GW1-2022-01343_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internai Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook aa.N'ATFk vriris. i., , t
FROM TO DESCRII+770N
Well Contractor Name ft. ft.
2043 A ft. ft.
NC Well Contractor Certification Number ,15:nUTER rA$YN ,forrmtilti c9sdl Ella;nit>IiINI r f[t'
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. ft,
I t
Company Name i 16 IhT.1R GjA�ilVlrt)RiTlJi3 (} eottie m`al elirgetd lbo _ �`<:
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Perutit ft. ft. .1 in.
List all applicable well permits(i.e.County,State,'Variance,11 jection,etc)
It. ft. in.
3.Well Use(check well use):
17.:SQREF a
Water Supply Well: FROM I TO DIAMETER I I SLOT SIZE I THICKNESS "MATERIAL
LlAgriculhtral CJM/unicipaUPublic +ff: -
0111dustrial/Commercialft. in.
CJ(ieothermal(Heat ing/Coolin Supply) LlIC ft.
g pp y) csrdential Water Supply(single)
C1Residential Water Supply(shared) ' �- TO
FROM MATERIALAMOUNTFNon-Water
;} . ft. y
Supply Well: �,�. �' " •g ORecove �: fL ell: ft. ft.
charge 0(yroundwater Remediation ;19 DIOIt YqorageandRecove FROM TO MATERIAL EMPLACEMENT METHOD
Recovery ❑Salinity Barrier
(]Aquifer Test OStonnwater Drainage
DExperimental TechnologyC1Subsidence Control ft ft.
20;DRtL4lNt3.G6'G.(it fa61ftg4 dIii6ki ih`ecialfin'"eati
OGeothennal(Closed Loop) C11(aCe! FROM TOO DESCRIPTION color 11"ne soil/rock rain size etc.
OGcothermal (Heating/Cooling Return 00ther(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed:la 7„?V•11 Well IDH,
It. ft.
Sa.Well Location:
tr. ft,
Facility/Owner 14aine Facility ID#(if applicable) - ---- --
ft. ft.
ii ft.
Physical Address,City,and Zip ;21 REI41AItfG. .' -
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latloug is sufficient)
W A-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): MPer'manent or OTemporary
By signing this farm,/hereby cert fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.07,00 Well Construction Standards and flint a
7.Is this a repair to an existing well: C1Yes or E10- copy of this record has been provided to the well owner.
1f flits is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks 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 wells constructed: construction details. You may also attach additional pages if necessary.
For muhiple innjection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /",),I (ft.) 24a. For A Wells: Submit this than within 30 days of completion of well
For multiple wells list all depths ifdiffercnt(example-3@200'and 2@100') Construction to the following:
10.Static water level below top of casing: t 4) (fL) Division of Water Resources,Information Processing Unit,
/f water level is shove rasing,use"+" 1617 Mail Service Center,"Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b. For Infection Wells ONLY: In(addition to sending the form to the address in
Rota 24a above, also submit a copy of this fonn 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,U iderground Injection Control Program,
FOR WATER SUPPLY WALLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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Method of test:"
m 13a.Yield(gp )1" Air lift 24c.For Water Supply At Injection Wells:
M_—
--"� Also submit one copy of this form within 30 days of completion of
13b,Disinfection type:H& H -!,T Amount: 12 oz• well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Huvironmeut and Neural Resources-Division of Water Resoiures Revised August 2013

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A. r
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Id1 a c o.n C o u n t;y NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
F.
Public Health -
°a PRIVATE DRINKING WATER WELL.
doe Lpsey 111 1'20121-p: NIA.. ..
u _
' Sin le Family Weli,'>Residertlal ,' 751395$44S M49:_ .. _
* Off i Hi hlands Road. .
:Highlands Rd,to L on Spll.....
oad right before picftivFite farm house.Follour soli toad to site on L.at.bend In:tle road!
W.fore the con0OW brid 'e;
Pennit:Conditions.
. -
Weil.shall be constructed in corhphance With all 3VCAC 2C:Rules,
Maintain:minifnum setbacks as applicable:
Any cibestionstaH:MCPH
Qiagram::(Not to.Scale)
Creek
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Proposed �,�c.e�At Concrete
VJeII Area 6e - Q� 9', dg
A a �ti� $�,
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is
a �f
Ibw
Power:
)urctron:.':.::
.......... .. _ ..... ....._........
ThIS pertrit iS valid for a periods of five;years exbept tt�at:if may be Yevoked:at any[irhe:l€:lt Is determined that ihere liar been a:mater[aI change In any fact or
elrcumstance upon whidi.the:permh is Issued. Well ioeation,installation;:and:protection rnust.ineet state regpaUons fine welvshall be Inspi i ed anal.approvetl:by Macon County,
Public -lealot fore ls:put Into.um 'Me Ideation of thewell indicated by:MCPH Is to provide:protecdon:frorr,possible scurces:of contan4ination blew volume{well yield}is:NOT
guaranteed at any site by M(:PH.
A WELLHEAD COMPLETION INSPECTION:MUST SE APPROI:ED BEFORE FINAL POWER IS GRANTED,QR THE WELL IS PLACED INTO .
SERVICE. PLEASE SCHEDULE A IlUELLHEAO INSPI CTION AFTER PUMP INSTALLATION o (828} =2490
Issue Date; 12/712021 Tanner 5tamey, S 2712 utha ized State Agent
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