GW1-2022-08906_Well Construction - GW1_20220912

W.EhIa CONSTRUCTION RECO:RI)
11iis font can he used for single or multiple wells For luteni li Use ONLY:
i
1.Well Contractor Information:
Mitchell Dean Cook 14 WAT!R 7QNb;s_
- - --' --
FROM�• TO �- DESCRIPTION
Well Contractor Name ft.
2043 A fr: rr: I _�
_ I
NC Well Contractor Certification Nwnber IS'OUTKR(ASTNZ!,(forrmi lit rob ed cvC la`U '[i1NF 7 (' 7ie9ble <
PROM TO DIAM11E ER THICKNESS MATERIAL T�
Dennis Holland Well Drilling, Inc. o ft ft 6 !, in
Company Natuc V
16 NE R CASING OR"111.8' Cs' eothorinal,2ldscd too s
'1711CKNESS
2.Well Construction Perm FROM 70 it (l. ft. DIAMETER. MATERIAL in. -
1,ist rd!applicable well permits(i.v.Counly,State, Variance,l jerrion,etc)
'
3.Well Use(check well use): ft. ft. _ n
Wat¢rSnpplyWell: .___. FROMl.TO DIAMETER SLOTSIZE— HICKNFSS T � M1IATER1Al.
ClAgriculhupl C3Municipal/Public T fl - ft. in.
00cothermal(Metting/Cooling Supply) &4fre'sidential Water Supply(single) ft. ft.
0111dustrial/Commercial (]Residential Water Supply(shared) 1$ GRt741T
FROM _ TO
f7lrri ation _ MATERIAL EMPI,A4F,MFNTMET110D:&AMOUNT
-
Non-Water Supply Well: p �ft� fr. {' ;/ -2- �
t7Monitoring URecovcry -�ft, zi . ft. s _ 9-e, u
Injection Well: fr. ft- -
DAquifer Recharge OGroundwater Remcdiation t9 SA:D/..CIlAVF iPpGK (fin 'tic e` ;j
ClAquifer Storage and Recovery (]Salinity Barrier FROM TO M1(A_A I. EMPLACEDIFNTMETIIOD�"
ft. _ fr.
OAquife.r"fast 08tormwater Drainage _
ft. �OExperimentul Technology C7Subsidence Control ft.
'2Q.aRR11N(,f Ul>_aNactiieddthonehti6¢cta Tito`,c�esee �:''
[/Geothermal(Closed Loop) El Tracer FROM TO U&S(RlY77UN color,hardoes�s,sorUrock type,train eiu etc _
C3Gcothermal(l-lcating/Cooling Return) CJOther(Explain under#21 Remarks)
4,Date Well(s)Completed:Q,q:y2,4Z;j,ZWell IDN ^, - ---
R. ft.
5u.Well Locatiou: --ft, ---ft. --- -- -
•: skma
Facility/OwncrName Facility lDH(ifnpplicable)
ft.-• oft.^ -
t
rt. fr -
Physical Address,City,and Zip
County Parcel identification No.(PiN)
51),Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
; T
(if well field,one IeUlong is sufficient) lop
��_. .Z1 _ N �j�a� or -dam' -
__.
Signnture ofCmtifted Wolf Contractor Date
6.Is(tire)the well(s): OD-6--pent or (]Temporary By signing rhi.s forn,,!hereby certify that the well(s was(were)constructer/in accordance
with 1 SA NCAC 02C.0100 at-15A NCAC 02C.02.00 Well Consn•uetlon,Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy ofihis record has been provided to the well owner.
/f this is a repair,fill oul known well construction information and explain the nature of the
repair under#21 remarks section or on the back of•This form. 23.Site diagram or additional well details:
You cony use rite back of this page to provide additional well site details or well
8.Numher of wells constructed: construction details. You ntny also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you con
subrniraneform. SlI11M1'I"l'A1.,1NSTUCTIONS
9.'fotel well depth below In»d surface: a _ _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: _.T T,- T_ _(ft.) Division of Water Re.soui•ces,Information Processing Unit,
/f,vorerlevel is above casing,use"r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_6" 24b.Tor Injec iqa Wells ONLY: 16 addition to sending the form to the address in
Rota 24a above, also submit a copy of this;fnnn within 30 days of completion of well
12,Well construction method:_ ry construction to the following:
(i.e.auger,rrnary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f ,
13n.Yield pro Air lift 24c.For Water Supply Rc In.je.ction Wells:
(gl ) Method of test: Ath
-----"-�"�"--"--""-""-"-'"- Also submit one copy of this fnnn 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.
Fomr GW I North Carolina Department of F•,uviroument and Natural Resources .Division of Water Resources Revised August 2013

QJoVe",
M •� Macon County NEW WELL CONSTRUCTION
01 Public Health CONSTRUCTION AUTHORIZATION
d • PRIVATE DRINKING WATER WELL
t i Frank Crumley T—` P07122 --SE�62035 7.99
o Just Past 1918 Water Gauge Road on Right _
' } a Rainbow S in to Just Past.1918 Water Gau e Road on Ri ht —
Permit Conditions T
Vv*eil shall bo constructed in compliance with all NCAC 2C Rules.
M.!intain minimum setbacks as applicable, including 100'minimum from septic components and 25"frohi building perimeters.
Permitted
Well Location
(Revised)
• (061521-P)
• (25'Min) (25'Min)
Ed © 00
J j °Mr„J Proposed
3 BRM DRM
/ 'transformer tij q'
ome
ry?os, 5'Min
eck
------ -----. i
A 1 1
135' et EF air Aremaa) i
b
J i
1
L- ---
J
A.
90,
is,Min 30,
�
-Water Gauge Road — c" nk
>50'Min to Creek
Diagram (Not to Scale)
This permit is valid for a period of five. years except that it may be revoked at any time If it is detemined that there has been a material change in any fad or
circumstance upon which the permit is issued. Well location,Installation,and protection must meet state regulations.The well shall he inspected and approved by Macon county
Public Hearth before it is put into use The location of the well Indicated by MCPhi 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 UR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALIATION. QUESTIONS?[phone]
Issue Date:pp7/13/2022 Jonathan Fouts, REHS 1979 � Author/zed State Agent
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