GW1-2022-07301_Well Construction - GW1_20220809

WELL C0NS'TR1JCTI0N RECO RD For Intenlai Use ONLY:
This farm can he used for single or multiple wells
I.Well Contractor Informatiou: __
Mitchell Dean Cook 14�YnTi x zoNE;s -
—� FROMT(1 DF SCRIi''I'ION -
_._..�
WcII Contractor Netnc ft.
2043 A _---
NC Well Contractor Ccnification Number 1S, nIJTNR(ASTNG, for multrcksCT`.wdlle (9L UIN13k,rf;" 7ie8hle,'? T
FROM TO DIAMETER THICKNESS !MAT�K�RJ�AL ____Den
nis Holland Well Drilling, Inc. fLc=
Company Narno CUB1Cy' "eot ermal'elii;ed lot
Ly TO _
2.Well Construction Permit#: CJ• .�. _ /- (t.FROM DIAMEn
� .R THICKNESS MATERIAL in. '-
List all applicable well permits(i.e..County,,Stale, Variance,Injection,eic)
ft. ft. —in.-
3.Well Use.(check well use.):
Water Supply Well: _ FROM_ TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
I lA riculhtrnl ft. ft.^ in.
g LIMunicipal/Public _
GGeothennal(Henting/Cooling Supply) CLAcsidential Water Supply(single) fit. tt, in.
tDindustrial/Commercial IlResidential Water Supply(shared)
FROM TO _ RATERIAI, EMPLACEMEMf MF.TIIOD&AMOUNT_
f.111'ripatioll _ ft.— fL - 7 ti
NoD-Water Supply Well: v
0monitoring URecovery A ft, a ._) (I. t"t
_ _ w, 2 _Z, -..
Injection Well: - '- ft. ft.
nAquifei Recharge OGroundwater Remediation 19. `A'lYD/bLiAVM 'I±AGK"if a uck6 e
FROM _ TO RtATER1AL EMPLACERIF.NTMETUOD T _
OAquifer Storage and Recovery f]Snlinily Barrier ft. fr. _
[]Aquifer'rest ❑Stonnwater Drainage
DExperimental Teclmology USubsidence Control
;2U 1)RTl)L1N(r:[Ut�(ettactl!eHditione_I iiti� ecte�lfta ea9a •°`i' T
ElGeotherinal(Closed Loop) ❑Tracer FROM TO D&SCRIPTION color,hudnen sorUrock type grainptu etc.
G(icothermal cx lain under#21 Remarks) ft. ft.
fr, ft.
4.Date Well(s)Com leted: �t`y - — -
P � :.c�:�.Well IDN�/t/. //i
t.
Sri.Well Locatiou: R. -fit.
5 G f ICE _ Al, 1 � ft.
FRcilit Fa
/Owner Natnc
Y Facility ID#(ifappliceble)
fit. fit. Unh
463
fLe . J fit.- fit U::QMOG
�
Physical Address,City,find Zip
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: _-
(if well field,one I8010118 is suRicicnt)
ZZ-
Signature ofCcoified Well Contractor Date
6.1s(are)the wcll(s): i915'ermanent or f17'emporary
By signing this form, l hereby certify that the wrll(s)was(were)constructed in ncrurdnnc•e
���^ with/SA NCAC'02C.0I00 or L.fA NCAC 02C.02.00 Well Construction Standards and that a
7.Is this a repair to an existing well: IaYes or YJ"'r' copy of this record has been provided to the well owner.
If this is a repair,fill aul known wall ConsaVCtion information and explain the nature of the
repair under#2i remarks section or an the back of this form. 23.Site diagram or additional well details:
You nary use the.buck of this page to provide additional well site details or well
8.Number of wells constructed: 1 ronstluclion details. You may also attach additional pages if necessary.
For muhiple injection or nor-water supply we/is ONLY with the same convirrtction,you con
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _ (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For rultiple wells list nil depths iifdifjercnr(example-3(rr�,200'and 2G(O/00') Construction to the following:
10,Static water level below top of casing: _ •Ja -_- (ft.) Division of Water Resources,Information Processing Unit,
Ifivoter level is above easing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole.diameter:_61 _-(iu.) 24b. For Inaecti(Ln Wells ONLY: ''In addition to sending the form to the address in
Rota 24a ahoy;, also submit a copy of this form within 30 days of completion of WcII
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,61:ct push,etc.)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WE:L[S ONLY: �— 1636 Mail Service Center,Raleigh,NC 27699-1636
tra ll Air lift 24c.For Water Supply&In'eIctiTnTWells:
13n.Yield
(BI )._._LQ Method of test:
Also submit one, copy of this form within 30 days of completion of
13b.Disinfection type:-H&F{ Amount:J_ UZ,_-_—___ well construction to the county health depnrtment of the county where
Fonn GW-I North Carofina Delnulment of fnviroument and Natural Resources-Division of Water Resources Revised August 2013

Q�otP�r
�A .m Macon County NEW WELL CONSTRUCTION
a Public Health CONSTRUCTION AUTHORIZATION
'v a' PRIVATE DRINKING WATER WELL
Family Trust 7 N/A
-- _............._.......__.. - - —._......._....__.........._._.__. .. -. -........._........._._ -- --.............
APPLICANTIOWNER
Shaffer _-.-._-. ..............._.........._..-- .......... • 01922 P •
INTENDED USE Single-Family Well, Residential .......................................... _,_ __.... T_............
-
• 710N 463 Jim Cochran Rd Franklin NC 28734
' amt. US 441 towards...Sylva to L on Coon Creek Rd to L on Jim Cochran Rd
--- _... .. .. .... ......
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. o
Diagram (Not to Scale)
N
PropegY t ine
Proposed Well
-1
Location
071922.-P She
..........---........._.
25'
,' Fk
a
Ex. ST \ O�
., Q
��OPer�Y Cirre zllz�a
Vo
fi
1
i .
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 fac.i of
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 Counb/
Public Health before it is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of Contarnination. Flow volume(well yield)is N01
guaranteed at any site by MCPH. '
i
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECT ION AFTER PUMP INSTALLATION. QUESTIONS? [phone]
Issue Date: 712 112 0 2 2 Jonathan Fouts REHS 1979 �U`f15
...._._....... .....:_.._a!"��"_- State Agent
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