GW1-2022-09871_Well Construction - GW1_20221028

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WE'LL CONSTRUCTION RECORI) For lutemal Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor-Information:
Mitchell Dean Cook as wnmFxroris T
FROM TO DFSCRIP'I]ON
Well Contractor Name ft. 7, ft.
204 A � ;ft � ft
NC Well Contractor Certification Number IS^n[J PFR 4A.ST1YfifoT mWh cAsethw¢Ila Oft IiINEtk,tf'a' feeble,"
FROM Dennis Holland Well Drilling, Inca l ft. TO DIAMETER THICKNESS MATERIAL
ft
Company Name 16 iNNT R CASIN(r012 TUBING:. e.'olhorrnahcla§ed
FROM -_TO DIAMETER I TIIICKNESS MATERIAL_
2.Well Constructiou Pernrit#: 0 L ?• [t. -T-ft. in.
List
all applicable well permits(i.e..County,,State, Variance,Injection,etc)
--- —
ft. ft. in,
3.Well Use(check well use):
Water-Supply Well: -FROM O DIAMETER Sr OTSIT.F THICKNESS I`MATERIAL—
(_]Agricultural C3Muni0ipaVPublic ft. ft. in. - -_
❑Geothermal(Hcatin Coolie.g Supply) CJResidential Water Supply(single) ft. Tft. in.'
(]Industrial/C:ormnercial PKI-131dential Water Supply(shared) 1ti CkRIJUT.
FROM TO MATERIAL F.MPI,ACF.MENTMFTHOII&AMOtINT_
❑Irri ration ft. ft. s
Non-Water Supply Well: f55&a _,� T-;i
CJMonitoring (]Recovery i R. �- ft
Injection Well: ft: ft.
DAquifer Recharge FIGroundwater Remcdiation 19'.SANn/GTiAV&^I I'A�'K:if a lrc4 1' � _
FROM _-TO M1tATF,RIAI. EMPLACEMFNTMI&THOD____�
OAquifer Storageand Recovery 17Salbuity Barrier ft. -_fr.
DAquifer Test 0Stonnwater Drainage — — - -
ft. ft.
DExperimental Technology flSubsidenec Control
hU attac
ritiYddlflogel<shecta•iflnrcesse
[:]Tracer `�
DOeothermal(Closed Loop) - `'-
FROM TO DE SCR (color.6ardoe eaiUrouek type, rein size etc.)
❑Geothermal (Heating/Cooling Return) (70ther�plain.tuider#21 Remarks) ft, q ft. T
4.Date.Well(s)Completed: /�7 sZU_ ;�Well IDN N• T ft. ft:
Sa:Well Location: - ft. M ft.
Facility/Owner Name Facility IN(ii'applicable) ft. .__ft.
Physical Address,City,and Zip
r�,str
County Parcel Identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: —^
(if well field,one lar/long is sufficient)
�i,N GY /,/ C,J�
T� it . /. �W
Signature.of Certified Well Contractor Date
6.Is(are)the well(s): crmanent or 1.71'cmporary
By signing this forn4 1 hereby certify,that the we/1(,rJ was(were)constructed in nrnndnncr.
with I SA NCAC 02C.0100 or 15A NC'AC 02C.02.00 Well Construction Standards and that a
7.Is this a repair to an existing well: L-Wes or kRI16 ' copy i fihis record has been provided to the well owner.
If this is a repair,fill out known well consrniction information and explain(he nature,of thr-
repair under#21 remarks section or on the backgfthisfonn. 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 it jection or non-water supply wells ONLY with the same construction,you can
submit one form. S1173M1'I"fA1.1NST[ICTIONS
9.Total well depth below land surface: a}f�,` _ _ (ft,) 24a. For All Wells: Submit this form within 30 days of crnnpletion of well
For multple wells list all depdrs ifdifferent(example-3@200'and 2(it;100') construction to the following:
10.Static water level below top of casing: _ -�_ (ft.) Iivision of Water Resources,information Processing Unit,
1(water level is above casing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617.
11.Borehole diameter: 61,
(ill.) -- 1-tO(n- eLl
6 24b. For In eerie u Wells ONLY: hL 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 wall
12.Well construction method: 'J _ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,IJuderground Injection Control Program,
FOR WATER SUPPLY WFLI S ONLY: 1636 Mail Service C:cnter,Raleigh,NC 276994636
Air lift 24c.For Water-Supply&Injectiou!Wells:
13a.Yield(gpm). �� Method of test:......-_........._.__..._.___--._ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type.: H & H __F.-_• Amount:.1-2 oz.-._ well construction to the county health department of the county where
- _ constructed.
Foruu GW i North Carolina Department of Environment and Natural Resoturccs•-Division of Water Resources Revised August 2013

•Qjoteer
'm M a co h G o u n t y ;" i.i. vI i.c?::�,.�NEW WELL CONSTRUCTION
Go Public Health � r.). CONSTRUCTION AUTHORIZATION
r PRIVATE DRINICNG WATER WELL
James Stiles NOV M. 071222-P • 071122-S
Shared Well Residential ' 6598235131 30.79
• • 370 Ellis Lane
From.28 N: R onto Cowee Creek Rd R onto Ruby Mine Rd, L onto Gemstone Dr R onto Ellis Lane- site is on right
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. v
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
Ellis Lane
2sy 27'
6z.
proPe� �6
Use,
h4' 96'
2�I
IP
-- -- - - -------- ------------
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. QUESTIONS?[phone]
Issue Date: 8/30/2022 Jonathan Fouts, REHS 1979 S J LM'f6Vt,R-e% Authnrized State Agent