GW1-2021-01726_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD
For[nterngl•Usc ONLY:
This form can be used for siugle or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 4 wa,::ER:r
FROM TO DESCREMON
Well Contractor Name T-23"L
"I'
2043 A 1,,ft. ft
NC Well Connector Certification Nwnbcr 1S;.n1:•LR.C,A'S7N(�` forrtiiSltrclsbdit; P ,raft>Li1IVF 7(t' 'licdble
FROM TO DIAMETER T1111CKNESS MATERIAL
Dennis Holland Well Drilling, Inc. rt. ft. io. Sam v
Company Name 16• ,NI':R i *0 cot'ermal?ctuleb Ibo �,i• C` :„..-: ..>..,. ,.:
FROM TO DIAMETER TiIICKNES3 MATERIAL
2.Well Construction Permiti'l: .�_o j,Q�• %.2//V- 9 �
List all applicable well permlrs(i.e.County,State, flariance,Injection,elc)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER I SLOTSIZE If THICKNESS I MATERIAL
OAgriculhlral ClMunicipaliPublic ft. ft. to.
❑Geothernial Ht',atin Coolin Supply) (9Residential Water Supply 1 fr. ft. in.
( � g PP Y) l p y(single)
Cllndustrial/Commercial (]Residential Water Supply(shared)
FROM TO I MATERIAL EMPI,ACF,MFN•rMFTIIOD&AMOUNT
rNon
i atioll ft.
-Water Supply Well: ),- ctonitorinB C1RecoveryfL tr tion Well: ft. fr.
uifer Recharge (]Groundwater Remediation
OAgttifer Storage and Recovery ClSalinity Barrier FROM ft. TO tr MATERIAL I EMPLACEMF:NTMETHOD
❑Aquifer Test ❑Stormwater Drainage
fa ft.
❑Experimental Technology ❑Subsidence Control
�"I0.DR11;siN(.r.I.<)'(i:aite6lhHtlltioiialxilti'ecl'a'ffih'`dita ,,r'�.�:�.,:{„�
OGeothermal(Closed hoop) OTracer FROM I TO DE,SCRUMON color,herdae soil/rock tya,grain due etc.
C.1Gcothermal(HeatinpjCooling Return 170ther(explain under#21 Remarks) ft• ft.
fr. ft.
4.Date Well(s)Completed:Ur3-bq- Z/ Well IDN il/1�} fr• fa
Sa.Well Location: ft. ft. ,j -�/
�.��.�
G; i JLfuxNir..•v >r .vl�rf�i�,e /I/-ZA , ft. M Facility/Owner Name dFacility ID#(if applicable) -ft. ft. — t �i--
S- ;�/ r0' S7�' .G'/L'4�d,( C/ ft. ft. -trr L.t c't1.�I .iiil(
�Sfl Il I N
Physical Address,City,and Zip '
Cownty Parcel identification No.(PIN)
Sb,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iaillong is sufficient)
j
'1 V / N. 23 ' /2 '.Z.-5 /y W
Signature ofCcrti6ed Well Contractor Date
6.Is(ere)the well(s): RlPeFinanent or OTemporary
By signing this form,1 hereby ccri fy that the well(s)was(were.)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and ilia/a
7.Is this a repair to an existing well: ClYes or dDNri copy of this record has been provided in the well owner.
lfthis is a repair,fill our known well construction information and explain the nature of the
repair under#21 remarks section or on the back gjthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple Injection or mm�waler supply wells ONLY with the same constracdon,you can
submit oneform. SUBMITTAL,l7VSTUC1 IONS
9,Total well depth below land surface: (ft.) 24a, For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferenr(example-3@200'and 2«100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For Injgction Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.c.auger,rotary,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(gp m) Method of test: Air lift 24c.For Water Supply&Injection Wells:
�1 _ _,�___�M__•�
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of 1?uvironment and Nantral Resources-Division of Water Resources Revised August 2013

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-T /$3I2019 / /' ENV Health Permit g
y
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-; Jackson County Department of Public Health
538 Scotts Creek Road, Suite 100
Sylva, NC 28779 Well Permit i
Phone: [phone] FAX: [phone]
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t
Reference Number: Permit Number: 2018-12114-9-7102
PIN: 7622-29-6332 Application Date: 1/25/2019
Owner: GUILBEAU, MARY K MATTHES City: MYRTLE BEACH SC
Address: 3291 FORESTBROOK RD Zip Code: • 29588
Lot Number: LT 82 HIGH GROVE
Service Type: IP/ CA/ OP/ Well Permit Bedrooms: 2
Directions To Site: HWY 74 WEST TO-HIGH GROVE ON RIGHT S�+' 7
I
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\ Pee: 660 f— _ _ _ _ --Receipt:
EHS• /�"�/ ��/KVl Issue Date:
EHS: Approval Date:
Signature: Date:
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