GW1-2022-06875_Well Construction - GW1_20220719

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WELL CONSTRUCTION RECORD
•fl1Lb form can be toed for single or multiple wells Poi Iatornal Use ONLY:
L Well Contractor Information:
Mitchell Dean CookrIr s:-
i; ..�:`•i?Fh.St':fr.4� :,}:irt.J"!'•CS' {' `. 2;S;Li�?r?�if;Y:?'n;°::�i
FROM TOI DESCRn"ITON
Well Contractor Name I ft. ft.
2043 A ft. rr,
NC Well Contractor Certification Nwnbcr ISi:O, 7 NR:GL".SYNC`•fo imii7ti=c3 dljs?:Q ,1�iN
f0 DUIMBTE $ t jf{ lc$6j�';;mot_<•2.;;;#t.;.;';
FROM R THICKNESS IMATERIAL
Dennis Holland Well Drilling, Inc. o •'ft.
Company Name 1'61i
FROM TO DfAMF.TER THICKNESS MATERIAL
2.Well Construction Permit#: mil` /J ' ,.� fr ft. in.
List all applicable well permits(i.e.County,State, Variance,In'e Non,etc.)
ft ft. in,
3,Well Use(check well use): -^ u'
,' a:';ta;?: : :.iti,•:i': 'NM „il r:•;a;:
Water'Sltpply WCII: FROM TU DWIFTER SL0TSMF, TEllCKNFSS MA
❑Agriculhual CJMunicipaUPublic tr. fr. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. rt.
Glndustrial/Commercial its•.
CJRe id Water Supply(shared) Rn .Tss < _; : ' .:ut1';i;:; , %;,. r;•; :,<'..;.
s entiel Wat �.t.... �;� :,:,:.:.��',...:::�is'S..::a,... ,.....:
PNon-Water
FROM TO `. MATERIAL-
' ' -•••EMPI,ACF.MENTMFTHOD&AMOUNT
© r it. ft. �p
Supply Well: r Z
ng GRecovery .3 ' ft• aft.
Well: ft.Recharge 0Groundwater Remediation .'11 n ' 1+
lfi I+a •t1C'a. a]'`; ^'.r: i�Ytr�tis :,tiu 5_..<...... 4�:`.!'i:r.`,:.::`.
❑Aquifer Storage and Recovery st:,�:,z:,�..,.,;R:::•._
GSulinity Barrier FROM ---[-TO MATERIAL, EMPLACF'.11fENTI1fETETHOD
ft. _ ft.
GAquifer Test 08torniwater Drainage
GF.xperimental Technolo ft. ft.
8Y ft.Control
`2t1i D1f 'L�kN.r3,t1#U'cs?t3":r iiiaal:eticofs•iflc`e�e .;,;""r:Y,_r:,.;Y`';$%'?!;;;;t;;::• :r
GGeothermal(Closed Loop) Cl tracer FROM TO DESCRIPTION color bardoem solUrockt rain Aze cic.
❑Geothermal I-Ieatin Ccolin Return) GOther ex lain under#21 Remarks)
4,Date Well(s)Completed:4y-30-24 Well ID# MIA, _ _ P Pry,�y^F YI)
ft. ft.
So.Well Location:
tr, �ft.
cr oy^i i / ft. ft.
Fncility/Owncr Nmne D# �� l•.s (' iO
r+�
Facility ID#(if applicable) �' ti
,5-d rt 9 rtn
rt. ,��. ^1 J1li 1
ft. (1l.•L
�„1 Il7
Physical Address,City,and Zip
ElY1AKi2S �`::
County Parcel Identification No.(PIN)
5b,Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification:
` l
Stgaature of Conifled Well Contractor Date
6.Is(are)the well(s): [FYI e�rmanent or L7Tcmporary
By signing this fonn,!;hereby reriO that the well(i)was(were)•consiructed in accordance
with iSA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construcilon Standards and that a
7.Is this a repair to an existing well: GYes or IPW6 copy of this record has been provided to the well owner.
lfthis is a repair,fill on/known well construction information and explain the nature of the
repair under#21 remarkssection or on the back ofthisform. 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: constuction 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 ane form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �lii5a
0 (ft,) 24a. Foc All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths ifdiffereni(example-3@200'and 2L100') construction to the following:
10.Static water level below top of casing: J .0 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Centl r;Raleigh,NC 27699-1617
11,Borehole diameter: 6 __ (in,) 24b. or In'ec ion Wells ONLY: In Inddition to sending the form to the address in
Rota 24a above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: constnletion to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
F'OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,:Raleigh,NC 27699-1636
13n,Yield(gpm)•_� (7 Method of test: Air lift 24c.For Water Supply Rt 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.
Forst GW-I North Carolina Department of Environmcut and Natitral Resources-Division of Water Resot�urocs Revised August 2013

Q�Ote�r
Macon County NEW WELL CONSTRUCTION
CONST
a ,d PUhIIC Heath RUCTION AUTHORIZATION
�d • a' PRIVATE DRINKING WATER WELL
Warwick f3Orris • 061122-P • Ex,
Sin le-Famliv Well Only Residential 7517045858 1.63
• ' 503 Jim Cochran Road
503 Jim Cochran Road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 50'from septic systems and 25'from building perimeters.
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Diagram (Not to Scale)
J1.
63
;��1 co '�
C3y' 'Qoa raa N
Septic O
'^e Tank E
,
if 1
N65'
91' S
® Well Site
36, Drive
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s.
�$3
Septic
Tank IQohran
as
Well Site -- Qm>�-- ---- ---
epejrY[tye ® #2 Q�c
6�
P,.ope�
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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 OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION: QUESTIONS?[phone]
Issue Date: 6/24/2022 Jonathan Fouts, REHS 1979 Authorized State Agent