__20210125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook T4: m¢Rxor7as. C (ei.W. ,
FROM TO DESCRIPTION
Well Contractor Name 0' R lr5o • IC
2043 A e27g11 c,27 -ft
NC Well Contractor Certification Manlier It'.QIITER YASnfonolWtkiYZdlwdE'e}e0I MB7(I1d`• 1lij'i W'S
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a ft. 7/ , ft in. j e c
Company Name Ili.^IWERCASIrySr"bR`Tt16N'et(Eadlbe'i' a i'p °lp@pl nta., v i.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /60/.10 '/° ft. ft. io.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): H7t'.SCREEP s, ;<,v r, <\r, ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DM icipal/Public ft. ft. In.
°Geothermal(Heating/Cooling Supply) 17Residential Water Supply(single) D ft. in.
Olndustrial/Commercial OResidentiel Water Supply(shared) `Ig4C�UT' ,. if+. ..... ,v; ' 1
FROM TO MATERIAL EMPLACEMEAT METHOD&AMOUNT
Obligation ft. fc .]
Non-Water Supply Well: 0 3' 113,7 64�,� .2. /sags , . / d�
/
°Monitoring DRecovery ? ft. f4 LO ,pv9 n b_i/A,2 - /i.s�S P;�....P"nA
Injection Well: ft ft.
°Aquifer Recharge ❑Groundwater Remediation ';19'$ANC OMYEEVAG1t.(tf;'gpph'Iobfa) ;*',..;'re,a;;,, - .,t r e" ti
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage ft ft .
❑Experimental Technology ❑Subsidence Control
30(.:DRItC era:E(.,(ariaehhildlfioallls eNifuespd$TR :Mcz. sr- ' ,°Geothermal(Closed Loop) DTmcer FROM TO DESCRIPTION(color,hardness,soil/retk type train size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft. ft.
D. ft.
4,Date Well(s)Completed:0/-o7-.1/ Well m# AL/A . ft. ft.
5a.Well Location:
R. to
L if,e/. yofAIti-/4nLraxii' 459f97.139h- ft. ft.
Facility/Owner Name Facility ID#(if applicable)
/ ft ft
C he;Lida' Sgnehs-c /Pcwa/ It ft
Physical Address,City,and Zip ,21:1tEMARKS . .. t .. -
f23 acJH %a/J L2O ..4-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
5°D3la // N R3°.357&5 w -r.4'%' .4iv�, /lam of-67- �.•tb
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IlliCnitnent or °Temporary By signing this fonn,/hereby certfy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.
If this Is a repair,fill out known well construction Information and explain the nature of Me
repair under#21 remarks section or on the back of this farm. 1 ,��p,�4e'bite diagram or additional well details:
'. \ t) ''3 1'You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: J� construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 0,
p .'3 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths idii ferent(example-3@200'and 2©/00) construction to the following:
10.Static water level below top of casing: J50 - (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6a (In.) 24b.For laiection Wells ONLY: In addition to sending the form 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 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) /5�j Method of test: Air lift 29c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 2 OZ. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

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y�� �m M a o n �hj n t Y NEW WELL CONS RUCTION
'L P olic Health CONSTRUCTION AUTHORIZATION PRIVATE DRINKING WATER WELL
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APPLICANT/OPIOEC dsay and Brian Leopard r. LOG# 100120-P OSWWA 101120-S
INTENDED USE Single-FamilytWell, Residential PID # 6596970396 ACREAGE 1.14
LOCATIOr Claude Sanders Road IRO
DIRECTIONS Left onto Sanderstown Road from Sylva Road, Left onto Claude Sanders Rd.,to property on left.
•
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. ;i- •
Maintain minimum setbacks as applicable.
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Diagram Mt to Scale)
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IP
9.2aa ��e\\P(Qa (0,1
k
A
Jae•
56 ae�cc, 9ose
100'
1P =min Encase Schedule 40 PVC
In DOT Traffic Rated Culvert
eep
Ptoposea NoJse uunder 9 grade ifr bury 30 poses sibleble
where it crosses through
Dec' Right of way.
3wi PL
Qo 3,ea
z• '° 0 IP
• PL v 4 0 Existing neighbors well
54' 90'
70
82'
10
70'1
`ss
25% Reduction
LEepair area,,,35 i
60'
, 153'
A
N
IP PL IP
en -
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
circumstance 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 OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 10/21/2020 Charles Womack, REHS 1300 Authorized State Agent