GW1-2022-10747_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Intanial Use ONLY:
*Ms form can be used for single or multiple wells
I.Well Contractor Information:
J4 ViATEkLQNES ;; z
Mitchell Dean Cook ::� ....:.:,: ,ri ;,:, ;>'..:. :...:.,.... ,.<.;:.•,?
FROM TO DESCREMON
Well Contractor Name �.{t, •{r, i
2043 A ft. ft.
NC Well Contractor Certification Nuinber 15':nU DFR G.''ShYG..Sormllti easrdlµllg aQ12aINE i[''' cable; �.,+,;: i
Dennis Holland Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
o• ft �. ft. /„ in.
Company Name 1611VNER`(ASIP1.(rOIZ PUBAVG:. uthermal
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#:�S��I �1' mm�^ ft. ft. in.
List all applicable well permits(i.e.County,.State, Variance,Injection,etc.)
.. 3.Well Ilse(check well use): ft. ft. in.
0
Water Supply Well: FROM TO DIAMETER SLOTSIZF, THICKNESS MATERIAL
DMunicipal/Public fr ft. in.
❑Geothermal(Heating/Cooling Supply) PKe'sidential Water Supply(single) fr* ft. in.
❑Industrial/Commercial .❑Residential Water Supply(shared) 18.. RQUT .s>..`...
FROM TO MATERIAL EMPLACF.MENTMETHOD,&AMOLINT
Olrri anion ft
p `
NaD-Water Supply Well: Z-1 . ft. • _ ��I r G4 i / d rd
❑Monitoring ORecovery ` ft. ft. ,
Injection Well: fr. ft.
OAquifer Recharge OGroundwater Remediation 19:$.'iVl)/Gl$AYEk?PA 1Ctf•e Ircnti'a, r. 4
s, t
OAquifer Storage and Recovery [ Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStorniwater Drainage
fa ft.
DExperimental Technology (]Subsidence Conti-of
2Q,3DR1i1}TN.f>!G(•)'ts?at(aclitaiidrhoniil.shecte.tftnece9se :.,ra•:,�'? � r
OGeothermal(Closed Loop) 01'racer FROM To D&SCRUIrION color, ardaM soil/rock lyV2,grain size etc.
DGeothermal (Heating/Cooling Return) 00ther(explain iutder421 Remarks) fr. ft. q
4.Date Well(s)Completed: j e q- Well ID#
�— A"-- ft
Sar Well Location: ft. ft. F 8
E• /�- v �Sr' -ZJ S ft, ft. (L{5
Facility/Owner Name Facility ID#(ifapplicable) Rom;^?e2 tft
ft. ft. tni0ie'f'v*�1%6�'u�Sy
dam_ t� led. ft. ft.
Physical Address,City,and Zip :;21,;REIVIA'RIG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: ^
(if well field,one lat/long is sufficient)
5
a �/�Jr''7.5 N
Signature of Certified Well Contractor Date
6.Is(are)the well(s):oper-ancut or OTemporary
By signing this form,/hereby caw fy that the well(s)was(were)constructed in accordance
frith 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RING copy ofthis record has been provided to the well owner.
!f thls is a repair•fill out known well construction information and explain the nature of the
repair under#21 remarks section 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
9,Total well depth below laud surface: (ft.) 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 1@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: (in.) 24b.For In'ection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this fornl within 30 days of completion of well
12,Well construction method: ry construction to the following:
(i.e.auger,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
I
13a.Yield(gpm) ? Method of test: Air lift 24cr For Water Supply&In'ection(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.
Foinr GW-1 North Carolina Department of Environment and Nattual Resources—Division of Water Resoitrces Revised August 2013

Q`ntNcr
.m Macon County NEW WELL CONSTRUCTION
O ' Public Health CONSTRUCTION AUTHORIZATION
�°�je
r�� PRIVATE DRINKING WATER WELL
L� •H. Peterson III . 1 P 0 21 5
08 2 08 8-Famil Well ResicJr ntial ' 751262-7239 14.81
ld Mine Road
ight on Gold Mine Road off Hi lilands Road continue to ro erl on left .ast 323�.
--.__.... ---..._...._._.9 _ ..........I ................................P__P Y . . A _..._..__.._.._._........_.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. °
-- - Diagram (Not to Scale) ---
Brandt
>25' 10, 87, n10y10setlfio
ose �c 6,��,
10, Well d`� )c'�'` �. PL
Site
min h
r
looter Fist;�
Pond
)y
r
r
Shallow oil to Rock -
°a
01
G
30' 75 3
SO't Drip
� Repair
Pt. t Area r 5S, 6?, K
GL
` Slope and
Topo change: � c
v
10, 0
PVC Pipw
Oa Tre
N
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 slate 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 MC:PH is to provide protection from possible sources of contamination. Flow volume(well yield)is NUT'
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: 12/15/2021 Charles Womack, REHS 1300 ,AJ PI) i /I�mUALAuthvrized State Agent