_Well Construction - GW1_20230320 (48)

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WELL CONSTRUCTION RECORD — —--�- ------�-
Ilus fonu can he used ter single or multiple,wells for Internto Use ONLY:
1,Well Contractor Infornlatiou:
Mitchell Dean Cook :aa:.wAt F :��•-_
FROM •_,:_.•••^• ,.'.5; �.`:---s•+--"....,'''�£::.�!`"•aa`_:_�,.''?.i'J•....''�` st:.,...:':ua:"•.<.":;;;;Jrt::�:r::'i
TO DFSCREMON
Well Contractor Name ,ft.
2043 A Z�n ft,
NC Well Contractor Cortificati r -
tor on Number
'=}w:O.UT:N•R'4' SYNCy.�:(iir?mu9�ti=ck�cllt,.:�.. .Of2aal 1, :'s.-xi�;r:r:,'","'
.FROM TO�-- DIAMETER TFiCKNES,S MATERIAL
Dennis Holland Well Drilling, Inc. rt ft. —6„ In; so �� wG ---Company Name
. `<tifi ;IhIN�Ft`C?•t�SIN('rUll`T17$[NG"'edltietina'cla�'� ;<„lor�` .F:C:iI•:.:'CL%`?'.ir", :1;5':d;i
� D a� FROM TO DIAMETER THICKN ESS MATFRIAL _
2.Well C'onstructiou Permit#: ft - Y.ft.
L1st all appllrable well permits(i.e.County,State, Variance.Injection,etc) _-
3,Well Ilse(check well ruse): ft. _ fr.'
Water•Su il Wcll• -- .�'-tiA '"`;x:� ,::;r�a.,;:s;._;::,..-..-.,,.—
PI Y FROM_ TO IIIAMFTKR SLOT3IZF "THICKNESS MATFRIAI
ClAgrieulhrral fJMunicipal/Public ft. ft in.
DGeothermal(Heating/Cooling Supply) Plr-s�idcntial Water Supply(single) ft.-
❑Industrial/Commercial 8: r a< Y>, ;,_;.:,
sidential Water Supply(shured) _." _.-,,.I;``;is,;:.: i{{,.................:T�-.,,�„:k::;�:�'�ss>,.j �•_c��:::�,s'e:
FT .
Illrfl [it"III
FROM --f� MATERIAI,�" F.MPI,ACF,MFNTMETHO &AMOUNT
ft ft,
Non-Water Supply Well: _ ¢
CJMonitoring ORecovery n. .� ft J
Injection Well:
fr. fr.
[.]Aquifer'Recharge FIGroundwater Remcdiation Ii;9; "ND/G AVE iI'AG' li e`i"t '> ls
DAquafer Storage and Recovery IJS(llblity Barrier FROM TO MATERIAL EMPLACEMENrMVnIOD
rI,.-"• ' -
DAquifer Test 08tormwater Drainage _
It.
DExperimental TechtlologY C7Subsidence Control R• ft.
�e)thermal R I?N.3}IiO: ;aurae I—
v i a "; nCJC ( Closed Lon a ti.o aL9fi'i o't's.fY" eo0e`•';a,;_#;•::a<„ ;�? a:%+;: i'=::-
FROM _TO UE,SCRIP'frUN colorLherdne solUrock I rain size,cic.l
I7Geothermal Hearin Coolin Return) C70ther explain tmderH2l Remarks) fr, � fr.
4.Date Well(s)Corlipleted:06X!2�Well ID#�J�/
Sn,Well Location: ` )
a-E77
-•dlly/Own r N �_ fl. R 2 0 2023 —.
Facility/OswrorNmuo Facility ID#(ifapplicable) --- - -- _ _ --_M�."..
-rt. rr.
Physical Address,City,and Zip
l <,1.;^-r
cl 7l.. �
Cotmty, Pareol Identification No:(PFN)
5b.Latitude and Longitude In degrees/minutes/seeonds or decimal degrees: -"-
(ifwcll field,one lat/long is sufficient) ¢��' r/p +y 22,.Certification;
Signnnre efccm ml Wcll Contractor Date
6.Is(are)the well(s): rmauent or Ill'cmpor•ary
0y signing this form,/her eby rert fy that the well(r)was(were)constructed 1n accordance
with 15A NCAC 02C..0160 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ©Yes or (>)Ne­1- copy ofthis record has been provided to the well owner.
If this is a repair,fill out laown well construction Information and explain the nature of thr.
repair undar#21 remarks section a)*on the backofthisfarm. 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 necessnry.
Fur rrrulriple injection or non-warer supply wells ONLY with the satire construction,you con
submit one form. SUBMITTAL rNSTUCTI_ONS
9.Total.well depth below land surface: __cat (R,) 24a. [/or All Wells: Submit this form within.30 (lays of completion of well
For multiple wellshst all depths ifdifferenr(example-3(rt),200'and 2@100') constrtiction'to the following:
10.Static water level below top of casing:-_ ,,� (ft.) Division of Water Resources,Information Processing Unit,
/f water•level is above casing,use"•F" 1617 Mail Service Center,Raleigh,NC 27699^1617
11.Borehole.diameter:�a R (iu.) 24b, Fr pjgctjggtells ONLY: In addition to sending the form to the address ill
Rota 24a above, also submit a copy of this form within 30 (lays of completion of well
12.Well construction method; Rotary -- construction to the fol)owing:
(i.e.nugcr,rotary,cable,direct pttsh,etc,) -
�- Division of Water Resources,Underground Injection Control Program,
F
ORWATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
ield m �__ / Air Ilft 24c,F.or Watcr Su)I &Injection Wells:
(gP ) ld.._•--_-,--• Method of test:
-— '-- Also submit one copy of this form within 30 days of completion of
isinfection type: H & H _ Amouut:�? oz. well construction to the county health department of the county where
- - -`- _ '-- constructed.
II
Forur GW-I North Carolfnn Depattmont of Environment and Natural Resources--Division of Water Rcsoi=s Revised August 2013
I I

Q�Ote�r '
Macon County NEW WELL CONSTRUCTION
° Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINIQNG WATER WELL
Nelson Stamey • 080822-P • N/A
Single-Family Well Residential ' 6582729404 i
• • 151 Morrison Church Rd Franklin NC
• 441 South,first road on right, pass welcome center to Morrison Church road,The house is the first blue house on left
at the start of pavement.
Permit Conditions
Well shall be constructed In compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100ft from septic system components.
Diagram (Not to Scale)
Septic Tank
NeIsoa
Dr�J e
M 1.00,
a ri Property line
38,
L
41, 79,
F7
c 20°
o �24'ks rep .
IP
Spy 2p,
O N
Existing Well
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 INSPECTIOON AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 9/14/2022 Jonathan Fouts, REHS 1979 �Authorized State Agent