GW1-2022-03602_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD For Interngi Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCREMON
Well Contractor Name fr. r fa
2043 A fl
NC Well Contractor Certification Number
FROM TO THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o ' `t• 76P 4DIAMETER
" in•Company Name '•') .•illy iu `GCAS[i`I $
2.Well Construction Permit#:����;L� / -� FROM TO DIAMETER THICKNESS MATERIAL
fa ft.
List all applicable well permits(i.e.County,Slate, Variance,Injection,etc)
3.Well Use(check well use): ft. f t in
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
OAgricultural OMunicipaVPublic ft. I ft in.
00cothermal(Heating/Cooling Supply) Bfc-sidential Water Supply(single)
❑industrial/Commercial ElResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT/
Cllrri atiott o r h. ft-
Supply Well: v /.t►w�✓ �•6.. 1 /emu-
3 . ft. 20 , ft es N
OMonitoring ORecovery -
Injection Well: ft. ft.
DAquifer Recharge C1Groundwater Remediation 19;
❑Aquifer Storage and Recovery USalinity harrier FROM TO MATERIAL. i EMPLACEMENT METHOD
fr, I
17Aquifer Test OStormwater Drainage tr.
OExperimental Technology OSubsidence Control rL tt.
AMDR '41Nii[t7Cs,et(a8 `mlditoael d ecfa•ift»""cs9 ",,. t:; r� r
❑Geothermal(Closed Loop) 01'racer FROM TO DESCRIPTION color,hudn aoiUrock grain size,etc. '
[]Geothermal Hearin Conlin Retum C70ther explain tinder021 Remarks) tt. fa
ft. ft.
4.Date Wells)Completed:&J.3 2 -��Well ID#_ n/,A rL fL
So.Well Location: tr. ft.
Facility/Owner Name Facility lDN(if applicable) ft. ft. p
J'a ow a L9 a h, fL
Physical Address,City,and Zip 21i 1tE1V1A I Tr.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
03 �_ 9A Ig S' 6EN "b� 344 5-S,9.> w
,Signature of Certified Well Contractor Date
6.Is(are)the well(s): fiiil?Tmanent or OTemporary
By signing this form,1 hereby cart fy that The well(s)was(were)constructed in accordance
Will 1 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: dYes or Via— copy of this record has been provided to the well owner.
/f this is a repair,fill out known well construction information and explain the nature of the
repair tinder N21 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
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: 2 .s (ft,) 24a. EgE AN Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffercnr(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7oO (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 Iniection 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:
Ge.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(gp m) Method of test: Air lift 24c.For Water Supply&Iniection Wells:
j.� ,
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: H & H Amount: 2 OZ. well construction to the county health department of the county where
constructed.
Fornr GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

. c
r
Q�Ote�r
Macon C o u n t y Et11811ed==, NEW WELL CONSTRUCTION
' 6/16/21; ECS
° Public Health CONSTRUCTION AUTHORIZATION
;PRIVATE DRINKING WATER WELL
Teddy Cook NEW= 042621-P • 044921-S
Single-Family Well,.Residential IMM ' 7504146034 3.28
• • Just Below#128 Guffey Lane
• Wells Grove Church Road to Fulton Road to Guffey Lane on Right to top of hill just below#128 Guffey Lane
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from septic components and 25'from building perimeters.
Diagram Not to Scale
Permitted
Well Area
042621-P
(10'x 10')
0
*4O Oak O 1Z.
Tree
`J�Oa, �tio 1Q'
�. e
�q Power 140' g
Pole
[+? �4;� 0 y�pFz
a
P
Walnut rop'nv tine
3 Tree/
I Corner
3
d
c
N
s� W . 0 . E
Poplar
Tree/ S
Corner m
,x
F
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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 factor
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. H
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?[phone]
3
Issue Date: 6/15/2021 Jonathan Fouts, REHS 1979 AuthoiizedStateAgent
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