GW1-2021-07850_Well Construction - GW1_20211102

TION RECORD For Internal Use ONLY:
WELL CONSTRUC
This form can be used for single or multipic wells
1.Well Contractor Information: ?>,.r'x,
1`°�YA!gSR< bIESI ~x t ! z rtS`r.it t:;
Mitchell Dean Cook VROM TO "DESCRIPT►°"
/L•--ft, �("r fL
Well Contractor Name C�J
ft
2043 A I
?'!'S,OUIP;SIt � S ,�Y1 foals, iil"tr;��edttti .e n' 1P1.Ill itt" LCUR t ti<v?S r t f
NC Well Contractor Certification Number FROM TO DIAMETER 1 THICENES,S MATERIAL
It.
Dennis Holland Well Drilling, Inc. c'
16,r11�lYE`R'ensmlryib nictlRIN19 eo't'o 'a1'et° +� `Q �.�'�MATIMzA�
s., TIILCfa'tESS MATERIAL
Company Name FROM TO DIAMETER'
t.r ft.
ft. io.
2.Well Construction Permit#: � -'---
List all applicable welt permits(i.e.County,State, Varlanre,Injection,arc.) m
-..iAo - 3 t•vt3iz,tv;sy-£
3.Well Use(check well use): >r'7 sS. [tE1)N,..` .• `
_- FROM TO DIAMETER SL;T SIZE TyICIQVFSS MATERIAL
Water Supply Well: fr ft in.
❑Agricultural 'Q�MunicipaljPublic ft ft 113. i
OGeotliermal(HeatinglCooling Supply) l�sidential Water Supply(single)
Z.•�.'L"' .e:.....:_:, rr ... ;. •u:. � ....S.i a Sa x, �s sty
Dindustrial/Commercial idential Water Supply(shared) FROM TO MATERIAL' EMPI ACEMENT METHOD&AMOUNT
ft.
fr.
❑Irri ation '
Non-Water Supply Well: • ft• S
❑Monitoring ORecovery ft. ft
Injection Well: g :;t"•ir _:•^4 �=r
❑GroundwaterRemediation -%t9r U/d •VkI:.RAGK fa" . a a EMPLACEMENTMETtiOD
(]Aquifer Recharge FitoM To MATERIAL
OA.quifer Storage and Recovery OSalinity Barrier
OAquiferTest ❑StormwaterDrainage ft ft
❑Subsidece Control :,
t❑ExperimentalTechnology 9 I t) ulii'uaarhd'nal i eta•.i d"' a '.1ivW f:�?'.e : atteu enra
FROM DESCRIPTION oor
00cothermal(Closed Loup) OTracer ;1 4
ft
C7Geothermal Heatin Cooling Retum C70ther ex lain tinder 421 Remarks) ft.
4,Date Well(s)Completed: Well LD# ft. ft.
ft. ft.
Sa,Well Location:
f
G�t<i fJ � f�...,....�..�-•----•- ft. —ft.
Facility Owner Name Facility IDN(if applicable) fr,GG (36J / d�c ft.
ft.
J )
Physical Address,City,and Zip 5 / ,L �'F J �
T
Parcel Identification No.(PIN)
County
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ledlong is sufficient)
��• f� �/ �{�,C) / Date
J�' �✓ / i J N - ^A J W signature of CertifiedW Il Contractor
6,IS are thlls: rroanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
(are) we O with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 well Cons
nxrNlon Standards and that a
7.Is this a repair to an existing well: oyes or -
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 23.Site diagram or additional well details:
repair tinder 921 remarks section or on the back of thisform. You may use the back of this page to provide additional well site details Or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed: I
For multiple injection or non-water supply wells ON[.Y with the same construction,you can SUBM'ITTAL.INSTUCPIONS
submit one form.
���••' (ft,) 24a. For AD Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: _ _ uction to te fo
constrhllowing:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') Division of Water Resources,Information Processing Unit,
(ft)
17
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-L6
ress in
if water level is above casing,use•'+"
to the a
24b. or Io'ec ion ells ONLY:of this fotim within n30 days of completion dof well
11,Borehole diameter: (in) 24a above, also sit bmiI a copy
Rotary constnicti011 to the following:
12.Well construction method:
(i.o.auger,rotary,cable,direct push,etc.) .Division of Water Resources, Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-163
FOR WATER SUPPLY WELLS ONLY:
/ , Air lift 24c.For Water Su &Ln'ectlon Wells:
of
13a.Yield(gpm)�L - -- Method of test:_� — - Also submit one copy of this f11ealth m wi department30 yof s of the rcounty where
well construction to the county j.
H & H Amount:1 OZ.
constructed. j
13b.Disinfection type: _______�— �"`
Revised August 2013
artment of Environment and Nannal Resources-Division of Water Resources
Form GW 1 North Caroline Dep
Y

Qioce�r,
J. Macon County NEW WELL CONSTRUCTION
C '' Public Health CONSTRUCTION AUTHORIZATION
r'� PRIVATE DRINIQNG WATER WELL
Greg and Kathy McGaha • 060421-P • 060721-S
O ' Shared Well Residential and for Shop6558574733 2.13
• 78 Cabe Cove Road
NN
• 28N to L on Tellico Road to R on Cabe Cove Rd.to left just before State Bridge.
Permit Conditions r
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,
Use Caution: Locate underground power before drilling. .
Dia ram Not to Scale
3 edWeUp�y��
Property Line Driveway aQo�e�`?rOpp5�5'tnt .`
aet '
Existing Big
I
f
>100'
O
i
ai
t �
-A i
I
o Proposed Shop
� I
� I
5'mi ;Spring Branch
50'min I
50'min ;
Low area ' , SO��4 10'min
Unsuitable !!wetness 50 m! H
�1 artiall
19'Rep fir ry NCO Ai I Repair
r Area 1 Areal
Property Line l `-- 41.
10'min Iron Pipe N
50'min from center
Overhead Power
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 O9jTHE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. .QUESTIONS?[phone]
Issue Date: 8/3i/2021 Charles Womack, REHS 1300 Authorized State Agent