GW1-2021-02470_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intern9l Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCREMON
well Contractor Name
SEP L35 J3 fL
K
2043 A fL ft.
NC Well Contractor Certification Number
-It S sc�iic FROM TO DIAMETER THICKNESS MATERIAL
1
Dennis Holland Well Drilling n ft. 6• '" In. .500-J.I e;_
461"M Company Name Jul
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#:
fL ft.
List all applicable well permits(I.e.County,State, Variance,Injection,ere.)
fL ft. in.
3.Well Use(check well use): ___ . . I I
Water Supply Well: FROM -1 TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
OAgricultural 13M icipal/Public fL in.
OGeothermal(Heating/Cooling Supply) 19zesidential Water Supply(single) ft. f, in.
Z ZM11 11
01ndustrial/Commercial DResidential Water Supply(shared) .......... .......
01ITigatign FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 •ft. fL a-
OMonitoring ORecovery ` .2o It- 2-
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation -it %
giiwaawg� n�mnn%,
DAquifer Storage and Recovery 08alinity Barrier FROM To
ft. MATERIAL EMPLACEMENTMETHOD
ft.DAquifer Test OStomwater Drainage
ClExperimental Technology OSubsidence Control ft. ft.
N OGeothermal(Closed Loop) OTracer 1 CA MOM
FROM TO I DESCRIPTION(color,hardoM Wilcock type,amin size.etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks fr. m
ft. ft.
4.Date Well(s)Completed:0 Well ID#
ft. ft
5a.Well Location:
ft.
DQ 44 Q S' /1/,LA ft. ft
Facility/Zwner Name Facility ID#(ifapplicable)
ft, ft.
Physical Address,City,and Zip
Cotinty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lotilong is sufficient)
N R.3
Signature ofCortified Well Contractor Date
6.Is(are)the well(s): MPeiimanent or 13Temporary
By signing this form,I hereby ceyio that the well(s)was(were)constructed in accordance
with 15A JVCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well; 13Yes or IaNd— copy of this record has been provided to the well owner.
ffthts is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks section or on the back ofthisform. 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 consiraction,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: (ft) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 6"
(in.) 24b.Lor ln*ection Wells ONLY: In addition to sending the form to the address in
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 WATER SUPPLY WELLS ONLY: 1636 Mail Service Cente r,1RaNigh,NC 27699-1636
1 ,
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
13b.Disinfection type:-H & H Amount: 12 oz. well construction to the county health,department of the county where
constructed.
FonmGW-I North Carolina Department of Environment and Natitral Resources-Division of Water Resources Revised August 2013

Q�pte�r
o� Macon County ( NEW WELL CONSTRUCTION
�d Public Health CONSTRUCTION AUTHORIZATION
'a a� PRIVATE DRINKING WATER WELL
I • H Douglas&Jane Harper — —A • 041721-p • existing
.Single-Family Well, Residential___
• • 395 Hazels Creek Rd _
' • Wayah Rd> R @ Hazels Creek> # 395 on right _
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Pre-determined approved well site marked with blue flag on left of upper driveway.
Click to enter text
Click to enter text
Diagram (Not to Scale)
.. xy=35*10'13.128"N ...
-::.
83*28'15.534" W
R R.
` 50'
y
395 Hdzel ..,.
. . . . .
ir e)....0. .. . . . . : ..:..::.:.:
: .
wr
100' +
OSWWIrBcR
Hazels Creek Road
N
i.
... ....
This permit is valid for a period Of five year's except that it may be revoked at any time if it is determined thadthere 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 oficontamination. Flow volume(well yield)Is NOT
guaranteed at any site by MCPH.
'i
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?i(828)349-2490
Issue Date: 6 10 2021 Harold Faircloth REHS 2189 l l ft,,�Authorized State Agent