GW1-2022-08908_Well Construction - GW1_20220912

WELL CONSTRUCTION RECORD For aterna,use ONLY:
This form can he used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Name fr. , ft.
2043 A fL
NC Well Contractor Certification Nmnbcr f or multi-eb6txlt blJa eO GiNE {'tt fable;:''•:..:,
PROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc.
Company Name ','1tO
PROM 7'0 DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: Qom$l�Z It. ft. in.
r..County,Slate, Variance,Injection,ale.)
List all applicable well perenirs(i.
fa ft, in,
3.Well Use(check well use); 77
Water Supply Well: PROM TO _ DIAMETER I SLOT SIZF, I THICKNESS I MATERIAL
lA Agricultural CM/�unicipa Public f1• rr. in.
OGeothermal(Heating/Cooling Supply) PI(esidential Water Supply(single) ft' ft.
OIn ustrial/Commercial CIResidential Water Supply(shared)
FROM TO MATERIAL EMPI.ACEMENTMETHOD&AMOUNT
anon fr. fr.
Non O[rri-Water Supply Well: d a
Oblonitoring ORecovery `to fL a� 1
Injection Well: ft. ft,
OAquifer Recharge OCsroundwater Remediation if:A% ";1)/b `vli 'sP
1:. AC�1C'�a..:11i
❑Aquifer Storage and Recovery OSalhlity Barrier FROM TO MATERIAL EMPLACEMENT METHOD~
OAquifer'fest ❑Stormwater Drainage
It. ft.
❑Experimental'rechnology USubsidence Control
?`20 bRh;I%fN.(isL•<)(`sl:atfgC tGd8iholiei ii`'eels t n"c93 ...ii°i�'v `s.?.,.- , '; `
0Geothertnal(Closed Loop) C)Tracer FROM TO DESCRIPTION color haudne solUrock type,grain size,e1c.
OGeothermal Heating/CoolingReturn) 00ther(explain under#21 Remarks) fr ft.
�-
4,Date Weil(s)Completed:C8•- — -
_ -.2ZWell IDIt Rom! ft. ft.
So.Well Location:
C S a-, ft.
Facility/Owner Name Facility IDH(if applicable)
--�9� �i.�t..,.re �e9U,.� /Pea✓. ft. ft. I �C sip:J:n v ..._.
Physical Address,City,and Zip21.;R�1�fARK
County Parcel Identification No.(PfN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
(if well field,one lat/long is sufficient)
.20 N /, w � �.
8iguatmme of Coll ified Well Contractor Date
6.Is(are)the well(s); 041fr'manent or OTemporary
By signing This jonn, !hereby rer16 that the well(T)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I.fA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: LlYes or CAW copy of this record has been provided to the well owner.
/f this Is a repair,fill out known well construction informmion and explain the nature of the
repair tender#21 remarks section or on the back of thine orm. 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; construction details. You cony also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL,INSTIICTIONS
9.'£otal well depth below land surface.: I 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) 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" 011.) 24b. oror Iniec�n Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.nugcr,rotary,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
13n.Yield(gpnl) 1� Method of test: Air lift 24c.For Water Supply 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 health deportment of the county where
- constructed.
Fomt 0WI North Carolina Department of Environment and Nanual Resources-Division of Water Resoturcos Revised August 201.1

•m Macon County �1 NEW WELL CONSTRUCTION
o
Public Health CONSTRUCTION AUTHORIZATION
'v a' T0 C !'1 I )" n PRIVATE DRINIQNG WATER WELL
� Cynthia Sjogren ® 051322-P � N/A
Single-Family Well Residential 6576400772 2.97
e e 1098 Willis Cove Rd. Franklin NC 28734
Airport Rd. to Olive Hill Rd.to Willis Cove Rd.to drive on right at the end
Permit Conditions
Vvcii � iall be constructed in compliance with all NCAC 2C Rules.
M. : `- r minimum setbacks as applicable, including 50'minimum from existing gravel drainlines.
iS in close proximii l to Property Line. Pull line from Iron Pipe to blue flagging tape before drilling.
Diagram (Not to Scale)
Io Telephone No JSes�tie
O Pole
S6'
9S,
! Well Area 1 50
50 �,„ 114' S�
fl� 051322 P --------- ------ ------
ravelDr ' lines on File
1010
pP
Pa; -
� a ei�P
If
I N
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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
SERVICF. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. (QUESTIONS?[phone]
Issue Date: 6/30/2022 Jonathan Fouts, REHS 1979 State Agent