GW1--06758_Well Construction - GW1_20241112

L1 CONSTRUCTION RECORDO For u,temal Use ONLY:
This form can be used for single or multiple wells
II.Well Contractor Information: — --
}- De..an 1Z WATER Z NES _ I
DESCRI
-_. I l�h�'I �l_l:Ln � FROM TO _ PTION __-r ___^_
Well Contractor Name Q y'7• i ft. ,J ' ft'
_
•
___ 15.OUTER CASING for awlti-cased wells)OR LINER(if appticande) .-
NC Well Contractor Certification Number .. . -
FROM TO DIAMETER _ - THICKNEESS ' MATERIAL:,
: :fin n i S 'i'1011 CLnd 1�lel l D.n i..l.(. l: x�'.- _. . _ _: �e fr. , rr. i. " to: `c%,,e) 1 I:�'Y_?'
Company Name . - • U -.--- 16.INNER-CASING OR TUBING( tbercaal closed-loop) .
/L� FROM_ TO DIAMETER THICKNESS MATERIAL
I Well Construction-Permit t9:•_ bO g�-r -T•- f- - • fn ft. - in.
,.../.it nil applicable well permits(i.e.County,State, Variance,Injection,etc.) It, ft. in. —
3.'Well Use(check well use): 17,SCREEN o
Wsutcr Supply Well: ____ _•.___. __.__ _FROM _ TO _ Y_DIAMETER SLOT SIZE THICKNESS MATERIAL
IL ft, M.
❑Agricultural OMunicipal/Public
IJGeothermal(Heating/Cooling Supply) t? dential Water Supply(single) ft It, in.
°Industrial/Commercial ❑Residential Water Supply(shared). 18.GROUT
FROM TO i MATERIAL. EMPLACEMENT METHOD&AMOUNT
°IfTipLion _ _ — a (t. � Lrrr.�, �
(out-Water Supply Well: — .14' ft
_ t_ pe r.-1.....!7�;^ arit�A)
�iriMonitoting C3Recovery / ft• 20 t (a '�C h t YC' � ' �/1N
Injection Well: __.,_ ft. ft.
:Aquifer Recharge °GroundwaterRemcdiation • 19.SAND/GRAVEL PACK(ifapplitable) __ ___ __---
FROM MATERIAL (EMPLACEMENT METHOD
]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage It,
ft. —
C]fxperimental Technology DSubsidence Control 20.DRILLING LOG(Mora*additional aLexa if0000saar
. ❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(co nr,hardneas,soiUrock type,brain size,etc.)
-[]Geothermal(Heating/Cooling Return) .❑Other(explain under#21 Remarks) it. ft. I •
el.(Date Well(s)Completed:/0•-.2 42. Well IDII--_-/ • ft. - ft. I.
;tn,Well Location: ___._ ,k.�y .y .•., - �
ft. ft. is Y.tm`-
ldi.11.1?+6-1...... I t7�n C_6.--03 ' ' ______J I.
i" • rt. ft. Q�- 2� ��L _. _
Facility/Owner Name Facility ID8(if applicable) - ft ft 4' —
•
-�"Qr 6m6 r�,. ,r nJf :. . ft. )riz.,,... . :z._ • _�
Physical Address,City,and Zip 21,REMARKS "'`•"'-='-`•=r
_,ALS G 2sf_}.Le_. 8 a 9 ___, --- -
County Parcel Identification No.(PiN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lei/long is sufficient) ,
_:-_a$ 'tS}t/ N - er/ r.... �t_____._._w _�� �t� , 7,,:l l.. r`
Signature of Certified Well Contractor Date
• li,is(are)the weil(s): tB ermanent or ❑I empm ary By signing this form, i hereby certify that the well(s)was(were)constructed in accordance
i with/SA NCAC 02C.'.0100 or iSA NC.•iC 02C.0200 Well Construction,Standards and rim a
7. Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
I/this is a repair,fill out known well construction information 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
II.Number of wells constructed: _, •! ___�__ construction details. You may also attach additional pages if necessary
For multiple injection or non-water supply wells ONLY with the souse construction,you con
subunit are farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605� „(ft.) 24a. For All Wells:. Submit this form within 30 days of completion of well
For multiple wells list all depth!f different(example-3©200'and 2@inn') construction to the following:
• Id:Static water level below top.of casing: " Z.�,.t• ' (ft.) Division of Water Resources,.information Processing Unit,
' 'If rioter level is'abode casing,use"+•' •'1617 Mail Service Center,Raleigh;NC:27699-1617
•
/
11.Borehole diameter:_ On /��_ (in.) 24b. Nor In Injection Wells ONLY: In addition to'sending the form to the address i
_
24a above, also submit a copy of this form within 30 days of completion of w.
12.Well construction'tnettiod: ",- l fr QrU' .. _. " ; constructtoflJQ the following:. • . . _ - _- .
fie.auger,rotary,cable,,direct push,etc:.)• ,;,• '.. .,•c . - , , DivisionP
of Water Resources,Underground Injection Control r'"-ranl
FOR WATER SUPPLY WELLS ONLY: _^_ -^_ _-- 1636 Mail Service Center,Raleigh,NC 27699-1636
j ((-� 24c.Fur Water Supply&Injection Wells:
13a.Yield(gpm) / Method of teat: I -- Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:11 4" H Amount: I el OZ• `_ well construction to the county health department of the county where
-^,•-_-_____
Revised August 201'
_ Y^_ - _-_ _ constructed,
Form OW-t North Carolina Department of Environment and Natural Resources-Division of Water Resources

Q,o.teor,
�, �� d -3 a P 1830 Lakeside Dr
e m Macon County
o Franklin,NC 28734
E � m Public Health (828)349—2490
ova Pa�0 [e-mail]
WELL CONSTRUCTION AUTHORIZATION •
"Owner t dnAN. lam'. . , QY n WELI `.hR912d-1 ' SEP ' ,o&3c.zq,f'
t Location• �C e t 6t,e .- 'Cru. 2c& //�g/ r 1 Nc 2R 9,-1( , •, pID . 7sYfl to8�93. ACREAGE', 5,33 Ac
Fdi_rections • --_-- (a,3?A
ti .Design`.r• 5,i4s4e r�t„,;( W,. % ,permitType' ,.. c A ; ;Expiration. . ?/5/2o21
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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.
5 2--Li
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Issue Date
(re...vis i'vlawk