GW1-2021-00344_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD For 6„eni4nlaa ONLY
MS form can be used for single or multiple walls
1.Well Contractor Information:
Mitchell Dean Cook 14.'WATER TONES
FROM I TO I DESCRIPTION
Well Contractor Nemc 74 ' h "/ n,
2043 A Is.
fit.
NC Well Coat-cow Certification Number IS:OUTP.RG'ASING formulti-need welb OR.(iWER iR 'Buble
mom TO I DIAMETER I THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. v ft, _; J - H. Z„ in. Its& 1 ✓" ,/
Company Name 16..INNE10CASING OR'PUBBYG'at he .'
FROM TO DIAMETER THICRNES4 MATFRUL
2.Well Construction Permit#: �.!%/% -/ O � 7' cf-/(J S� fr. H, ie.
Lirr a!l applicable wet!permits(i.e.County,3rme, Vnriarrce,lnjec0on,era) --
3.Well Use(check well use): A. ft. in.
'97.SC:REEN
Water Supply Well: PROM I TO I DIAMETER SLOT SIZE THICIINES$ I MATERIAL
❑Agriculhual OMunicipaVPubhc R. fL
❑Geothermal(Heating/Cooing Supply) []Residential Water Supply(single) ft. ft.
Llindustrial/Commercial Residential Water Supply(shared) 18i'GROUT I i
FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
Obligation O f4 1. ft. a
„2G . 'S r' 5 C
Non-Water Supply Well: r,,,1/sl'ft. ft.
❑Recovery
Injection Well: ft ft.
OAquifer Recharge ❑Groundwater Remediation '49:.SANp/GRAVEL PACK-f -like6le
FROM TO MATERIAL EMPIACEMENr METHOD
❑Ayuifer Storage and Recovery ❑Salinity Barrier ft. ft
E)Aquifer'fest LIStornwater Drainage ft f.
❑Experimental Technology []Subsidence Control
Room RIPI'
hING'IiOG etieeh edditidad ( 'Lfn'p1
❑Geothermal(Closed Loop) OTm mom
OM To D&SCION ON co mint hardnew,roiVrock grain s'va eta.
DGeothermal (Heating/Cooling; Rehm ❑Other(explain Order 921 Remarks) fL fL
ft. ft.
4.Date Well(s)Completed:a-JS-,i / Well Ill#- 4 & Is. fL
5a.Well Location: TT f. A.
LgJ)G Y /'L.i -MNacdGYU�L..GG �/, //� D. fL
Feci6ry/O ar Neon, Facility IDN(ifepplicable) --'- ---
fL ft.
C-cane:v d4e{. - Gci7z'lylo lyC� f,,4 r. Lf h ft
Physical d6ws,City,and Zip
Jac-.Y50<3 - e z f
County Parcel Identification Na(PM) '-------"-------- --- ----
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one laVlong is sufficient)
N Y.7`°0.5 1-2'7 W
.S,manateof Cenifed Well Contractor Dam
6.la(pre)the well(c): ®1 s msn•_nt or DTempor^_ry
' By signing this Jura,,/M1ereby carry tear the wells/was(were)constructed in uccordnnre
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Vill Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 6N6 copy of this record has been provided to the well owner
If this it a repair,fill out known well conraacbon information and explain the nature of the
repair under#21 remarks section or ou the back ofthisform. 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 non-wares supply wells ONLY with the same comtrucdon,you can
submit one form. 6 1C`BMl,fl'Al,INSTUCTIONS
9.Total well depth below land surface: /%7 (fL) 24s. For All Wells: Submit this form within 30 days of completion of well
F'nr multiple we!!r list nil depths efdi[(Brent(example-3(t�i 200'and2@100') construction to the following.
10.Static water level below top of casing: / t9 (ft) Division of Water Resources,Information Processing Unit,
IJwater level is above coring,use"." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6- (in.) 24h.For Iniectiou Wells ONLY: In addition to sending the forth 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.auger,rotary,cable,direct po6,cte.)
Division of Water Resources,Underground Injection Control Program,
FOR N'ATER SUPPLY WELL S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Be.Yield(BP m) Method of test:(� Air lift 24c,Fos Water Supply&Injection Wells:
—cT.�
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.
Farm GW-I North Carolina Department of Environment and Nanual Resources-Division of Water Resources Revised August 201.1

��ivrcu� ENV Health Permit '
JACKSON
� COUN_TY I
oryryww ,.
�u411['MAIM 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
Reference Number: Permit Number: 2019-16087-9-10538
PIN: 7579-91-7078
Application Date: 12/8/2020
Owner: Caney Fork Meadows LLC City: Lancaster SC
Address: 3005 Bronwood Place Zip Code: 29720
Lot Number: LT 62 CROSS CK EST
Service Type: Well Permit Bedrooms: 4
Directions To Site: Caney Fork Rd to left on Cat Nip Rd to right at first driveway
1
1 1 Well Depth:
Case 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. Stay 50' from lake or pond. Well shall be cased to a
minimum of 20' below ground surface. Well for single family residence. 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 1/14/2026
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS
IDOCUMENT 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. — --- —I
Fee: $3220i1
41 —�—
�� i � Issue Date•
Ems• - - Approval Date:
LSignature: __ Date'._.
:Inudapp.roktech.netlJacksonPennits/EnvHealthPermit/EmailWellPernlit.aspx7EnvHealthpennit=13892 +�+