GW1-2021-00281_Well Construction - GW1_20210125

"MC S singleU N Sl!? For Internal Use ONLY:
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1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Nerne, 1746 IL '1t
2043 A .9 951L _4R.' "'
NC Well Contractor Certification Number W 2 K.
FROM I To I DIAMETER THICH3NIESS MATERIAL
Dennis Holland Well Drilling, Inc. fL
b.
Company Name . . ..........
FROM I TO I DIAMETER THICROIESS I MATERIAL
2.Well Construction Permit 9: /.10 7—10 1, tL in.
List all applicable wellpernsurs lic.CounlyState,Variance,injection,oc) 0. ft.
3.Well Use(check well use): 711
Water Supply Well: FROM TO DIAMETER I SLGTSIZE I TIRICROGUIS I MATERIAL
OAgricultural OMunicipal/Public ft. f, in.
OGeothemnal(Heating/Cooling Supply) OR ntial Water Supply(single) h fa in
Obulustriallcommorcial �Zldntial Water Supply(shared)
FROM I TO I MATERIAL I EMPLACEMENTMETIOD&AMOUNT
UIrrikation 01 ft. , ft.Non-Water Supply Well: Is It
0t,tri,
Oftecurvery
Is,jection Well: It. ft.
OAquifer Recharge OGroundwater Remediation 0MAV9194i"FAU JIM
OAquifer Storage and Recovery LIM unity Barrier mom TO tt. ft, MATERIAL EMPLACKMEFFrMETIME,
OAquifer Tot OStomawat"Drainage I& fL
OExperimental Technology OSubsidence Control
DOwthermal(Closed Loop) OTracer FROM I TO DESCRIPTION color hcAuses.milicock type,terain d.,ate.
O(loothermull(Heating/Cooling Return) 00ther(explain under 921 Remarks) ft. &
fL h
4.Date Well(s)Completed:0 1-J I- Well IDN N. 11A, & ft.
5a.Well Location: ft ft
n,n,j,c,g,A J. 4-Agrn /5 7/4.1,0 It. ft,
Facility/Owner None Facility ma(ifuppliast,k) ft fL
Z-go/ It. fL
Physical Address,City,and Zip I 7­777,
MA I
AA a con 2.E it.19 7 iLA J,,4
County Pence]Idenuftation No.(PIN)
St.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one lat/long is sufficient)
_250 7 '14, 311 N 93 0 /7 5 w
Signmann,ofConified Well Contractor Date
6.Is(are)the Wallis): Of'armament or OTemporary By signing disform,I hereby certify that the wells)was,(were)constructed it,accordance
with ISA NCAC 02C.0100 or 15A 2/CAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or 011,11— copyofthis,recordhas been prouldeda,the well owner.
Ifift Is a repair,fl1lout known well construction information and"plain the nature ofthe
repair under#21 remarks section or on the backofthisforin. 2 Site diagram or additional well details:
%3LU may use the back of this page to provide additional wall site details or well
8.Number of wells constructed: 1 _3 T construction details. You may also attach additional pages if necessary.
Ywuhlhiisamatt'msshnu�o
For multiple injection or non-water supply wells ONL It an
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: *05 (ft.) 24a. For AS Wells: Submit this form within 30 days of completion of well
For outdople,wells list all depths itdifferse,(example-3@200'and 2@100') construction to the following:
10.Static water level below top of using: .10 (ft) Division of Water Resources,Information Processing Unit,
47whir level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6' (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
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 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(gpm) 6o Method of test: Air lift 24c.For Water Supply&lq*ection Wells:
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,
FormGW.I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

p ((�� t
ec' m Masts eF C o u n t y NEW WELL CONSTRUCTION
L Public Health CONSTRUCTION AUTHORIZATION
,d PRIVATE DRINIQNG WATER WELL
t Damon Jotham • 120720-P • 071420-S
r t Shared Well Residential • 7512874614 0.89
• • Peeks Creek Road-Lot 2 Old Lot 6
r • 64 East to Right on Peeks Creek-Properily is just after bridge on Right.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from all septic system components and 25'from building perimeters.
Honor D.O.T. Rights of Way
Diagram (Not to Scale)
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This permit is valid for a period of five years except that it may be revoked at any time If it is determined that there has been a material change in any fact or
arcumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.The well shall be Inspected and approved by Macon County
Public Health before It is put into use. The location of the well indicated by MCPH Is to provide protection from possible sources of contamination. Flow volume(well yield)Is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED QB THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 1/4/2021 Jonathan Fouts, REHS 1979 Ufti`7zed State Agent