GW1--05227_Well Construction - GW1_20240903

J.,Ia CONSTRUCTION RECORD ....._-_--......------
For - ---
'fins form can be used for single or multiple wells Intentyl Use ONLY:
r
1.Well Contractor Information: _
Mitchell Dean Cook is WATER ONES•
• �- -- -
WellContractor'Nate ""'-" " ----^ -- ,__._.
2043 A
NC Well ComractotCenitication Number 15,nUTER(:ASING. for:multi,eased•wells'ORLINE if ^1{eable
-FROM, TO S� P �.RIAL__.-
Dennis Holland Well Drilling, Inc, DIAMETER iFIICKNES. MATERIAL
Dennis _
_ O , rt. It, in. -
------.._.. _ __ .- 6 'sue.�� I Pv
Company Name ;� -/___ _ _ �' • I.6;INNER CASING ORiTU8 G' eothermal.closed-loo
2.Wall Construction Permit//: 7� a� FROM TO DIAMETER 7 ''i MATERIAL
040
Liar all applicable well permits(i.e.County,State, Variance, rc.)_.....-.__-_...�... rt. ft. ^ _ in.
•� � V
ft. io.^ �-
fr.
3,Well Use(check well use.); __,,,____ -
17.SSCREEN T ------------
WMer Supply Well. �- -"- FROM TO�- ER SLOT.SIZE TIIIC
_ FUVRSS MA�I'F: 1AL R
()Agricultural 1JMtmicipal/Public ft. ft. _DIAMETin.
T
°Geothermal(Heating/Cooling Supply) 7 sidential Writer Supply(single) '~ ft. ^'�ft.-^^ in. -��
Dlnthtslrial/Conunercial IB.�GROU1'_._.-.-.-.----"T�"-""'
t.3Residential Water Supply(shored) _ _
f 111TIta11011 ,_FROMT_"'To _ _ MATERIAL EMPI.ACEM ENT METHOD 0.AMOUPCT
Non-Water Supply Well: '' --- 0 •ft. , ft. y4, ^•:? eJ P
°Monitoring �� 1.3Recovery _f y R• j 1 fr. _ -
Injection we:i �'- "-• _ ft. ft.
°Aquifer Recharge - ()Groundwater R.emediation 1.9,SAND/GRAYF7;PACK If.A IICgh.Ie-
()Aquifer Storage and Recovery I)Salinity Barrier / FROM TO MATERIA•_-��- EMPLACBM}HTMF.THOU M_
ft. _ __ ft.
°Aquifer Test 13Stonnwater Drainage - -- _ -- _-
Technology()P.xperimentalft, ft.
0Subsidence Control _ _
20.DRILLING LOGCattacli additional sheets if neeesb l_.•
°(ie.0lhermal((:lased Loop) liTraceP FROM TO DESCRIPTION color,hirdoeas,soil/rock 1,,,-1 2la�ei'rdn sill,rtlf.L^
f°Geothermal(Hcating/Cooling Return) °Other(explain under#2l Remnt'ks) ft, ft.
4.Date Well(s)Completed:4)6"- Z Well III/ /Y/ �.- �� _ �-
___. rt. -ft. .._ - .
Sn.Well Location: • -- - - .._.
y gar Q���L X..lr ` e t.. ft, ft. S E f r 202
Facility/Owner Name Fncility1DY(if applicable) -
ft, ft.
/-
Physical At css,City,and Zip 75 ) /9.5 ,.-_-_,__.�_.__ ^. -
2.) 21.REMARKS
County Ptu'ral Identification No.(PIN) ^------ -' ..
^_____ ^^ T-
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: -
(it well field,one IaViong is sufficient)
� .Z _ --5-'. ! c,_/ w ._.A 1, 1' : ... /. _._ik"...apz...__CeP��__. &'� .6- frt.
Signature 0fCertitted Well Contractor .. Data
fi. Is(are)the well(s): (411efillanent or f.1 cmporasy
fly signing this focal,/hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7. Is this a repair to an existing well: (7Yes or 1 - copy of this record has been provided to are well owner.
if this is a repair,fill out known well consnvction inlormnton and explain the nature of the
repair under 1121 remarks section or on the back of this form. 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:_I _ _ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ON6Y with the sante construction,you can
submit one form SUl1MITTAL,INS'l'UCTIONS
9.Total well depth-below land surface: ,�, 4 ._..(ft.) 24a. qL ll Wells: Submit this form within 30 days of completion of well
Fur multiple wells list nil depths if different(example-3 t 200'and 2®l U0') construction to the following:
/�� T ,__-__ _(ft.)
Division of Water Resources,Information Processing Unit,Static water level below top of easing:
limner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 _ _ (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
Rota fy 2'Ia above, also submit a cop)' of this fi mi within 30 days of completion of well
12.Well construction method:^ _- _ _______ constuuction to the fiillowinl;:
(i.e.auger,rotary,cable,direct push,etc.)
__ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: T -T 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield nl _..__ / Air lift 24c.Fur Water Supply&Injection Wells:
(gP ) ,L5_:___.._..__. Method of test:__._.._.__._._-_._........_
Also submit one. copy of this form within 30 days of completion of
13b.Disinfection type:•I_{•.&..H well construction to the, county health department of the county where
Amount,.12„c_z,,._..._.-_.-.
-- _:__._.:_ _ constructed.
Revised Augu
st umat 201.1
OW-1 Notth Carolina Department of Environmcnl.and Nat cal Resources••Division of Water Resotuccs

Ivotece
Al It Macon County 1830 Lakeside Dr
c Franklin,NC 28734
,� Public Health (828)°+d � [e-mail]
WELL CONSTRUCTION AUTHORIZATION
Owner Lorna Cook WEL 080824-1 SEP N/A
Location 201 Sage Road,Franklin PID 7514145698 ACREAGE 0.57
Directions Highlands Road,left onto Sugarfork,left on Sage Road,last house on top of hill
Desi•n Single-Family Well Permit Ty.e New Construction Ex.iration Valid for 60 Months
P/L
•
Propane Tank
Sage Road Proposed Well
\ 91'
111144S'
a
P/L
O JSe
cois-
Diagram not to scale
Permit Conditions
1) Well shall be constructed in compliance with all 1SA 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.
August 14, 2024 A „' * H'Vfl
Issue Date Anna Hokrein,REHSi 3384