GW1-2022-01868_Well Construction - GW1_20220216

NAWLL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemyl Use ONLY:
L Well Contractor Information: t
Mitchell Dean Cook "`­ ��q ► a
FROM TO DESCRD'TION
Well Contractor Name ft � t f4
2043 A r t6 1 6 nzz rr. rr
ur& �.
NC Well Contractor Certification Nwnber ��;�;1�+w'''�"�� g y(f,."''' -
t
(j;R FROM TO DUMF.TER TH[CFOVESS MATERIAL
Dennis Holland Well Drilling, Inc. a , fL
rr Company Name
2.Well Construction Permit#: L I 2_ _2 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State, Variance,Injection,etc) ft. ft. In.
fr. in.
3.Well Use(check well use): fL
W111¢rS1lpplyW¢II; FROM TO DIAMETER SLOT SIZE THICFOYFSS MATERIAL '
QAgricult ral QMMUnicipaVPublic It. rt. in.
QGeothermal(Heating/Cooling Supply) 06idential Water Supply(Single) fr. ft. in.
Qlndustrial/Commercial QResidential Water Supply(shared) B..CwR UT. Y.
1.{. .::r,.•--. ^,.::,Qlrri ati0rl FROM TO MATERIAL EMPLACEMEN•rMETHOD@AMOUNT.
Non-Water Supply Well: d ft 3 , ft.
a
QMonitoring URecovery r ft. , ft.
Injection Well: ft. fr.
"
Aquifer Recharge OGroundwater Remediation •;:_
QAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIA►• EMPLACEMENT METHOD
QAquifer Test
QStormwater Drainage
QExperimental'rechnology []Subsidence Control fb tL
QGeothermal(Closed Loop) Q7'racer ''FROM �G1NtiGfi' ';atfac ndtlittoaellstiedl"s`•if"a' a ;',f, 15, e s
• FROM TO DESCRD�TION'color hudn aolUrock raJn aiu crc.
QGeothermal (Hearing/Cooling Re tum QOther ex lain under#21 Remarks) tr. fr.
fr. ft.
4.Date Well(s)Completed:O_ -p16_�2 Well ID# /Ay
So.Well Location: ft. ft.
ft. ft.
6�rJ�
Facility/Owner Name Fncility 1D#(if applicable)
L/ fA ft.
Q/ % �✓VdGrJ ,�T/�� �d�i� It. ft
Physical Address,City,and Zip
ir►. �,-••�ra•h _ %✓.,l F},4• ..fie /� G
Coway Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one]at/long is sufficient) 22.Certification:
3 S'• 7,� 6�o N 83', �a g w '1 �_ •_ as -Q, -�.�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): r 'ermanent or ❑Temporary
By signing this form,I hereby cert�that the wells)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or el.Now copy of this record has been provided to the well owner.
Ifthis Is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks.seciion or on the back of this form. 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 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: 5 (ft,) 24a. For AD Wells: Submit this form within 30 days of completion of well
For muliple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: /30 (ft.) Division of Water Resources,Information Processing Unit,
IJwater level Is above casing,use"+' 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 6" in. . t '( ) 24b For�njgc�tQ,n 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air lift 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: H & H Amount: 12 oz. well construction to rite county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resotmcos Revised August 2013

� `Q~oteer II
Macon County NEW WELL CONSTRUCTION
o ,d Pub EM CONSTRUCTION AUTHORIZATION
ILED � HORIZATION
�" • a' PRIVATE DRINKING WATER WELL
t [28N
1121221-P • 111921-S
le Family Well, Residential g A 6.36
.....--...._._Snow HiII Road _ _to R on Cowee Creek Rd.,to L on Snow Hill Rd.,to L on drive justpast theOld African American Church to the
e _—`_.._.... ----
Permit Conditions ------------._�__— �� � s
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. FEB 19 2027
Keep well out of the Road right of way 15'from center of road.
{niOri<95.2�F'^b1'i�P4.Gic'. 1fl j Un,5
Dth'.�v2i`150G
Diagram (Not to 6caIP1
PL
Approved Well Site 15'x 5'
20' 5/8"Rebar
43'
FXisti
152' ng Access Road
Propose
Barn
5'min
130'��.. ; 130'
PL �i ari PL
t t
i
N
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 tie 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.
4
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]
i
I
Issue Date: 12/20/2021 Charles Womack, REHS 1300 Authorized State Agent
I i