GW1-2021-02476_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD For Interngl Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Name •ft ft "
2043 A ft. ft
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 0 - ft 56 ' fr. in. f
Company Name1
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#:_0 7..2.1-2 1 ft ft In.
List all applicable well permirs(i.e.County,State,variance,Injection,etc..) fG ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipaVPublic ft. ft. in.
OGeothermal(Heating(Cooling Supply) OResidential Water Supply(single) ft. ft In.
Clndustrial/Commercial 21Ces idential Water Supply(shared)
etion
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on
j.
Non-Water Supply Well: ft. it.
ft ft. `
OMonitorin9 ORecovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation :asi'r' Dl ? lti}r�1fi3P1 f• a s".' .. 7`#s
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr. fr.To MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test OStormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control
9 .It Cs5"a t d fin s .•i .,
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardn aoiFrock type,snain size etc.
OGeothermal (Heating/Cooling Return OOther(explain under t121 Remarks) ft. ft
' ft. ft.
4,Date Well(s)Completed: 0 9:&L-.21 Well ID# IV. �,d , ft ft —
5a,Well Location: fr. fG
S"2i4�t7s�4 fate /l9p. A/..Z4. ft. ft
Facility/Owner Name —T Facility ID#(if applicable) ft ft.
t rQt;
5� Aga&/.4 �e�a�/ ,SS ft ft pWR B�
Physical A ss,City,and Zip
anu Gmv,,Pi
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer iklai oa:
(if well field,one lrat/long is sufficient) ''LL // •� �%J
.3yS tl�f .2.2�_N
Signature of Certified Well Contractor Date
6.Is(are)the well(s): anent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or AaM�' copy of this record has been provided to the well owner.
(/this Is a repair,fill out known well construction itlformation and explain the nature of the
repair under#21 remarks section or on the back of ihisform. 23.Site diagram or additional well details:
You may use the back of this page to;provide additional well site details or well
S.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: '!SO � (ft) 24a. For A l LVells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
s
10.Static water level below top of casing: %410 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Injection 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 Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 56 Method of test- Air lift 24c.For Water Supply&Injection 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,
Form OW-1 North Carolina Department of Environment and Natural Resources-'Division of Water Resources Revised August 2013

C-77Q te orl-I. Q_ 1
QiOtecr \
�m Macon County NEW WELL CONSTRUCTION
' a Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Wmes Bell,current owner,Samantha Stauch, representative • 072221-P • 074721-5
ared Well Residentiale o Road take#55 Drive to site
1N to R on Rabbit Creek Rd. to L on Gregory Rd. to First drive on right#55.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Shared well requires a-minimum 100'setback.
Diagram-(Not to Scale
PL
o
c� pr�v
Fccess PL
Pavillion PL
Green Power Vault
V
1 ,^15' 250' ��o�P�Pe coC�eCs
128' RA's 25 '251.
5'min 100, Well Area
35 12'52"N
6 ' 1 min 83 19'55"w PL
6 r 66' 6
.6e q�ea i 15'
Od
O
N
This perllllit 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 OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 8/20/2021 Charles Womack, REHS 1300 Authorized State Agent