GW1-2022-06876_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Inteniol Use ONLY:
L Well Contractor Information:
Mitchell Dean Cook a;w` Fit: QT�Fst�: tt:<2'.'s+:F: :. :,;.,:,f .: ,.:, ;:,•,-.•, <;
PROM 7'0 DESCREPInON
Well Contractor Name rfL �, ft.
2043 A-
ft. . .0 ft.
NC Well Contractor Certification Nwnber
UWPN 15; Ri '`'$ 4 :fdY;mtilti eb" SitibUs;.()lt?'I E 7 ff�' cA6 e;'•sr' :i,=si't :•
FROM Dennis Holland Well Drilling, Inc, TO DIAMETER THiCiOVESS MATERIAL
y ft, ft.Company Naive ,.,.,- . ..... ,...... .... .. - _ -e16's ,1 RG•AS1N(r:Ulssj fil1B1N7Cr"edttie hie:clb@iloB' ;;:�_ �"
-�� l J, � ` FROM 1'0 DIAMETER THICKNESS ,MATERIAL
2.Well Construction Permit#: / 7' tL ft, in.
List all applicable well permits(i.e,County,.State, Variance,Injection,etc..)
3.Well Use(check well use): ft. in
, inRpm
.:
Water Supply Well: :•• .. :. .,.x ,...:;.,,�.. •:.,}>:.; .�.:� -_;, ' i...,-..
FROM TO _ DIAMETER SLOTSIZE I THICKNESS MATERIAL, .
f_lAgricultural UM� uun�nicipal/Public ft. fi. in.
0(jeothermal(Heating/Cooling Supply) b�Kesidential Water Supply(single) ft.
❑Industrial/Commercial gyre` :,.` z; a:>:xt;..;r >t.c;,r: ;r::._-:n,•:;.
QResidential Water Supply(shared) �"X.. 1;OU.T:>'.•'s. ;2;;:. ,..;?�s`��.-.r<.�.�:,:;':�� ::r.:•:>�:.1.4i;
. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lrl l a11011
on
ft.
N -Water Supply Well: � '
.Monitoring ORecoverY ,,j ft. ' tL
Injection Well: ft. fr.
.Aquifer Recharge QGroundwater Remediation ;$'.i`[ ./,Crk'.tVNks.F:':,G1Er fa>,• cdB'g,.,;._,,r.r�.�;:=:=t;?�`i.: _i:;?�:,••.,,,,•�; ,, :�:,•;:;:
.Aquifer Storage and Recovery [7Salinity Barrier FROM TO h1ATERIAI. I EMPLACE.MFNTMETHOD
�
0Aquifer Test ClStormwater Drainage ft. fr.
.Ex erimental Teclulolo ft. ft.
p gY L7Subsidence Control
.Geothermal(Closed Loop) 01'mcer 2Q;liFiI�I:TM33?i U"cs?aifac i�aa tionei.ii''i ofa`•ilYii'"esgi+ zzrzi: 0-01
FROM TO I D&SCRIVrION color hardaM sollfrock raiai .cic.
.Geothermal (Heating/Cooling Return .Other(explain tinder#21 Remarks) r.ft. fr. yr$ "..,v
ft. t
4,Date Well(s)Completed:Q,�Gi� VVell ID#___QL 1 r
ft. fa
5n,Well Location:
utF,�rz
Facility/Owner Name _ _ ft. as <n�.. 1} ,, `,�Y��t it Jv}i 1�7 v11• i
Fncility ID#(if applicable)
Physical Address,City,and Zip
70
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22•Certi6CAH0n:
(if well field,one ladlong is snfficient)
.3 5° 115 ' /�2" N �3® /9 ` !O " W ? � .fig ®Pz--" 2.2
Signature of Certified Wall Contractor Date
6.Is(are)the well(s): [�nent or OTemporary.
By signing Ihts fawr,/hereby rerr fy that the wall(i)was(were)constructed in accordance
��� with I SA NCA.C 02C.0100 at-1 SA NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: C1Yes or L+mo copy of this record has been provided to the well owner.
ff this is a repair,fill out)mown well construction information and explain the mature of the
repair under#11 remarks section or on the back ofrhisform, 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 welts constructed: 1 construction details. You may also attach additional pages if necessary.
Far mulliple injection or non-water supply wells ONLY with the same construction,you can
submit one form• SUBMITTAL INSTUCTIONS
9,'rotal well depth below land surface: _(ft,) 24a, For All Wells: Submit this tbnn within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 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 In'ecti n Wells ONLY: In additionto sending Vic 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: ry construction to the following:
(i.e.augur,rotary,cable,direct push,etc,) .
Division of Water Resources,IJoderground Injection Control Program,
FOR WATER SUPPLY WELLS ONI.,Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnl)•v_—7 Method of test: Air lift 24c,For WaterSuppIX Rc 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 healtli department of the county where
"- constructed.
Fomi GW-1 North Carolina Department of ruvironment and Natural Resources-Division of Water Rcsoiucos Revised August 2013

r
Qtotect,
Macon C q u n t y NEW WELL CONSTRUCTION
' Public Health CONSTRUCTION AUTHORIZATION
OoJa �� PRIVATE DRINIQNG WATER WELL.
Michael Langman • 061422-P • Ex.
Sin •le-Famil Well Only setbacks Residential ' 7517057276 1.98
• • 429Jim Cochran Road
' • 429]im Cochran Road
Perini(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.
Diagram (Not to Scale)
acne
propel :�
v
oa, .
r a`
Well Site
CO #2
ch�h ® .
IP
67' 14'from C1,
32'
#429 Jim Well Site
Cochran #1
Road Gam
---
s Tank m
J. QP
This permit is valid for a period Of five years except that it maybe revoked at anytime 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.
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: 7/1/2022 Jonathan Fouts, REHS 1979 Authorized State Agent