_Well Construction - GW1_20230320 (51)

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WELL CONSTRUCTION Imca2D
'Ilus fonu can he used Ior single or multiple walls For Intrnnri(Ise ONLY:
I.Well Contractor Infordlatiou:
Mitchell [dean Cook i4 wnftlFs�?5Niv5 r: M
^FROM ^ TO ,....,_._
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Well Louu'actcr Nntnc' ' '^^— OF SCREMON� --• - ._
1048 A 2- ��� ft. _
rr. ',-.
NC Well C onir ctntCcrtilieehon N ct J4 QIJ,1"•NR CAw ti•-_WC' roc court cLsrd sti clla OR'C'I�INFC� tC;'' rcmblc :>
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•' FROM _ TO. IAM FT)IICKNF:S.SMATETRLII_D.e'rinls Holland 1Nt,ll D�Illinc� 'Inc. -
-- - _- — a- n �a
Company Nuns _---�_ ^ ft r. in. S,pR Z( P VG
ATM 16"INNER C ASiN(r 011 CCIDING. eoihortnal.closcd laid _
FROM IO DIAMETER THICKNESS MATF.RIAl
2.Well CDnstruciiou Peru)it#: O — — DIAMETER -•-
J��i _ ft ft. in. _— --
List all applicable we0'prrmlls(i,c.County;.S'ratc, Vnrrnnrr,/njerainn,rrc.j
3.Well Use(check well use); m
1'7 S(�RFFN .4.
��'etP.t'$Ilpl)ly Well; 77.
�•_ "�—"" —'-•• ---'-- FIiOM�� 90� _ n1AAf FTFR �S[nT SIZE 1Tl1(KNFSR� AtATkR)AL�
ClAgricultural f;)Nl/�unicipaUl'ublic ff. ft: in.
fJGeotheririal(1lcatiitg/(:ooling Supply) ( Itrsidcl)tial Water Sul (single) in.
0Industrial/Cinmmercial L:1Residenlial WaterSu))I ; , (r'RnUT
I I Y(SharC(1) - FROM 10 MATFRIAhmm FMPI ACFM EN'r MFTHO &AMOUMI'
I�III'rl (1lIOn _
Nnu-Water Sup ply Well: "__�___.._ _ O_ft. fr.
1- _-?_.�
3-
[n cr.tion Wclli
DAquifef Recharge FlGroundwalcr Rvinedialion 19.tiA.Nn GItA EI PAGK ifie hagble', : w
DAquifer Storage and Recovery 08uliuily Barrier FROM --.TO MATERIAL ^� _ EMPL.ACEMENTAfF 1910D�
0Aquifer Test a ft. -ft.
f_L.itormwater Drainage
ClExperimental'l'ecluli)lo+' ft.
by (Allbsidelm;Control
00cothermal(Closed Lon 20 -ft".(1 7.N(r IO(r atfaah;eildrhunal sfie8te'iRh&iMnfY - -
P) (a'hracer FROM — TO UE S(RIYrION(rolor�6ardnsoNrnck�Ype�greul+¢e1 ctc�-._
C]Geothcrmal Hcatin /Coolin Return) T(aOther(rxplain under#21 Remarks) ff.
4.Date Wcll(s)Com)lcte(1;03 e)8� A i
_- _ ._ ___
rt. rt• �m > u ^
Sn.Well Location:.
(acility/(Omer Name' _
Fncility
ft. ft - lfie e rT rh '1.�f�. •? S^�vrfi Y
apt^ r_:._ _ ft
Physical Address.(:ity;.and Zipr' _
ft
colulty
- Pnrrcl Idrnuficatioi)No.(PfN)
Sb.Latitude nod Longitude In degrees/minutes/seconds m•der.imal degrees:
(il'wcll field,one lat/lung is sufF;jeiit) 22,C:ertificafion;
3 50 1 '�ll _^N 230
�,�---- Signmure of Ccttified Well Contractor Datc
6.Is(arc)the well(s):RrTPcrmauent or 01'empornly
- ,(ly sighing.ihi•s form;.L hereby reri fv-lhal-the.well/sJ'was-(wrie)-ronslrucled.in accurdrrnr.•e-
.�.�,�i ' ' rirh 7:SA Nl.'rIC 02C.01(10 ur IsA KCAL 02C:0200_;V0!Conslructlun S1nnrinrtLs unrl ihnr u
7.Is this a repair to all existing well: I.Dyes or �C.TtTO copy(Y'lhis record has been provided to the svell olvmr.
If this is a repair.fill atrl krlowa well consu-uction information and explain der.maarr.oj'dn:
r•epiir ur(htr#21 remarks sevaun or on the hack gfthis funn. 23.Site diagragi or additional well details:
You may use the.back of this page ty provide additional well site drtails or well
F Number nj wells constructed: 1 _ ctulsbuclion detiiils. YOU play also attach additional pages if necessary.
For multiple injection or nun-malrr supply wel/s ONLY with the scone construction,you can
submit one jurrn. S1171N11.1fAl.f_NS'1'l_1CT_'[ON5
9.Total well depth helow land surface: 26) 5 _ _ � (fL) 24a. Igor All Wells: 'Submit this form within 30 days of completion of well
For muh(ple wells lire all depths ijdrjjerent(exainlife-3@200'mid 2@)100') M-T construction to the following:
10.Static waicr.levcl lielow top of casing So (ft) . Division of Water-Re.sources,luformation Processing Unit,
l/wnrer.level'is above rasing.use!!+ c. Kh,NC 27699-1617
1617 Mail Servo a Center,Rafe1
' 1.1.1361 holed6rfleter ___ iu. ;.24b: For Ira ecti( Wells ON,L,Y.' In nddition to sendiil the form to the address ill
f Otnry z4<I above, also submit a (op'y of this f6mi-within 30'days of completion' of,well.
11.Will ccilishuction mr.thod,. construction lathe following
0,c.11ugdi,roiary,cable-diicct push,ofe.)
Di"vision of 1Viiter Resources,Underground Injection Control Program,
FCi1(WATER.SUf 1'1.Y WEI,I S ONLY: 1636 Mail Service Center,Raleigh,NC,'27699-1636
l3a;Yield m _ D Air lift 24c,P:or Water S pj)LA Injection Wells:
•
I(;P ) __.._..:..__-•__-_• Method of test: _. ._.__.._._
Also subniil one copy of this form iwithin 30 clays of completion of
131).Disinfection type: H & Altlount:,12 oz. well coilstfueliol to tho county healih'_�department of the county Where
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Tam CiW•I Nonh.Ctvolinn Dep ulmatrof linvironment and Nanual Rrsomoes••Division of Weiler Resml a Revised Atippm 2013

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�A .m M a c o n C o u n t y NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
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_c��.��� `Jasr --- - ----- • L4Lb_?2-��- • '(p3o22•-S-
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, a
Diagram (Not to Scale)
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Y
This permit is valid for a period of five years exccpt that it may be revoked at aw"time if it is deter: ried that there l.as been a material chance in any fact or
orcumstance upon:vhich the permit is issued. Nell location, installation,and protection nn,st meet state regulatuns.The well shall be inspected and approved by Macon county
Public Health before it is put into use. The iocation of the V.ell md:,ated by MCPH is to provide protecron from poss hle sources of ccntam,na=t:on. Flo.v volume(,,veli 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: �( ,l I�Z2 C �__-- �t Atithorize(f State A 2r7t