GW1-2021-02479_Well Construction - GW1_20210923

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WELL CONSTRUCTION RECORD For Interngi Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook i.rl Ef � 'y� .'l\b$.'.`,h'::fi i :t-icgi.:d• ...(t. 'ne? iF' .:1. at.
FROM TO DE DLq CRIPDvI'ION
Well Contractor Name ft J , ft
2043 A 8,f'tt 3e6' &
NC Well Contractor Certification Nurnbor `r1 t:0_ LR`C'Si
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a ' ft, • ft, 6 V In.
Company Name
P Y ::11: . i1.iPJ i6`.. .:1 t' 'a f S M+IM
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: '00 fa ft.
List all applicable well permits(I.e.County,State,Variance,Injection,etc)
I ft. ft, In.
3.Well Use(check well use):
t'�{f ' 1�i1'i 4:"a';%c���'ii�>C;i:�:�`.- �ii```f�ii.�;:. ;iz:.��:�. �n.� s.`51.f. ^'�..a�S:�•'r.S,i.:
Water Supply Well: FROM To I DIAMETER I i SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial £ a+..{� •'.e;:s.,. •.. vMrJ4f.. .', F: w ;: �y
Ie�esideritial Water Supply(shared) �Q�:.-.ma-�•;._>,�:r;�a'�;z:�<:°���f,�,;.��:�:, .. , A. �,{.;<�,i .,• .:. �__,�
OM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri alien FRd e ft. ft. t
Non-Water Supply Well:
OMonitoring ❑Recovery ' ft. ,-W ft.
Injection Well: ft. ft.
❑Aquifer Recharge ClGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO i MATERIAL EMPLACFNIENTMETHOD
ft.❑Aquifer Test ❑Stormwater Drainage ff.
[:]Experimental Technology fL ft.
P BY ❑Subsidence Control _
❑Geothermal(Closed Loop) ❑Tracer >' 0� - :'sLO. a " tmd '�aLs '`t�i _ ,' , `,,..;ice•...r.:,i^:;fit
FROM TO DESCRIPTION color,hwam solUreck type,arvid size etc.
❑Geothermal Heatin Coolin Retum ❑Other(explain under#21 Remarks) ft. ft,
4't.LI ft. ft.
4,Date Well(s)Completed:42g.G77 a Well ID# y,1.
ft. &
Sa.Well Location:
tr. ft.
d%CS7s'MBM�' �J!`alr_l��7.�d.Z ft. tt.
Facie /Owner Name Facility ID#(if applicable)
/ ft, ft.
cs �d ti sF'� 11
Physical do L41 ft. ft. Irfcrr^3tlon rCCeL'
Address,City,and Zip
sr 1yi .. :r'. is,`;i�.� ..•; "� .•1 1 s�J.._,s;y4!j
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient) j
3:0. `r71Al N r �a�r�.�/,S, .l llJ W rf o, a-® 7•-
Signature of Certified Well Contractor Date
6.Is(are)the well(s):-immanent or ❑Temporary
By signing this form,I hereby eerio that the well(s)was(were)constructed in accordance
with/SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: QYes or MN,6 copy of this record has been provided to the well owner.
If Ibis is a repair,fill out known well constructlon inform aIIon and explain the narure of the
repair under#21 remarks section or on the back of thlsform. 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 wells constructed: construction details. You may also attach additional pages if necessary.
For multiple inJecrlon or non•water strpply wells ONLY With the same consdacNon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:P (ft.) 24a. or a ll: Submit this form within 30 days of completion of well
For multiple wells list all depths fdfferent(example-3C3a 200'and 2@1001) construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in 24b.)!of InleFlion 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) ,f Method of test: Air lift 24c.For Water SuRpty&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: �2 oz. well construction to the county health department of the county where
constructed,
Form GW-I North Carolina Department of Environment and Natrnal Resources-Division of Water Resources Revised August 2013

Qtotec,
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a c on County Pau,/
//,-GNEW WELL CONSTRUCTIONPublic Neaith / J CONSTRUCTION AUTHORIZATION
J" • a' a5-1 — t3 7 S 6117 PRIVATE DRINKING WATER WELL
GP2 Investments (Gary Aard) • 061121-P • 062921-s
a6sozl-s
Shared Well Residential 6566577202 26.77
' • Off Burnin town and Middle Burnin town Roads.
28N to L on Iotla Church Road becomes Burnin town Rd. to L on Middle Bumin town to L on first driveway to sites.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Dia ram Not to Scale
Open Top Survey Stake
3g Ada
J�
AProposed Shared Well
% 62'
Survey
Nail 130' 62�',-
in ground
5'min from any footer
Proposed House Site
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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.
A WELLHEAD COMPLETION,INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED 4$THE WELL,IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 7/20/2021 Charles Womack, REHS 1300 Authorized State Agent