GW1-2021-00345_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD
Fur loternal Usc ONLY:
Tlas form can be uaM for single or multiple wells
1.Well Contractor Information: _
Mitchell Dean Cook 14.WATER ZONES .
FROM TO DESCRIPTION
Well Contractor Name -. 1' ft. Ear ft.
2043 A fL ( 'fL
NC Well Contractor Certification Number 15:'OUTPR OAS INC farmWti-eaaedweW Ok`'INER ff" leible -
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. rL J . H. in. ]) Pb,
Company Name -16.INNER CASINO OR'TUBING eothermaFel6�ed-lob
FROM TO DIAMETER THICKNESS —MATERIAL
2.Well Construction Permit p: .} i).1 C)��/�S j)_i-- e�,-/O /` �- 4 ft. in.
1As/all applicable well permas h.e,County,State, Yoriance,Imec/iam ercJ
ft. ft. in.
3.Well Use(check well use): '17.^SCREEN
Water Supply Well: PROM T(1 DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Mmacipal/Public ft. ft. in.
❑Geothermal(Ueating/Cooling Supply) []Residential Water Supply(single) R. ft. in.
❑Industrial/Commercial residential Water Supply(shared)
FROM TO MATERIAL EMPIACCMENFh1ETRODh AMO11NT
Olrri anon ��
Non-Water Supply Well: 'f� a � / �'.
OMonilor'ing ClRecovery fL : ft
Injection Well: fL ft.
❑Ayuifer Recharge 19i❑Groundwater Rcmediution :SAND/GRAVE PACK fiF'Hceble
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL F.MPLACRMk2,TMETHOD
(t. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental'feclulDlogy ❑Subsidence Control fL fL
❑Geothermal Closed Lou 20,DRILLING LOG'atmeh additional eheele'ifu ease
( p) ❑Tracer FROM I TO DESCRIPTION Oohnu heolnea,soiprock One,indo siere,etc.)
❑(isothermal lieatin Coolin Return [)Other(explain under#21 Remarks) R. m
ft. ft.
4.Date Well(s)Completed: C1/-/'/-Z-/ Well II)k IV, /i R. fL
Stu.Well Location: ft ft
R4rL. Gl iFtkilK� /Us 44 ft. fL
Facility/Owner Name Facility IDa(if applicable) --
f. ft.
i y/l" Lf/ /Y Lr/ S _ fL fL
Physical Address,City,and Zip 21:REMARK$
(:away Pascal Identification Nn.(I'IN)
Sit.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(ifwell field,one lat/long is suRciem)
•� /,(l.1 i �, :s, `i N (a 7 W7y -.Cp ,�+—t._bar.y _
� ,,�� Signauve ofCem i ed Well Contractor Dete
b.Is(are)the well(s): �TtPermanent or ❑Temporary
By signing this form,!hereby certify that the wed(sJ wns(were)constrained in accordance
/' with 15A NCAC 02C.0/00 or 15A NCAC 02C.0100 FVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or e71`1 copy of this record has been provided to the well owner.
1f rhos is a repair fill out brawn well construction information and explain roe nature of the
repair tender k21 remarks.section or on the back of this farm. 23.Site diagram or additional well details:
r, n may use the back of this page to provide additional well site details or well
LS.Number of wells constructed: cstruction details. You may also attach additional pages if necessary.
For muhiple injection ar non-wmer supply wells ONLY with the same conrtiueYmn,you con
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ..�6,5 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wellt,hvaNrlep/hso`diiferent ticeple-3@200'and 2ts100') construction tothe following.
10,Static water level below top of casing; /LSD ` (ft.) Division of Water Resources,Information Processing Unit,
!/wmer level is shove casing.use"r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24h. For Inieetiou Wells ONLY: In addition to sending the fort to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.eager,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 m U Air lift 24c.For Water Supply Ar Injection Wells:
(gP ).____ Method of test:
-- 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 UW-I North Carolina Department of Envuomnent and Nanual Resources -Division of Water Resort c s Revised August 2013

'
JACKSON
.our IT
Y
::C�G.auC`
i
The Jackson County Department of Public Health
S38 Scotts Creek Rd. .Suite 100 * Sylva, NC 28779 i
Tel: 828-S86-8994 * FAX: 828-S86-3493
Shelley Carraway
DIRECTOR
Shelley Carraway
Well Permit
Reference Number: Permit Number: 2020-19802-9-1OS76
PIN: 7539-1B-1966 Application Date: 12/23/2020
Owner: QUIRING, RUTH E TRUSf EE City: SYLVA NC
Address: 12S CRESTVIEW HGTS Zip Code: 28779
Lot Number: GREENS CREEK
Service Type: Well Permit Bedrooms: 0
Directions 7o Site: Hwy 441 South to left on Glen Cabe Rd. to Windbrook Lane on right.
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Well Depth:
Case Depth:
Grout:
Yield:
Contractor:
Driller: j
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 1/12/26,
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS I
DOCUMENT DOES NOT GUARANTEE YIELD OF WELL OR POTABILITY OF WATER. i
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. 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.
Fee: $320.00 Receipt: _
EH$:- /.•/."� /1[-715 /xf7 Issue Date; 11-il LI
EHS: Approval Date:
I
Signa e• _ -- Date: —�