GW1-2022-10745_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECO.RI)
This Form can be used for single or multiple wells For Iutemal Use ONLY: j
I
I-Well Contractor Information:
Mitchell Dean Cook :W;�s.�
FROM TO DESCRIPTION
Well Contractor Name —"ft. ft V
2043 A ft. ft.
Contractor ion Nu ` 7
o ctor Certification Number
NC Well C Isl a:`a' I3•R G''S .(s, foYlmiilti.cek'Cil}grill,".
FROM TO DIAMETER I THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. o" ft. J ft. inA-
Company
I. ._.. .
Name r<,�t • , .T•,`ItC•A.INSsr':0lr lJ$XIV.(s'''�'uilliet€!i>§eilzl`o =%:+_`<5.,;:-�+.�;':�;i:�.:.;•,:";:;:
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �Q� 2 fc ft. in.
List all applicable well permlrs ft.a.County,Slate, variance,injection,etc.)
3,Well Use(check well use): fL fr. in.
;�s147Sr,S.(#RF.•,N': ..;:r; _ s;;,.,,:r��:^y--i+i.,�i,;- �:��,...� -s--!-•y-:-°_";�..:�:'
Water Supply Well: FROM TO DIAaETER I SLOTSIZF, I THICKNESS MATERIAL.
DAgliculhtral DMunicipaVPublic fr. ft.
DGeothermal(Heating/Cooling Supply) 7P j1 esid'cntial Water Supply(single) ft, fr.
_ ❑industrial/Commer ial C]Residential Water Supply(shared) �i,l'.;.C'�R(1U:�' ax.r>f..'ts,,:t.r,�.:::�,..i ss::?;:::,:�c•,,..,.F...,:>...:
�r^>.:-';�,:>,•,,�::::-°z:;,�.:r FROM TO MATERIAL EMPLACEMENT METHOII&AMOUNT
Olfri anion ft. ft.
Non-Water Supply Well: �Yf'f�' . .-<•^ 4 C -'y
OMonitoring ORecovery /fL i fL
Injection Well: fr. ft.
DAquifer Recharge DGroundwat r e -e R mediation `=3`<i. It.T`1C�`Ifi'rfa" 2a a r",�• ;=s":� �" =:Fz
OAquifer Storage and Recovery DSalhtityBarrier FROM TO 14AMtlAi, EMPLACF51ENTMETHOD
fr. ft.
OAquifer Test DStormwater Drainage
D6xperitnental Technology gSubsideltce Control ft. ft.
OGeothermal(Closed Loop) O'I'rncer ;2Qi311R 'R!!J.f a'tfac iNdditi�on�l.sSe`edi fin es4e"'. `•,i;=; t<-?.h,;.nrt> tx+ ;;
FROM TO D&SCRIPTION color 6erdne solVrock I rain size etc.
DGeothermal Heatin Coolin Return GOther explain under421 Remarks) ft. ft.
4.Date Well(s)Completed: Well IDN
ft. ft, n�
Sa.Well Location: _ tr, fr. ULU V N,��
Facility/O%ncrNatuc Facility ID#(ifapplicable) {i}`=�+= r 'ooj
ft ft.
f0��i���R r�
ft ft.
Physical Address,City,and Zip ,;•
f2h.,E14hi';. _ ;y<. `."y5:,��-�:�?ra.;�::'�a�';�:�:.raFt< �.F:•:.
CownY Parcel Identification No.(PIN) Js�� � •�
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if%yell field,one latllong is sufficient)
N Cl J 2 /1 " W
Signahre of Certified Well Contractor Date
6.Is(are)the well(s): [i•Permanent or 07'emporary
By signing this jonn,1 hereby rwv fy that the well(s)was(were)constructed in ncca•dnncr.
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.07.00 Well Construction Standards and thal a
7.Is this a repair to an existing well: DYes or -&No- copy of thls 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#21 remarkssection or on the back of thisform• 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
a
9,Total well depth below land surface: (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For mu li le wells list all depths i di erenf(example-3 ,200'and 2 a7100' construction to the following:P P f If ( i C� C. )
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" 24b.For Ineectisim Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.ouger,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
13a.Yield(gP m)___ ^^ Method of test: Air lift 24c.For Water Supply&IR'ection Wells:
Y ,
Also submit one copy of this form wttlun 30 days of completion of
13b.Disinfection type: H & H Amount: OZ. _ well construction to the county health` department of the county where
- constructed.
Font OW-1 North Carolina Department of linviroument add Natural Resources-Division of Water Resoureos Revised August 2013

n Macon County NEW WELL CONSTRUCTION
o �=Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINMNG WATER WELL
Ralph A. Estevez • 091622-P • N/A
' Sihgle-Family Well Residential ' 7505605978 1.32
• 1100 Bethel Church Rd
' Highlands Rd to left at Bethel Church Rd to left at 1100 Bethel Church Rd
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100ft minimum from all septic system components.
Diagram (Not to Scale)
n3'Lihe
90' -
Existing drain field AO4ser
120' Rdthej Chu 0 Permitted WeU
h Area(091622-P)
(�g vve
PrOAe gibe -- - — — - - - — — -
This permit is valid for a period of five years except that it maybe revoked at anytime if it is determined that there has been a material change ln:-any°fact or
circumstance upon which the permit is Issued. Well location,installatign,and protection must meet state regulations.The well shall be inspected and approved by Maron.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)•rs'NOF
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: 10/13/2022 Jonathan Fouts, REHS 1979 q,a y '�".'L AutborizedStateAgent