GW1-2021-00262_Well Construction - GW1_20210125

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells ,
L Well Contractor Information:
Mitchell Dean Cook 14.WATER ZONES
FROM TO DESCRIPTON'
Well Contractor Nome f, , ft.
2043 A H. m
NC Well Contractor Certification Number 15.OUTER CASING for Lbfir ed wnlh OR LINER fffaa, eable
FROM TO DIAMETER I THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. rL o. n. to. -
Company Name 16.INNER CASING OR TUBING eothermal2lwed•loo' -
FROM TOI DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#:la,_„2v - i 5', > > S -y- e�/QJ It. It. im
List a!1 applicable wet!permits(i.e.Cuunry,Score, ✓ariance./nlean..,etc)
fr. ft. in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: Most To DIAMETER sLOT size THICIINDSS MATERIAL
OAgriculmral 0MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n. fL in.
G It
ZR:6 ential Water Supply(shared) 1S.GROUT -
FROM TO MATERIAL EMPIACEMEWMETHOD&AMOUNT
❑IRA 8I100
Non-Water Supply Well: .t - -
OMonitorin8 ORecovery rc -
Injection Well: If. ft.
GAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if• lhaa1g -
GAquifer Storage and Recovery ❑Salinity,Barrier FROM io MATERUI EMPLACGIENf MErH00
fI. fr.
❑Aquifer Test ❑Stormwater Drainage
R (L
❑Experimental'Cechnology ❑Subsidence Control
❑Geothermal(Closed Loop) GTIRC¢t
20.DRILLING LOG'(stanch additional sheeb'ir n sash-
FROM TO DESCRIPTION color hardy aoiVrork rain lye,eta.
GGeothermal Heating/Conlin Return) ❑Other(explain under#21 Remarks) H. fL
fr. (r.
4.Date Well(s)Completed:61-13 n2.1 Well ID# y1/ ZA
ft. fL
5a.Well Location: ft R
Facility/Owner Nmue Facility ADO(if appio.W.)
It. it.
Po rn x K x v ft ft
Physical Address,City,end Zip 21.REMARKS
ar A_.Soo 76.6 C' c�-
Comity Parcel Identification No.(PM)
51b.Latitude and Longitude to degrees/minutes/seconds or decimal degrees: 2
(if well field,one Iat 22.Certification;
/Iong is sufficient)
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): Frermanent or GTemporary yy sopmg thu form, l hereby cart that the wells/war!were)coosouaed u;accordance
whir 1Sd,VCAC 02C s beep en alto t we own Hrell Ca-rrraaiaa Sra^dards and that a
7.IS this a repair to an existing well: ❑Yes or ®Ntf copy offhis retard has been provided to the well owner.
/ffins is a repair,fill out known well construction information and explain the nature of the
repair render#21 remarks section or an the back ofthisform, 23.Site diagram or additional well details:
ou may use the back of this page to provide additional well site details or well
S.Number of wells constructed: c,,nc nstruction details. You may also attach additional pages if necessary.
For multiple i jectron or non-rater supply wails ON/.Y with the same construction.you�n
submnt it onne form CI, - SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ")-SS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list alldeedslfdyrvoi(example-3aW00'andl©l00f construction to the following.
10.Static water level below top of casing: A6 (ft) Division of Water Resources,Information Processing Unit,
lfwmer level tr above casing,use"1- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For toiection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this forth Within 30 days of completion of well
12.Well construction method: ry construction to the following:
0 e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Loderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (o O Method of test: Airlift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

)]AW ►-) C icy
r
The Jackson County Department of Public Health
538 Scotts Creek Rd. Suite 100 • Sylva, NC 28779
Tel: [phone] • FAX: [phone]
Shelley Carraway
DIRECTOR
Shelley Carraway
Well Permit
j Reference Number: Permit Number: 2020-18225-9-9103
PIN: 7650-04-4383 Application Date: 7/14/2020
Owner: GATES, DAVID City: DILLSBORO NC
Address: PO BOX 848 Zip Code: 28725
Lot Number: TR 2B OFF LOCUST CREEK
Service Type: IP/CA/OR/Well Permit Bedrooms: 3
Directions To Site: ;OLD CULLOWHEE RE), LOCUST CRK, PURPLE MTN, 1/4 MILE ON LEFT
i
WiMl Depth:
i Case Depth:
Grout:
Yield:
Contractor:
Driller:
Well Type:
Well Size:
Stay 25' from any building perimeter Stay 100' from any septic system and repair area. Stay 25' from creek,
stream or river. Stay within property lines. Attached drawing not to scale. Stay out of power line right of way.
Stay out of any road right of way.
THIS PERMIT EXPIRES ON 8/31/25
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS
DOCUMENT DOES NOT GUARANTEE YIELD OF WELL OR POTABILITY OF WATER.
Remarks:
ATTACHED WITH YOUR WELL PERMIT IS A SCREENING REPORT WHICH SHOWS ANY KNOWN SOURCE OF
RELEASE OF CONTAMINATION THAT IS LOCATED WITHIN A 1000 FT RADIUS OF YOUR PROPOSED WELL SITE.
I THIS IS A GENERAL LOCATION WHICH ONLY INCLUDES SITES THAT ARE IN DEQ'S SITE INVENTORIES, AND IN
NO WAY REPRESENTS THE EXTENT OF THE SITES KNOWN OR SUSPECTED CONTAMINATION. THERE MAY BE
OTHER SITES THAT ARE NOT COVERED BY DEQ'S AUTHORITY THAT COUNTY HEALTH DEPARTMENTS WILL
WANT TO CONSIDER. DIRECT ANY QUESTIONS TO YOUR LOCAL COUNTY ENVIRONMENTAL HEALTH
SPECIALIST REGARDING SPECIFIC KNOWN RELEASES OR ANY FURTHER WATER SAMPLING THAT MAY BE
RECOMMENDED.
PSS: .4480 00 ReceiQL _.
EH& // 57 Issue Date: 31 Za
EHS: ARproval Date:
.4lgnature: Date:

Jackson County Department of Public Health
538 Scotts Creek Road, Suite 100
Sylva, NC 28779 Well Permit
Phone: [phone] FAX: [phone]
Reference Number: Permit Number: 2020-18225-9-9103
PIN: 7650-04-4383 Application Date: 7/14/2020
!Owner: GATES, DAVID City: DILLSBORO NC
Address: PO BOX 848 Zip Code: 28725
Lot Number: TR 2B OFF LOCUST CREEK
Service Type: IP/ CA / OP / Well Permit Bedrooms: 3
Directions To Site: OLD CULLOWHEE RD, LOCUST CRK, PURPLE MTN, 1/4 MILE ON LEFT
V'
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Fee: 3480.00 Receipt: _
EHS: Issue Date:
EHS: Approval Date:
£gn ur : Date: