GW1-2023-01073_Well Construction - GW1_20230125

W.rLIa CONSTRUCTION RECORI)
11us form Call be used for single or multiple.wells For lutom41 Use ONLY: i
I.Well Contractor Information:
Mitchell Dean Cook = =
Well Contractor Name FR
DFSCRIpI ION
NC Well Contractor Certification Number 15 Q.UZ i R G`AS1NC: tot mutt,egg' 1�ty e(�t'�)f UINEI t,�'t:' 1-4—He
Dennis Holland Well Drilling, Inc. FROM _ To DIAMF.TF.R THICHNESS MATERIAL ^
ft ft Od m
Company Name - L-,Y,J ���•�
16 INNRRxCA I1Y(r 0RITU13AVG. eul erina:cloJiilzlu�"''_
FROM _ TO y
2.Well Construction Permit#: O% 1) ETE TIIICIQVEss MATERIAL
List all applicable weNpermits(i.e.Counry,,Skate, Parlance.Injection, -
3.Well Use(check well use): ft ft, in.
Water SD )I _ �171";.SCRIa}EN �' -
P! Y Well: .-:.- ?. '?t:::•Y,t,i :'>: : .<:;
FROM TO�.,...�.,.� r•DIAM6TF;R �SLOTSI7.F. '[tiIGKNESS atATER1AL�
DAgriculturnl C7Municipal/F'trblic rt• fr. '" io:
130cothermal(Hcating/Cooling Supply) R.'Rcs dldi cntial Water Supply(single) ft. ft. in.: '
Oftidustrial/Cominercial
C.]Restdenttal Water Su)�I
I I Y(shored) ye. , ...1 r.t. �.,,t i ..t,^�•,.•i -.-...-
FN
tion FROM 90 _ MATERIA EMPIACFMENTMETHOD&AMOUNT
Nonater Supply Well: ft. fr.
!r �f 7 �L�•;:LAY
toringUReeovery ft ` ft.n Well: -- -` rl�s tsG' -
{tr Recharge00roundwater Remcdiationp d�ti er Storage and Recovery 1�Snlilrity Barrier F1tDM To MAfFEMPLAr Test ft• ft.
11Storniwater Drainagemental Teclulology C1Subsidence Controlft ft.rmal(Closed Loo uonel?shecfs.,fl p) f..l'1'faCer FROM To DESCRUM color 6ardne Soit/rock type,grain size,etc.)
Deothennal Heatin Coolin Return) 00ther explain tmder#21 Remarks) I ft. ft.
4•Date Wells)Completed: ft,
Sa.Well Location- ,
N- ft. -ft. a-� -
t✓ r..
Facility/Owner Name Facility IDk(if applicable) JAN�� ----- —•-• -" —'»-
_ ft. ft.
ft. CL r,
Physical Address,Ci ,and'L,ip
a"21 REMA�RIC.� .'t' a' r_-_•...� ;^,- ......:. �.
Cowtty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t L ,1L
Orwell field,one lat/long is sufficient) 22.Certification:
Signature ofCertifie'd Wellt.tractor T Date
6.Is(are)the well(s): �cl^J.tcr'manent or [.]Temporary
By signing this form, I hereby Teri fy that the well(r)was(ware)constructed in accordanc•r.
/� with 15A NCAC 02C.0I00 a)-15A NCAC 02C.07.00 Well Construction Standards and flint a
7.15 this a repair to an existing well: t7Yes or AgK0 copy of[his record has been provided to ilia well owner.
If this is a repair,fall out known well construction information and explain the nature.of the
repair under#21 remarks section or on the back of this 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: conSil-tion details. You may also attach additional pages if necessary.
For tnuliiple tt jection or non-water supply ire//s ONLY with the same construcion,you can
submit one form. SIAIMITTAL 1NS'I'UCTIONS
9.Total well depth below land surface: 1"`
..,_...:��'1.....,.e_�.._____._-_._ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•orimulliple wells list all depths ifdlfferent(example-3@200'ofd 2@100') construction to rile following:
10.Static water level below top of casing: _< - (ft•) Division of Water Resources,Information Processing Unit,
lj water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" _��(in.) 24b. For Itifcctig n Wells ONI.,Y: It)aildition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 clays of completion of well
12.Well construction method: Rotary construction to'the following:
(i.e.auger,rotary,cable,diroct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SIIPI'I,Y WELI S ONLY: � 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Win)_-__ — ^ -^ Method of test: Air lift 24c.For Water Sup.1y&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 iiealtll department of the eounly where
_ _ constructed.
Fmm C W-I North Carolina Department of Havironment and Natural Resources--Division of Water Resotu•ces Revised August 2013

Q<°tecr
Macon County NEW WELL CONSTRUCTION
' Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
WRobert,Adam, &Leisa Baliles _ _ • 090722-P_— • 100419-S
le-Pamir Well Residential ' 657 od Rd 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. o
Maintain minimum setbacks as applicable.
Diagram Not to Scale
Drive
O O
o Ex 2 BR 60
a� ST 39'
llh,
peck 25
31 S
74' Flow Divider '``� i
to' 60-
93'. 74'
32'_ Permitted
15'i - 49
^� ' Well Area
Repair Area
Gate ___-_ (090722-P)
O 75'
Pine
(1 Cedar
This permit is valid for a period of five year's 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 6a AAA A uthorized State Agent
t