GW1-2021-03065_Well Construction - GW1_20210624

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WELL CONSTRU TION RECORD For Intomill Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook .a er.. ,r r.4; x:'l'" },:�:_ � ' :=t
FROM TO DESCRIPTION
Well Contractor Name ft
2043 A ft. ft 6
NC Well Contractor Certification Number ;FRON
TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 3 . ft. � 1 in.Company Name TO DIAMETER THICKNESS MATERIAL
2.WellConstructionPermitN: 'L..ZJ-e2ooni. I- /p jag
List all applicable well permits(I e.County,Stare,Variance,Injection,etc.) ft ft, in.
3.Well Use(cheek well use): i `.it .{1t1 .� c r+ a,•75 fn`�ASiiv 9r':'St,.a3Ff:nY6 7^�Stka ;,'!
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
io.
OAgricultural OM,/uunicipaUPublic ft. fA
❑Geothermal(Heating/Cooling Supply) Ql(esidential Water Supply(single) ft. ft, in.
P
OlndustrsallCotnmercial OResidential Water Supply(sltared) M TO MATERIAL EMPI.ACEMENTMETIIOD&AMOUNT
❑hri ation
Non-Water Supply Well: 40
ft. �Ll . ft. f
OMonitoring ❑Recovery
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation l.r lb'4?i�lt?P - =s" a b"U<;se-; '..<
OAquifer Storage and Recovery ❑Salinity Barrier FROM ft To ft. MATERIAI. EMFLACE111ENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer FROM I TO DESCREMON color,bardnM soiltrock type,grain size etc.
OGeothermal (Heating/pooling Return OOther(explain under#21 Remarks) ft, ft.
ft. ft.
4.Date Well(s)Completed:.06-o7-a _Well ED# W-1.
ft ft
is,Well Location:
/ it, ft.
w y14T7',0,t�,.0 Y1 p 1V•/•�• ft, ft,
Facility/Owner Name Facility ID#(ifapplioeble) ft ft.
Mitt
Aa Rex ;)r Lqszz ft. ft llnfQEr,.at; processing
royaieal Address,tatty,auu...,r '21:e K.: ���..r 7 r _ .,!'i 'irr
s.�L>✓�� 7q�Cl-47.6"IS LAd Ro a r
County Parcel Identification No.(PIN) S
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
3.S" Jq- 36 4g N 9.3' .27 6'Gt W 72 � -46.. / ara-Q7
Signature ofCortified Well Contractor Data
6.Is(are)the well(s): anent or ❑Temporary By signing this form,I hereby cerl(fy that the well(s)was(were)constructed In accordance
:t•ith/5A IdCAC 02C.0100 or 15A NCAC 02C.0200 FFlell C'OnstructtOn Standards and that a
7.Is this a repair to an existing well: dyes or C_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 the
repair tinder#21 remark section or on the back of thisform. 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: R 'a (ft.) 24a. Eigr AD Weill: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2ta 100') construction to the following:
01
10.Static water level below top of casing: 9W Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For 1niegjion Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,lRaleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Airlift 24c.For Water Supply&IDjection Welts:
Also submit One copy of this form wtttirn 30'days of completion of
13b.Disinfection type: H & H Amount: Ox• well construction to the county health!department of the county where
constructed.
Form GW-t North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

' 6/3/2021 ENV Health Permit P5' o
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JA 011T
DYYIG 11WIh:
The 3ackson County Department of Public Health
538 Scotts Creek Rd.Suite 100 *Sylva,NC 28779
Tel: [phone]* FAX:[phone]
I Shelley Carraway
i DIRECTOR
Shelley Carraway
' Well Permit
i Reference Number: Permit Number: 2021-20802-9-10838
PIN: 7620-67-0365 Application Date: 3/31/2021
Owner: WYATT, DAVID City: CHEROKEE NC
Address: PO BOX 2192 Zip Code: 28719
Lot Number: SUTTON BRANCH RD
Service Type: Well Permit Bedrooms: 2
Directions To Site: 1240 Sutton Branch Rd. on right.
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Well Depth:
sCase Depth:
'! Grout: I
f Yield:
Contractor:
Driller:
Well Type: Drilled
Well Size: 6 Inch
* WELL FOR SINGLE FAMILY RESIDENCE. Stay 50' from any part of septic system or repair area. Stay 25'
j from any building perimeter. Stay 25'from creek, stream or river. Stay within,property lines. Well shall be
cased to a minimum of 20' below ground surface. Stay out of any road right of way. Owner has approval
from DOT to directional bore water line across Sutton Branch Road to existing residence. Make sure all
utility lines are marked and follow all guidance set forth by DOT.
Attached drawing not to scale.THIS PERMIT EXPIRES ON 6/3/2026
} APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS
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Remarks: DOCUMENT DOES NOT GUARANTEE YIELD OF WELL OR POTABILITY OF WATER.
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
j 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.
F-PM Receip _
EHS: ,r .rcc /-,, 9� �Ll=t-I.S Issue Date: Ln ` 'a
EHS: Approval D te:
,�gnature: •P Y", Date: r � �•G'
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6/3/2021 ENV Health Permit rc5- v 14 ,
Jackson County Department of Public Health
538 Sc
otts Creek Road, Suite 100 Sylva, NC 28779 Well permit
j JILKSON
t ' •� Phone: [phone] FAX: [phone]
{ iY�We11e1rA.
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Reference Number: Permit Number: 2021-20802-9-10838 ?
PIN: 7620-67-0365 Application Date: 3/31/2021
Owner: WYATT, DAVID City: CHEROKEE NC
i
Address: PO BOX 2192 Zip Code: 28719
Lot Number: SUTTON BRANCH RD
Service Type: Well Permit Bedrooms: 2
Directions To Site: 1240 Sutton Branch Rd. on right.
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foor
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Fee., $ 23 0.00 Receipt: _
EHS• ��� 'R S Issue Date: (.o'3 -oZ)
EMS: Approval Date:
Signature: P—mu;1e) Date, G ` 3 ,J-t 04-
cloudapp.roktech.net/JacksonPermits/EnvHealthPermitANellPerTnitDrav ing.aspx?EnvHealthPermit--14188 1/1
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