GW1-2022-06049_Well Construction - GW1_20220629

. - =1'11ECL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internai Use ONLY;
I.Well Contractor Information:
Mitchell Dean Cook as)iATER:7 NES, r`
FROM TO DESCRIPTION
Well Contractor Name � ft. 1w ,
fr
NC Well Contractor Certification Niunber 15;OUTNR(�dSING fo>mtilf>cGsc111wElla tQ12:biIN+R!tf,'`1tck6je;:'si.,, '`,..i;
[rROM To Dennis Holland Well Drilling, Inc. DIAMF.TF.R THICKNESS MATERIAL
ft. , ft.
Company Name 16:1NNElt CASIN:Cr 08?TUB Cs eotharmnliclosetl!od
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C�� <� j ? —/� fr — ft in
List all applicable well petmlrs(i.e.Counry,Stare, i/arlance,injection,ere)
3.Well Use(check well use): ft ft in.
N.
17 FSf.RN.FN ,
Water Supply Well: FROM TO DIAMETER ` SLOTSIZE THICKNESS t„ AtA TER 1AL
❑Agricultural ❑Mull icipaUPublic fr, ft. in.
UGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial l8•: 12nUT,
091<"—idential Water Supply(shared)
❑Irri atiofl
FROM TO MATERIAL, EMPLACEMENT METHOD,&AMOUNT'.
Non-Water Supply Well: _� - Gio•. ��n: /`-LLz—
❑Monitoring ❑Recovery
Cam-
Injection Well: fr. fe.
❑Aquifer Recharge ❑GroundwaterRemediation 19r ';D/ 12 `YET:?PpC,K,'ife
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IVIATERIAI. I EMPLACEMENTMETHOD '
fr. fr.
❑Aquifer Test ❑Storniwater Drainage
❑Ex erimental'reclulolo ft. ft.
p gY ❑Subsidence Control
i20.11R1111N(.?sI<)(, etfrichimiiiittlaaaifshecra,fin` else
❑Geothermal(Closed Loop) []Tracer FROMTO DESCRIPTION_(color,hafdacaheoiUrocktypeypraineiu c1cJ'
DGeothermal I-Icatin Coolin Return) ❑Other(explain under421 Remarks) fl. ft.
ft. ft.
4,Date Well(s)Completed: Cali-%,77. J Well ID# ri%. �ij ,
ft. fL
So.Well Locution: tt. fay
Facility/OwncrName Facility iD#(if applicable)
ft ft. `
ic,�
Physical Address,City,and Zip i
=Y2L�Ah14hARIG�, 5'; ,,, ..yr<. s•
155
Comity Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat long is sufficient) ��'��'
N �GZS�e:o`��T W K ��1 ' � �o�JJ
Signanre ofCoilificd Well Contractor Date
6.Is(are)the well(s): OI ermauent or ❑Temporary
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
wilh ISA NCAC 02C.0100 at-ISA NCAC 02C.0).00 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &IN'o copy of this record has been provided to the well owner.
If this is a repair,fill our known well construction information and explain the nature of rile
repair under#21 remarks section or on the back gfthisform, 23.Site diagran1 of 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-woler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r'�2. (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@!00') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
/fu-ater level is above rasing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b.For Infection Wei ONLY: In addition to sending the font to the address in
Rotary m 24a above, also submit a copy of this for within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.uugcr,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 m ) Air lift 24c.For Water Supply&Injection Wells:
(gp ) JC Method of test: _
�" `^ 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 heaith'department of the county where
-- constructed.
Form GW-i North(.:arol na Department of i LIVirenmern and Natural Resources-Division of Water Rcsomces Revised August 2013

Qtote�r
Macon County NEW WELL CONSTRUCTION
o�'+a'i' ,°s Public Health EMAIL CONSTRUCTION AUTHORIZATION
'v a' PRIVATE DRINKING WATER WELL
+ Leonard E.Shafer T • 0221.22-P • 010922-S
Shared Well Residential _ _ _ - ' 6593869082 1.62
• • Lot 21 Franklin Stables off Wooten Ridge Road
' • Clarks Chapel Rd. to L on Wooten Rd.,to L on Wooten Ride to lot on left at switchback.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. a
Diagram Not to Scale
PL
30,
rr9h
t orwa
y
PL
Repair Area
r �
t " lob,'— r
PL
�100
1 ' in
100'rnin 'mi
From
Any
Proposed foote
Propo ed 1Nell W40 House
175'
IP 66' —50' Drive
Wooten Ridge
Green Box
N
IP
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 OR THE WELL IS PlkED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?(828)'349=2490
Issue Date: 5/6/2022 Charles Womack, REHS 1300 Authorize dStateAgent