GW1-2022-01938_Well Construction - GW1_20220224

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
Thus form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM I TO DESCREMON
Well Contractor Name O o ft. µ ft.
2043 A tit. ft.
NC Well Contractor Certification Number 15;QUT•NR C ASIN',,to1 multi cgsClhe%ella i(?�2c'IIRE r it. :' ic7lble
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o ft ft' ,r In.
/f'-.Z/. VG
Company Name >,16 1tSN1uR(�A91P11;bR Tll13TP1CS 'a'8i b 'ilit;jW1166
1 FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#:_f� j_. P fr. R, in.
List all applicable well permits(i.e.County,State,P rlance,injection,etc) ft ft. in.
3.Well Use(check well use): ;`12{t5`GREF �. .:.,�<;
Water Supply Well: FROM TO DIAMETER SLOT SIZE a THICKNESS MATERIAL `
❑Ag"culhual C1MunicipaVPublic tr. tit. Im
OGeothermal(Heating/Cooling Coolin Supply) OResidential Water Supply
( g/ g PP y) pp y(single)
Dlndustrial/Commercial ClResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT 1
Olrri ation - ft. �HM�o
Non-Water Supply Well:OMonitoring DRecovery - 64
Injection Well: fl. ft.
OAquifer Recharge OGroundwater Remcdiation 18 S'.';D/(ik.`YEi ?PANIC to '' r
OAquifer Storage and Recovery ❑Salinity BarrierFROM tr TO ft.
MATERIAL I EMPLACEMENT METHOD
OAquifer Test OStonnwatcr Drainage ft tr
DExperimental Technology OSubsidence Control
:20,DRfIL71Y(i'Gh'(`r'atfaelf(g'ditto`el�lliecfaifiii''' ea 1..i .��a,,, ,-.;:
OGeothermal(Closed Loop) ClTracer FROM I TO DLSCRIVnON color,bardnM 7oitlrock rain size etc.
OGeothermal (Heating/Cooling Return OOther(explain tinder.#21 Remarks) ft. fa
ft. ft.
4.Date Well(s)Completed:D Well ID# Iv..L. g
ft. ft. '. F
Sa.Well Losefl
,fp ara 1/a g°` G %.�h ft. rt. FEE
h�A t�y ��s�Zs�e� rt. ft, -
Facility/Owner Nmne Facility ID#(if applicable) ft. ft.
IQNfC /s�• {CY'/��S �/l�i� .��s fr. ft. Ft t. 14 tit u..0 1 �1
Physical Address,City,and Zip r °?
MaGa.6 K579..u¢9 :z ,a
County Parcel Identification No.(PIN) 1 /4
.5b.Latitude and longitude in degrees/mim»tes/seconds or decimal degrees: 22.Certification: l
(if well field,one latiloug is sufficient) ?
3.5� /. 7 r N t�J�,�ry W
Signature of Certified Well Contractor Date
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6.Is(are)the well(s): <Imanent or OTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed In accordance
with I SA NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: Oyes or 9. o copy ojthis 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 under#21 remarks section or on the back of this form. 23.Site diagram or additional well rletails:
You may use the back of this page to provide additional well site details or well
g.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: /D (ft.) 24a. For All, Wells: Submit this form within 30 days of completion of well
Fm•multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10,Static water level below top of casing: r (ft.) Division of Water Resources,information Processing Unit,
ff warer level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
6. (in.) 24b.For Infection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR RATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m .___ Air lift �� 24c,For Water Su &In'eclion Wells:
(gp ) /QfLf' Method of test:._ � Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H V Amount:.12 oz._ _ well construction to the county health department of the county where
constructed.
Revised August 2013
Fornt GW-I North Carolina Department of F.rrvironment and Natural Resources-Division of Water Resources
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Q�ote��
Macon County NEW WELL CONSTRUCTION
o�JL�,d Public Health CONSTRUCTION AUTHORIZATION
'd • a' PRIVATE DRINKING WATER WELL
t 4
N\;c� e Coi: 61! �� �iCJ
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• • Clark 120,�1
31
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
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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.
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A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR'THE WELL IS PLACED INTO l
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP/INSTLLATION. QUESTIONS?[phone]
Issue Date: � / Zo Z � c .�_ I Authorized State Agent
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