GW1-2021-02520_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: (�
Mitchell Dean Cook �ag': ±F ( eraT'q=4 .•d,•'`4 Z7^7 1.i• QY i-yi4,.4Yy
:`.&.=•.:.r.i^:i'ac�'',:i:�.:t.tir(s�..l..v:�Jxr :'�.s .3�s=r:� ::�:��t r:�c:;;:_P:tt.
FROM TO DESCRIPTION
Well Contractor Name Ays ft. - 'ee;, {t
2043 A �`i�'rt 6f' ft.
NC Well Contractor Certification Number 1$ bUR BR± "SYL[' f fo'idImiilh,cas�' S'a :U Owl-
NC It)i c Yv%�' !°?) t`!
FROM TO DIAMETER'. THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. p ft. : ft. r, 'In• R,-1/ /�1/c
Company Name q
:1:tii •.k'1Z_G'dSI1YSy, liIl!7Gt'iwf
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: :'4 71) 2 J - .00 ft. ft.
List all applicable well permlis(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): `^
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE t THIC^NESS MATERIAL7z' t
❑Agricultural OMunicipal/Public tt. ft. in.
OGeothermal(Heating/Cooling Supply) Iential Water Supply(single) fr. to in. 1
Olndustrial/Commercial ❑Residential Water Supply(shared) '`gt R'_Um"' rF..'.'u•<' i*' + sr. z• cso c...a��f` ''4 ' :;.;
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irri anon Q • ft. 3 - ft. 4.4
Non-Water Supply Well: -
❑Monitoring ORecove n ft. '.' ft.
ry �
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Ren tediation �`.i9r �$jD/, ,VB1t'i��yy f .s4.;'=a,Y Y; 4 �=:r�:�•`*• + .'Y=9;_::
I+.F� l•a' d � �4.,.' w.fi': .•=fF2:'J;•' Y:L�i%f!v' `."1K:. -}'i
OAquifer Storage and Recovery ❑Salinity Barrier FROM tr. TO MATERIAL EMPLACEMENT METHOD
fr.
❑Aquifer Test OStormwater Drainage
erimental Technology ft ft
❑Ex
p gY ❑Subsidence Control
24::b ^I = a""i§ tLlartio elfs eettSi >a i a �_,. 3r ; rl v❑Geothermal(Closed Loop) ❑Tracer FROM TOj DESCRIPTION color,hardness,sollfrock type,graln size etc.
❑Geothermal Heatin Cooling Return ❑Other(explain under#21 Remarks) fr. ft.
ft. ft.
4•Date Well(s)Completed:c'J&'- O'- Well ID# lU. �,�,
ft. ft.
Sa.Well Location:
fr. fa
�i_'A " X� y' /� tJ�l �1!d ft. ft.
Facility/Owner Name Facility ID#(if applicable) S E P X 3
ft. fa :�' 'n Unit
Physical Address,City,and Zip
' `. }ion
Cowity Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification,.(ifwell field,one fat/long is sufficient)
Signature of Certified Well Contractor Data
6.Is(are)the well(s): erroanent or ❑Temporary
By signing this form,I hereby cert6 that the well(s)was(were)constructed In accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or b'f1o­ copy ofthis 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 thisform. 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: _ .0
(ft.) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifalfferent(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: (� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level lsdbovecasing,use"+" 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Iniecfion 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 WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm)_ L) 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 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

i
Q�o�e�r
�� •m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
i
Nicholas Allen • 070221 P • 031920-S
Sin le-Family Well, Residential MT-T.. 6508780067 IM 1.03
• • Comer of Ned Hill and Old Liberty School Road —
' 28N to Cowee Creek Road, left on Leatherman Gap Road ri ht on Ned Hill Road,property on left off of Old Libert School Road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 25'from building perimeters and 100'from septic system components.
Diagram Not to Scale
/ Permitted
a
Well Area E+o\de
(070221-P) 4
(50'x 20')
Zs M�
�e
P�PeM J .
Creek / 1a'''••
�• � ae or
/
Pro 37' 3 BAR
/ MOj^C
J
aP n
7•
e eel
k et
ewer 69'
Ned,fill \ S
w
Road a A,��
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 fad 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]
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Issue Date: 8/12/2021 Jonathan Fouts, REHS 1979 51 Authorized State Agent