GW1-2021-02514_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD For Interm ll Use ONLY:
This form can be used for single or multiple wells qq+
1,Well Contractor Information:
Mitchell Dean Cook 6� ` 3 r9� ",,;:y t't ��.
a5\ FROM TO DESCRIPTION
Well Contractor Name �pC
2043 A tV2�rp ,e FL Ft,
�n Q.
NC Well ContractorCortification Number X
FROM TO LD!UMETER� TRICKNES.4 MATERIAL
Dennis Holland Well Drilling, Inc. Ft• ft. tn.
Company Name 1'l4:IrY Ft:Ci( _t4(o:•, 14�1 f'ett . 'o r` ki'9
FROM I TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. al�t r Ft. ,r .' in• Y
List all applicable well permits(i.e.County,State,Parlance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): h a r, u .r-� = Nt l
:'? :f E�N�^: ,r.s-,e,� ..lFr,_a'..w•?u`s:�i's i=,:+"•+'S� etc• .<a.:a^' ..r . r>.
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Ft. FG In.
❑Agricultural OMunicipaUPublic
Ft. ft. In I
OGeothermal(Heating/Cooling Supply) IKesidential Water Supply(single) yy r1ry�
+' jitYl{ �.'!•H' .fi,r-,-�_. r!.—, 'S :v:<-t,"�-t {'?>t"_tiw"•Q%?s �:£:a Stkra'^°�'t '', `!ly'�,'
Olndustrial/Commercial OR ,
esidential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation �' ft, r ft,
Non-Water Supply Well:
21
OMonitoring ORecovery r it -tea ft
Injection Well: ft. ft.
OAqui£er Recharge OGroundwater Remediation 29:' ;D( '1'rI)ur.A K"ria' c b < z s '• 'rx= J .f=3:= 's{a`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft, MATERIAL- EMPLACE111ENTMETHOD
OAquifer Test OStormwater Drainage
ft. ft
OExperimental Technology OSubsidenee Control
u, 01� p>�t�'a� �i{�'c•iaaattt`'ual.�-.:t;il - 3 n :�r,,��,�.
OGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION color,hullo sollfrock type.trria size etc.
OGeothermal Heating/Cooling Return 00ther(explain wider#21 Remarks ft. ft.
ft. ft.
4.Date Well(s)Completed,61-D3-Z Well ID# Al.A
ft. ft.
Sit.Well Location: ft. fa
ft. ft.
Facility/0wncr Name Facility IDN(if applicable) ft. ft.
,6.2.Z-0_ Lowe.- Rid —,h 0 zfj ft. fa
Physical Address,City,and Zip
,jam a Go,Gr 7
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
Signature ofCertified Well Contractor Date
6.Is(are)the well(s):4M—rmanent or OTemporary By signing this form,I hereby cer16 that the well($)was(were)constructed In accordance
with 1SA 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 tiM copy ofthis record has been provided to the well owner.
If thus is a repair,fill out known well construction information and explain the nature of the
repair under#2I remarks section or on the back of thtsform. 21 Site diagram or additional well details:
You may use the back of this page to yprovide 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: D (it) 24a• For Am W h+,: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3Q200'and 2 r@100') construction to the following:
10.Static water level below top of casing: 7a ` (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 Infection IV_eRs 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: constntction to the following: k
(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) 410 Method of test: Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this farm 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 GW-1 North Carolina Department of Environment and Natural Resources-Division of Walcr Rosources Revised August 2013

4
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`� •m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
'd • a' 'PRIVATE DRINKING WATER WELL
_ -- ----.-............_ -------- -._......... _.._
Robert Miller
• 100320-P _• 103920-S
Sin le-Family Well Residential
_ 9 Y —�_...__._ -.---...-.---_..__.._..---............_ 6 S 6 7 5 3 7 9 6 8 5.94
• • 6220 Lower Burnin town Road
' 28 N to L on Air ort Rd. L on Olive Hill Rd. to Lower Burnin town Rd., L on S rin Creek Rd. stay R to house on hill.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Any questions call MCPH.
Diagram (Not to Scale) E
IP
Well Area i PL
:25'
Ex. Well 25 M�� ? 25'
Prop Pool
>25' Nso'
I&R
OSWW
4 BR ;
House
Text Box
i
I
try
y
PL IN
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.
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. QUEST NS?(828) 34 -2490
Issue Date: 11/30/2020 Tanner Stamey, REHS 7712 ___ _. .. 1� izedStateAgent