GW1-2022-09156_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD
Mils form can bo used for single or multiple wells For Intenrgl Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook 'hfES ri :i •,
FROM TO DESCRIPTION
Well Contractor Name
2043 A g$•h. 386' ft,
NC Well CoatractorConificationNtunber i:'1 '... "T.ilRit'G^A mu
: + AN( a:t^ti;:,ar, •.;
NZ`,fuc; lti�ck , slyly.
FROM To DIAMETER THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. v, ft. rt. in,
Company Namc
1't's E }:4'A91N1>()12 PUS a'dl :L�� :�,_a.:
FROM 1 TO DIAMF,TF:R THICKNESS
2.Well Construction Permit#: MATERIAL
�S D.�',� p to fL in.
List all applicable well permits(i.e.Couny,.Stare, Variance,Injection,etc.)
3,Well Use(check well use): ft.
^r�ft. r in.
•t'1:7!t,5<i1IEb. ;•. i; `.£i:; .v,:,"..<•..t:•:
warer•slrpplyweu: � �:,:."�` :..:. _.:•::•;:°:�:, >�>�:;...: ..:::;,...:::.,< :_.:�>:� �.-.:
FRUM TOO _ DIAMETER •�SLOTSIZF,•`I THICKNESS I MATERIAL.
nAgricultural C]Mu/�nicipaVPublic ft. h. in.
OGeothermal(Heating/Cooling Supply) R esidential Water Supply(single) fr, ft.
O n ustriRl/Commercial OResidential Water Supply(shared) "'$`-R a .- • :.%+-.,•:;T:::,-b-:r::':..:rv,._.;.a;;r a.,,c•.:,,.:.
_Dom TO MATERIAL EMPI,ACF.MENPMF.THUD&HMOUNT
C]Ir(1 atlOtJ D A ft. ft. a q
Noa-Water Supply Well:
OMonitoring ORecovery tr
Injection—Well: ft. fr, a
OAquifer Recharge 00roundwater Remediatiori ^'19. ,'rF:}:+PihY�IC
.ii '* c..i ?;T
OAquifer Storage and Recovery OSulutity Barrier FROM TO MATERIAL EMPLACEII1ENTl11ETllOD
fr. _ _fr.
OAquifer'fest QStormwater Drainage
rt rJF.xperimentel Technology C7Subsidence Control I L
C1Geothermal(Closed Loop) Q1'Iacer r201DittL iINC1k[<)(>?attiic Ii ellig&I.tieo'te'1 i `fie'-';'r`Y; ;;;:x:i';-1..f:.,•::i; ;:.':
FROM TO DESCRIP•ION color hardae solUrock qe!,grain size etc.
OGeoth',rmal I-Ieatin Coolin Return CJOther(explain under#21 Remarks tr. fr.
ft, ft.
4,Date Well(s)Completed: ,z Nell ID#�
So.Well Location: fr. �ft.
4r1;-ti urf�.tL4t2wl LPG_ ft. tr.
Facility/Owner Name Facility lD#(ifapplicable) -- ---- -
J / ft. ft. Ufi•',-i'
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Physical Address,City,and Zip
aPts1FRkA'ttK$ �
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County Parcel Identification No.(PIN)
5b.Latitude find Longitude In degrees/ininutes/seconds oi-decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
N ° D.� W 24 Signature ofCortified Well Contractor Date
6.Is(are)the well(s): anent or OTcmporary
By signing this join+,/hereby iI that the we!!(s)was(were)constructed In accordance
with!SA NCAC 02C.0100 or 15A NCAC 02C.07"00 Well'Construction Standards and that a
7,is this a repair to an existing well: ❑Yes or $fNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Information and explain the nature of the
repair under remarks section or oil the bark ofthisform. 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 may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9.Total well depth below land surface: (ft,) 24a. Fo Wells: Submit this form within 30 (lays of completion of well
Far multiple wells list all depths if ehfferenr(example-3(rr M0'and 2@100') construction to the following:
10.Static water level below top of casing: 6,0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwarer level is above rasing,use ,+,, 1617 Mail Service Center,Raleigh,INC 27699-1617
11.Borehole diameter: 6" (in,) 24b. For Illiecliqu elli 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Utiderground Injection Control Program,
FOR RATER SUPPLY WELLS ONLY: 1636 Mail Service C,'enter,Raleigh,NC 27699-1636
13n.Yield(gpm)._ Method of test:© Air lift 24c.For Water Supply&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 department of the county where
constructed.
Form GW-1 North Carolina Department of finvirmtmcnt and Natural Resources•-Division of Water Resoitreos Revised August 2013

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Q,atect — 2-
o m Macon County
Gl NEW WELL CONSTRUCTION
o o Public Health Q CONSTRUCTION AUTHORIZATION
°d • a' �/ PRIVATE DRINKING WATER WELL
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Permit Conditions I
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
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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 factor
circumstance upon which the permit Is Issued. Well location,Installation,and protection must meet state regulations.The yell shall be Inspected and approved by Macon County
Public Health before It is put into use. The location of the wen Indicated by MCPH Is to provide protection from possible sources of contamination. Flow volume(well yield)Is NOT
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 INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone] f
Issue Date:
_,(' tZEfkS 7�('q 3
12-'1 22, t �--� � Authorized State Agent
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