GW1-2022-07303_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD
11's form can be used for single or multiple wells For Luterngl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook )wei ERe"7'T IvS ae
Well Contractor Name FROM TO DESCRIPTIONt. ft.
2043 A ft. fr.
NC Well Contractor on Nu '
o Certification nber 15<Yi, TRW, S i(y'=tor'multi cg9sd,SSYd ';:.0 ,1�1NE it <"
Dennis Holland Well Drilling, Inc. fr. fr. c<
FROM TO DIAMETER TAICFQVESS MATERIAL
Company Narne ;'16 itVNti jtTCASliylr T11t3 f1 edt`ermati(1"edI16'' 't+
a a- FROM TO DIAME R THICKNESS MATERIAL
2.Well Construction Permit#: _ fL ft. in.
List all applicable well permlrs(i.e.County,Srnre, Parlance,Injection,etc) Su4`9 l c—
ft.
3.Well Use(check well use): ft. r
PP Y WCII: FROM TO _ �;DIAMETER s +{,SLOT SIZE..„ Tut XNES MATERIAL
❑Agricultural CJMunicipaltiPublic fl. fr. in.
IJGeothermal(Heating/Cooling Supply) tsti7r'lfesidential Water Supply(single) ft. rt. in.
0 htdustrini/Commercial
C1Residential Water Supply(shares!)
Dirfi ation FROM TO MATERIAL EMPhACEMENTMF.THOD&AMOl7NTy
Non-Water Supply Well: ICJ _
Olvlolitoring ORecovery ft. ft.
Injection Well: fr. tr.
fJAquiferRecharge QGroundwaterRemediation --hQS`.'.;D/(ikA•Y>}'?;AC�If°fia`"c` e' tr'%:`> "'.:' :`'rr.:=
OAquifer Storage and Recovery ❑Salinity Barrier FROM To aIATERIAI'. EMPLACEMPUMETHOD`
fr. _ _fr.
iJAquifer Test OStormwater Drainage
OEx erimental'rechnolo ft. ft.
p gY C7Subsidence Control
2QitD tli iI1Y [U'(s'eHac ti!'tlilo alrs7iecte=lfYi "`:3e i+rilY:;",•t :L7(ieothennal(Closest Loop) ClTracer FROM TO DESCRIPTION color hardne soill t rain size Cie.)
UGeothermal Heatin Coolin Return UOther(explain wider#21 Remarks)
ft. ft.
4.Date Well(s)Completed: Well ID# NL&__ —
ft. ft. { l �.
Sn.Well Location:
ft. ft.
fa fa
Facility/O•pw'ner Name j Facility ID#(if applicable) 1 r Q 2Q2
50 �I� _ p ,� " I ft ft.
t:�l, 'F-�Jtu�Y rt. ra
Physical Address,
City,and Zip —7 61 gip!
Q -^
County Parcel identification No.(PIN) T
Sh.Latitude and Longitude In degrees/Ininutes/seconds or decimal degrees: 22,Certification:
(if well field,one ladlong is sufficient)
Signature ofCettified Well Contractor Date
6.is(are)the well(s): ftlPermanent or ClTemporary
By signing this form,i hereby cert fy that the well(,)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or l.SA NCAC 02C.07.00 Well Construetlon Standards and thai a
7.Is this a repair to an existing well: C1Yes or FlNo copy ofthis record has been provided to the well owner.
lfthls is a repair,fill out known well consImcdon information and explain the nature of the
repair under#21 remarks section or oil the back of this form, 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 some construction,you can '
submit oneform. SUBMITTAL INSTUCTIONS
9,'rotal well depth below land surface; (ft.) 24a. &E All Wells: Submit this torm within 30 days of completion of well
Far•multiple wells list all depths if(fifferenr(example-3@200'and 2L100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff water•level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b. For Jn*ectiqn We 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: ry construction to the following:
(i.e.nugcr,rotaty,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C,'enter,Raleigh,NC 27699-1636
13a,Yield(gpm),�-_p Methnd of test: Air lift 24c,For Water Su I &Injection Wells:
Also submit one copy of this form viitliin 30 days of completion of
13b.Disinfection type: H & Amount:._� off. well construction to the county health Idcpartment of the county where
constructed.
Form OWI North Carolina Department of Environment and Native Resources'-Division of Water Rcsotvccs Revised August 2013
I

Q%Otect C PPL'
�,� Macon County NEW WELL CONSTRUCTION
�' Public Health CONSTRUCTION AUTHORIZATION
' PRIVATE DRINIQNG WATER WELL
Cynthia Copple ° 071322-P • Existing
e Single-Family Well, Residential _ ffM= 7517044508 2
583 Jim Cochran Rd.
e US-441 N L onto Coon Creek Rd. L onto Jim Cochran Rd. 583 at end of Jim Cochran Rd.
Permit Conditicns
Well shall be constructed in compliance with all NCAC 2C Rules.
M�intaln minimum setbacks as applicable.
Diagram (Not to Scale)
PL Neighboring Septic Tank
c4r
90, 100,
IP
i 45' %
51' v
49'
66 34'
Septic Tank ;
Driveway
583 Jim
Cochran Rd.
N
PL
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. QUESTION'S?[phone]
Issue Date: 7/21/2022 Jonathan Fouts, REHS 1979 / AuthodzedStateAgent