GW1-2021-07778_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Intemql Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Mitchell Dean Cook ,te�ra >; = isx:,^r<< r;4.,:tU«-�}�r -f- i7: :•.4.. Cin
FROM TO DESCRIPTION'
Well Contractor Name `ft 'ft.
2043 A / ft oft.
NC Well Contractor Certification Nwaber
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a-ft, "t• in. S pv4
Company Name R}eASIP).Cr°5D..n1tUB .rs.+. 1.e...alt i'ed .:o` ;� un�' 7°'7
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: �513 .$„2.�P ft TO
List all applicable well permits(I.e.County,State, Variance,Injection,etc) ft ft. dn.
3.Well Use(check well use):
Wat r
e Supply Well: FROM I TO I DIAMETER ISLOTSIZE THICKNESS MATERIAL
❑A riculhual a. ft in.
g ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑hldustrial/Comm ; s"='if•; '.a•," =`7e;i?;.ai' i'i�Y .s.i<. 'J
ercial f��R<dential Water Supply(shared) U '=:e.., ...........x...s.'>r..a,ti,.,ti.,,,,�sox •s, i_,a �::%:,- t.
FROM TO MATERIAL EMPI•ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: �
❑Monitoring ORecovery ft. ft �•
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation "1: "'{ D/.d ?,VQ .p i�,` +a`' r a", `•:3's '%x gk�T'`s �4 sk:2%cue;;e:':ftl
❑Aquifer Storage and Recovery ❑Sal pity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. fr.
OAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
i ; ;"S
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardneh sollfrock tyin,trab size etc.
❑Geothermal Heatin Coolin Return ❑Other ex lain under#21 Remarks ft. ft.
` fr. ft. R.••
4,Date Well(s)Completed: 1 Well ID# ft. ft. v �.•
Sa.Well Location:C,Vsl.Y ft. fa
FecilitylOwnerNarne Facility ID#(ifappEcable) ft ft. e1GC5��n
�brc /t>,ad .c�12G4u�s,Lo%®/'f tiy./��FGa��. ft. ft
Physical Address,City,and Zip 2'1"%- ,�.. .v;+:.. rc.e,,.C=; _ .5ity 'L�;Ss i:..; •.1sQd^�%"lip:�..�..;•.;.;�;�y
ACA C51h 714Z26 1 `762
Cowity Parcel identification No.(P1N)
Sb.Latitude and i.ongitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3.5- / 'I q-7 4>3 N -&' sg�> �1�d� w
/ igii Lure of Certified Woll Cohtractor Date
���
6,Is(are)the well(s): �rmanent or OTemporary
By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
��"/ with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lgu ro copy ojthls 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 secilon 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 ifnecessary.
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: L3 (ft.) 24a. For All ells: Submit this form within 30 days of completion of well
For multiple.wells list all depths ifdifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
IfwaterlevelIs above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6" (in.) 24b.For Inieclion Wells ONLY: In addition to sending the form to the address in
Rota24a above, also submit a copy of this form within 30 days of completion of well
ry
12.Well construction method: 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) SCE Method of test: Air Lift 24c.For Water Su &In'ection Wells:
Also submit one copy of this form ;within 30 days of completion of
13b.Disinfection type: H & H Amount: 1 2 oz• well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Euvirontnent and Nantral Resources-Division of Water Resources Revised August 2013
P

From: Emily Stepp esteppOmaconnc.org OFM
Subject: Well Permit
Date: July 15,2021 at 9:07 AM
To: jbcoram330gmail.com
Hello,
Attached here is the Construction Authorization for the new shared well at 41 West
Highlands Way(Wildflower Creek RV).
Thanks,
Emily Stepp
Processing Assistant 111
Environmental Health
Macon County Public Health
1830 Lakeside Drive
Franklin, NC 28734
Phone[phone]
Fax[phone]
E-Mail.g [e-mail]
www maconnc.org
www.facebook.com/­`­M­­­`aconPub/f*cHealth
Accredited by the NC Local Health Department Accreditation Board
Pursuant to North Carolina General Statues Chapter 132,Public Records,this electronic mail message
and any attachments hereto,as well as any electronic mail messages that may be sent in response to
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• Macon C o.0 m y NC W WELL CONSfRUCTiON
Public Health CONSIRUCTi(NN AUTI4ORIZATICNJ
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