GW1-2022-07829_Well Construction - GW1_20220822

WELL CONSTRUCTION REC(.):RI)
This fort can he ascd for single or multiple wells For latcrull Use ONLY:
I.Well Contractor Information:
I
Mitchell Dean Cook 3
14W.•A1ER l.QNFS
FROM TO :.�DFSCRIMON
Well Contractor Name -
3a, r. ft,
2043 A
NC Well Contractor Ccrtificetion Nwnbcr f5 t71)I ER CAS1N4 for muJtwceycih"rvC16 f) c ARF, ?rt fekble FROM - 'r0 DIAMETER TAfCF:NESS MATERIAL-^
Dennis Holland Well Drilling, Inc. ft. n In f0 —
Companym Nae42 3 16..IlVNPR C ASII!t(r bR"l1713ormaliclpsed Ida
FROM T'0 DIAMETE THICKNESS MATERIAL
TERIAL
2.Well Construction Permit>4: 7 j � ft. fr. in. -
List all applicable well permlrs(i.e.County,,Starr., Variance,It je�etc.) __-
_ - T
3.Well Use(check well use): ft. f,•_ _ d
-_ _�_ T9 S(iREFN 977
r
Water•Supply Well: DIAMF.T6R �SLOT SIZE. Tfl K FSSNatAThR1A1,
ClAgricultural 17MunicipaVPublic _ ft.
CJGeothe;anal(Heating/Cooling Supply) l ential Water Supply(single) . ft. ft. in.
CPubdustrinl/Commercial L:1Residential Water Supply(shared)
f7lrrl ntion FROM TO MATERIAL- EMPLACE.MENTME,TIIODA AMOUNT•,
Non-Water,Supply Wcll: _ L�� %csh s► �
UMonitorittg LJRecovcry r to7 ft. PA��1 �
Injection Well: -" �'-" fL ft.
(]Aquifer Recharge (-]Groundwater Remcdiation 19:SAN"A%G14-V PAGK'(fap cgti e
T
ClAquiferStorageandRecove FRAM _ ro _ AIATFRIAI• EMPLACEAWNTMETIIOD
Recovery 17Salinity Barrier -
L3A(luifer"rest 0Stormwater Drainage
CJC•.xperintental'l'eclutologY CJSubsidence Control
DGeothennal Closed Loop) 20,ll1Zh LINFr L<)YC atiacNf§ildihtigel'ehecfa:ifin`e��e
( p) L.I'1'rTlCer FROM T0� DE,SCRn'n0N color hardne eo,Urock type,tram Size,etc.)
DGcothermal Heating/Cooli�Return) C-Other(explain tinder#21 Remarks) ft• � ft.
4.Date Well(s)Completed:� U •�7J Well IDH_ _--
fr. ft.
So.Well Location:
ft. ft.
Facility/OwucrNatne FncilityID#(ifapplicablc) -- - -•_-. =.--- _ .I� �._2f1�?_
ft, ft. •= '� L��
1rs�t 1 ft. tt IlTfviFteit�(1i'f^GiG&at2
Physical Address,City,and Zip
;21 1iEMA1tIf� 7.
County Parcel Identification No.(PIN)
i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is suQicient) 22.Certification:
_gal_ st
���.s� Siguahae o(Ccrtificd Wcll Contractor Uetc
6.Is(are)the well(s):4ecrmanent or OTcmporary
By signing this form, !hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC'01C.0100 or 1 SA N(_'AC 01C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: I-)Yes or QUIe — copy of this record has been provided to the well owner.
1f this is a repair,fill vier known well construction information and explain the nature of the
repair under#21 remarks section or on the bark of thi,sforen. 23.Site diagram or additional well,details:
You stay use the back of this page to provide additional well site details or well
g.Number of wells constructed: construction details. You rnny also altach additional pages if necessary.
For multiple injection or non-water supply wr/k,ONLY with the same construction,you can
submit one forin. SUBMITTAL,INSTUCT1ONS
9,'rotai well depth below laud surface:•�fG,� (fL) 24a. For All Wells: Submit this jfornt within 30 clays of completion of well
hot;-multiple wells list all depths ifdihermnr(example-,4(r�200'rmd 2(a100')�� construction to the following:
I ,
10.Static water level below top of casing: _3l,-5 ^_ _ (ft.) Division of Water Resources,information Processing Unit,
lfwaterlevel is above rasing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617.
11.Borehole diameter: 6 ill. legtion WcUs ONLY: In addition to sending the torn to the address in
Rotary 24a above, also submit a copy Of'this tDrtl within 30 days of completion of well
12.Well construction method: __ construction to the following:
(i.c.nuger,rotary,cable,(Erect push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELI S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield mt Rc Method of test: Air lift 24c.For Water Supply IgiectiJWells:
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. I
Fort GW-I North Carolina Department of Gnviroument and Natural Resources.-Division of Water Rosmirces Revised August 201.1

Qc9�'cer ,
Vir
•m Macon County NEW WELL CONSTRUCTION
� -d Public Health . CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
___...._ .__......_........__......................................._-......_.._....._.............
.. __._..._... _....
_ '
•" I Leila awrenr-e • 07152?.-P
Sin Le-Family Well Only Residential 7517067321 1.76
LOCATION �
_1141 Coon Creak Rd Franklin, NC:28739 _ _..._..._..._.___._._.___._..._..___. _..._......_...._.-.-......_..............._.._.._._ --- - ---
._._._..._._
DIRECTIONS lJS 441 toward Sylva to_L on Coon Creek Rd
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. r e
Diagram (Not to Scale)
Lew
N
v
QQ OS o
M
Proposed._..
Well
I
c°<L Location
This permit is valid for a period of five years except that it may be.revoked at any time if it is detemlinod that there has been a material oange in any fact of
circumtitance upon which the permit is issued. well i0cati0n, installation,and protection must meet state regulations.The well shall be inspected and approved by Macon county
Public.Health before it i5 put into use. The.location of the well indicated by MCPH is to provide protection from pos,ihle`sources of contamination. Flow volume(well yield)is Pici i,
guaranteed at any site by MCPH.
A WELLHEAD COMPLk-TI.ON INSPECTION MUST BE:APPROVED BEFORE F-INAI_ POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INST'AI_LATION. QUESTIONS? [phone]
Issue Date: 7/21/201,1 3onathan Fouts, RFHS 1979 \I�n
g�� Authnrizctrl.5tate Agen,