GW1-2022-10776_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD
Thus form can be used for single or multiple wells For Intem0l Use ONLY: ( '
1,Well-Contractor Information:
Mitchell Dean Cook
FROM TO I DESCRIPTION
WellCentractorName
2043:A fr. ft. f
NC Well Contractor Certification Nurdber 'ISi"Q TRR't(`' 74i:foisimiilfi;cltt3'Cd£iYP QI2 '1N ?ift""''tali a ^-_? =;:r is
Dennis Holland Well Drilling, Inc. FROM TO DIAMETER THICKNESS I MATERIALrG ft-
Company
�•, ;n S _ �iG
s.Name :<y1b:t : .R `G'•ASTl`1(r?(31t"Aitl$ _G.. "of''e lnec!'bYi:`dglS�`".r:'�;;°�ir;t5. " �;}a�,,�•i_:,. ,s>';
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:� _ ft tt. in.
List all appflrable welt permits(i.e.County,Slate,Variance,injection,etc..)
3.Well Use(check well use): fG fr. in.
�s17{lrt<•1tEk:!$u%".:�' �";i° 3__�c'��''. ';r:'`:?i ',l,'.t;,;t:-�y-ir .�:.r�...r,;:;, ,..
Water Supply Well: FROM TO I DIAMETER 11 SLOTSIZE I THICKNESS I"MATERIAL
QA riculhaal ft. ft: in.
g QMu icipalet ublic
❑Geothermal(Heating/Cooling Supply) t3Residential Water Supply(single) ft, ft. in.
Qhidustrial/Commercial s'8°; ..,�: w^,.':<: .,�•• •• .. r a; �.. .._
C1ResidentmalWaterSupply(shared) 13- Q,Ti%. :. ! al :± rty ,•:•syr,•=':=s<::
FROM TO y MATERIAL, EMPI,ACEMENTMETHOD&AMOUNT
Qirri ation 4 + ft. + ft._ �`¢�
Non-Water Supply Well:
tG ft. ;
0Monitoring [)Recovery
Injection Well: rr. ft.
QAquifer Recharge l7Groundw t r �±a e Remediation o;19..z? j'yt:1T�:1.':.� tM-
QAquifer Storage and Recove FROM To MATERIAL EMPL CEltENTME•rHOD ..
Recovery L7Salu»ty Barrier ft. !r.
QAquifer Test QStormwater Drainage
tG i
QExperimental Technology USubsidence Control fG
7. „..
Q r.2 :1)R
QGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,bardoM solFrock type,grain size etc.
QGeothermal Heatin Coolin Return) ClOther(explainiumderf{21 Remarks) ft, fG
ft. ft.
� - I a V 4t:4.Date Well(s)Completed: �� 1�?Well k
$a.W.II Location: ft.— ----8EC
L e lz am A,U l7 e. ft. J Ur'u
Facilit/OwncrNarnc _ It1GP+ ++=� i:': �,: i_
y Facility IDII(ifappliceble) ft. ft.can& IT al
ft. ft
Physical Address,City,and Zip _ • ' ,
'!Lt E AF1K;;;;�`;•t .+..x...,,. .�:rig,;: •• .:::,:.,r.,::,.• ..,., ,:...•.
I �.;ia';�:^,'-:,.�. .'•,iY era``i%`:z::.:4,tk.,.nrv:„:✓u.:;:�.j•i:.yy:,,,;�i
4 A • �J= >a
County Parcel Identification No.(PIN)
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if wclll Field,Ono laviong is sufficien ,t) !
��� Signature of Certified Well Contractor Date
6.Is(are)the well(s): Ifat°ermaucnt or C7Tcmporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance.
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: QYes Or VV_0 copy ofthis 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 tender 921 remarks section or on the back of tli form, 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.multlple Injecton or non-water supply wells ONLY with the same construction,you can
`s'ub&oneform. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: +
p �J�..7 (ft,) 24a. For All Wells: Submit thisifoim within 30 days of completion of well
For multiple wells list all depths 1f dii fercnr(example-3@200'and 2@100') constuction to the following:
10.Static water level below top of casing: ..S4W (ft.) Division of Water'Resources,Information Processing Unit,
lfwarer•level is above casing,use"•F" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Fix (in.) 24b.For In'ecti n Wells ONLY: Ibi,addition to sending the form to the address in
Rota 7.4a above, also submit a copy of this form within 30 (lays of completion of well
12.Well construction method:ry construction to the following:
(i.e.aiigoi•,rotary,cable,direct push,etc,)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY/WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13.9,Yield(gpm)_ ` Method of test: Air lift 24c.For Watery Supply&In'ectiou Wells:
.
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & Amount: 2 OZ_ well construction to the county health department of the county where
constructed,
Fomi OW-1 North Carolina Department ofGnviroamcnt and Natiaal Resources—Division of Water Rasourros Revised August 2013

Q'Ote°+
w �m Macon County NEW WELL CONSTRUCTION
o �
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Robert,Adam,&Leisa Baliles • 090722-P • 100419-S
Single-Family Well Residential ' A578817242 35.53
• 54 Cody Rd
• Take 28 N to L onto Cody Rd Then L to 54 Cody Rd
Permit Conditions
Well Shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale
Drive
o
o p
oEx.2 BR 60'
Doi S. 39' 114- -
k, <<> peck 25 ,
to' 315
74' S Flaw Divider i i
io'
93' 74'
32' Permitted
15'I `'------------1 44' Well Area
Gate I Repair Area I
--- -----— I (090722-P)
Q 75' -
Pine
(1 Cedar
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: 10/3/2022 Jonathan Fouts, REHS 1979 _Authorized State Agent