhennal(Closed Loop) .2Q:DRII,LING LOG��attaelf add itional sheets U neea>a�,• --'1.iTracer FROM TO _ DFSCR1PTION eolor,hudses rojUroek I nln riu,nts.
OGcothern7ul Hratin (.00lin Retrm1 UOther(explain under N2 P Remarks) ��' �" `� )
4. ()ate Wells)Completed: -q�_ 54 Well if)H A,...... . f t, ft... _____ ��-
_......
SR.Well Location:
:�' ,�� �
i /.e l 1�iC 11P 11,E 5 ft. ft. v.. _ .._
Far.ility/Uwnc,NAM �. ae •__ _••••
facility IDN(if applicable) -- ...-_.- -._._._............_.....__._.__--._.__/'__-_._-.._..-.._...._...._._
—CILIA-Cr ft. ft.
- UV-.J
Physucasl1 Address,City,and lip �' T-�--_ _
-.c1 1441ek34r? �5 I D D 21,REMARKS `---_..�.._.� Dfr3.r. e-D 7.r 7—__..__
q 1 Q `.�":.'7
Parcel Identification No (PIN) --________
Sb.Latitude and Longitude In degrees/minutes/seconds ordecimal degrees: __ /_1_____1ll �_ r9"ev s___
- _�_._-_
(it well field.one IaVlm,g is sufficient)
22.Certification:
tion:
3 5° a, 56 . 5,4e4 g-5 't?,9-2Q, q,2Y W t 1-0;::Le.LL_._,ac'rtii.._-_ 6gif_, a R-c s)- -zo a 34
Signature of Certified Well Contractor •. Date
6. Is(arc)the wcll(s): ipefmaocnt or f.'ITcmporar•y
By signing this Jorin,/hereby certVy than the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
1. Is this a repair:o no existingwell: 17Yes or EciNo� copy of this record has been provided to the well owner.
If this is a repair,fill out known well constvction information rind explain the nature of the
repair under 1/2l remarks section or on the hack of this Joan. 23.Site diagram or additional well details:
1 You may use the back o1'this page to provide additional well site details or well
S.Number of wells constructed:_I ___-___ construction details. You may Itlso attach additional pages if necessary.
For multiple injection or non•water supply wells ONGY with the sane rorutructinn,you ran
submit ones form. SUBMITTAL..INSTUCTIONS
9.Total well depth-below land surface: 8 S ' ) '-. 4f t l (l;: -�� daysP
Q ,_,-M. 24a. \I_We Submit this firm within 30 of completion of well
Fur multiple wells list all depths if different('crumple•.i a 200'and 2 100') COnSIIlICIio17 to the following:
((p) Division of Water Resources,Inlonnation Processing unit,
If.Static water level below top of casing:•___ --•
I/water level is above casing,use"-," •__�._..__-_-
1617 Mail Service Center,Raleigh,NC 27699-1617
II. Borehole.diameter: 6 _ (in.) 241. FoL.InAccti.on We..lis ONLY: In addition In sending the form to the address in
Rotary 24a above, also submit a Copy of this form within 30 days of r:onuplction of well
12. Well construction method: _ . _ construction to the tbllowing:
(i.e.auger,rotary,cable.direct push,etc.) '~ •-^.- •.--__
___ Division of Water Resources,Underground injection Control Program,
FOR WA'rF.R SUPPLY WELLS ONLY: - T ___ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpn ' Air lift 24c.For Water Supply&Injection Wells:
Method of test:__, .
-- __' " -'-' Also submit one copy of this form within 30 days of completion of
I;ib.Disinfection type:,�i.&.H, well construction to the county health department of the county where
p ......_ _.._.. Amount, 1?_ oz.
_ constructed.
Form OW-I Not III Carolina Department of Environment and Natural Kesuurces••Division of Water Resources Revised August 2013

, Otecr
• mMacan COunty1830 lakeside Dr
Franklin,NC 28734
tido•
Public Health [phone]
o �a [e-mail]
d • a
WELL CONSTRUCTION AUTHORIZATION
Owner Joseph Jones WEL 071724-1 SEP N/A
Location 1701 Coon Creek Road, Franklin PID 7.517050910 ACREAGE 2.04
Directions N Hwy 23,L Coon Creek Road, property on left
Design Single-Family Well Permit Type Repair Expiration Valid for 60 Months
Coon creek Road
Itt
gs,
Carport Ot`.,„\to
Ns-
50' Min Ex. House
II Ex. Septic
r
eI�
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.
4) Update well head to be in compliance with all 15A NCAC 2C rules.
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.
I �
August 1, 2024 �f �010044einie
Issue Date Anna Hokrein, R384