_Well Construction - GW1_20230320 (52)

" W: I111 CONSTRUCTION REC():Rll
'this fonu can he used for single or multiple wells For IntcrilO Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook �4 1YALfFRIQNEb _ 71
pF:SCRIP'ITON
Well Contractor Nnmr, - —
2043 A ft. IV ft.
t
ft r ft
NC Well Coutraotor Cetlifivarion Number
IS QU7.NR(+AtiT7y(i(firm "wctls_ ()12;IdNE ,(rto''icablc �
FROM Dennis Holland Well Drilling Tn DiAMFTF.R TFI KN MAThRIAI
, Inc. IC ESB
---
ft.
CompanyNaluc � i d ....rt �-S �i. to S,0R-- 1 �fJG
Iti:.li`fNiv'R(iASi1V.('r(5R'C(JBING erithorrnaTclo3ed too
2.Well Construction Permit#:_p Q FRom nIAMF:THR 'rF3tcftivEss MArF,RIAL -
list all applicable well prrn+irs(i.e.County,Slare, Variance,Injection,etc)
ft
3.Well Use(check well use): ft in.
Water Supply77
FROM _T 90 DIAM FTFR _S[OT S17F 1-fiICKN FSS MAT7:RIAL—
IaApriculhlral f. micipaf/P(lblic ft. -ft. in. --
_ _ ._ _._.__ -.__.._.._.
fJC3eothrrmal(Iieating/Coolirlg Supply) OResidential Water-Supply(single) ft• ft. in.
1:31n(lustrial/Cominercial CJResidential Watcr Su 1)I 18 GR(2t17 f
i I Y(SharC(1) FROM, tKATEHIALT _F,MPI ACFMF._NTMETHOD�&AMOUNT
[11rr1�2_1T11 _.._ ..,....
Non-Water Supply
C:hl9onitoring - t fr~ - In. I r
CJRecovcrY a bG�'Lx Zc��L�Zt� J- •�2 In
jertion Well: ft
(.]Aquifer Recharge 00roundwater Rrmcdiation 19 SAry�/Cy1tAVFI ICAGKi i(•e i llcatile' _
C1AquiferSiorageandRecove FROM _ TO _ MArFR FMPLACIENINTMEC
1Al TIIOD
rY L1Salulily Barrier fL_ -
OAquifer'fest C')Stornlwater Drainage;
OFxperinlental'hcchnolo, R,
6Y [:)Subsidence Control
(:1Gcotlrennal(Closed 1.00 :.20bRtl f31N(r,I nC (attach gd.d!(ronl+sti'ecfsif nicesserY) „_
,. p) (.J'I•racer FROM _ TO— __I)FSCRIPPlON_(colorthardaess�saiUrocki�e�rainetaelctr�R,
(.]Geothermal(lieath LCOOling Return) (:']Other-(explain tuuler 921 Remarks)
rt. rr.
4.Date Well(s)Completed:Q3a- 3-,2.� Well 1PH ) ___- ___T_..-._____ _..-•--. �-.. .� _ _ ...,-_
Sn.Well Location; _.-____
ft. _ ft.^ _
ft
Facility/Owner Name Facility IDH(ifopplicable)
if i •+t s -1 + �tir i
Physical Address,City,and'Lip —
'21 HEMA�RK
County Parcel klcntitivnlinmNo.(PfN)
.b.latitude and Longitude In degrees/minutes/.secouds or decimal degrees:
(if well ficid,one Intllong is suffir.icnt) 22,Certification:
35'� N
Signature.uf`CerliGcd Well Con(rnctor Date
6.Is(are.)the well(s):,WK.i•mauenl or r.]1,cmporary
- 0y signing thisform, 1 hereby reel fy that the well(,)was(wrrc)constructed in ncca•dnncr.
with I SA N(:AC 02C.0100 ur 13A NC-AC 02C.02.00 well Cnncaucrion Stnndnrrls and rhol o
7.is this a repair to an existing well: L')Ycs or i&WPo copy nJ'ibis record hos been provided to the well owner.
//this is a repair,fill out kilo",well canslnrclioa it jorinntiat and explain the nature of the.
repair under p21 renmrks section or on the hack of this form, 23.Site diagralt)or a(ldilioual well details:
You may use the.back of this page to provide additional well site details or well
8.Number of wells constructed: consi action details. You may also attach additional pages if necessary.
For multiple htjection or non_water.supply sveNs ONL Y widi die scone construction,you can
submit one form. SuI3M1'ri-AL INSTUCTIONS
9.Total well depth below Ina(]surface: �a _- (ft.) 24a. For All Wells: Submit this tbnn within 30 (lays of completion of well
For rtndrlple wells lire all depths ifdifferunl(example-.3@)200'and 2(a,100') construction to the following:
10.Static water level below top of casing: (f(,) Division of Water Re.sourcey,Information Processing Unit,
1/warer level is above rasing,use."r" 1617 Mail Service.Center,Raleigh,N(:.'27699-1617
11.l3orehnlc.dianie.tcr: 24b, For Injection Wells ONLY: In addition to sending the form to the address in
�Otaly 7.4a above, also submit a copy of this fonn within 30 Gays of completion of well
12.WCI1 coils trucNon method: constructiim to the following:
(i.c.auger,rotary,cable,direct push,etc..)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W1e1,IS ONI.,Y: — -�-� 1636 Mail Service Center,Raleigh,NC 27699-1636
1:38.Yield >m QQD r Air lift 24c,For Water Supjlly&Ltjectiou Wells:
(P,1 )._...__.�J.........._..___.____. Method of test: "�—
H & f i Also submit one copy of this form within 30 (laysofcompletion of
13b.Disinfection type:. Amouut:, 2 QL. well construction to the county health department of the county where
I:01131 Gw-I North(..arolum Department of l3uvifuument and Naural Rcsourees_Division of Waier Resources Revised Augur(200

46
r l c�2 T
Macon County NEW WELL CONSTRUCTION
.' Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL ,
eir w �o • • of z�-
1p t • (oS&S 't3 qO Z c
Wdl shall be conshucted,ln,comPlianoe-with all ..CAC 2C Rules:
Mahiul!n agnimtirri'sededcs as applicabte. '
Diagram(Not to Scale)
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(- ,of fh►!rlirls except tiW k_asy be ne+abee as arty time U It is ddemd+xd that aa7e`tas been matcrHl charge in any tact or
�; [ t0i t tThf.�soada�ri,fstl�rtfail,and p la►A*meet Sate repf6atlonS.The vrd stwu be Inspected and approved by HaM County '
x„tAraufl ►i>Fnfi'w�r id atad ty MCO"is to van from possbe sources or cwumtnaw�, flow vduma v a is Nor
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E;'I1I -POWER CS GMNTF�0THE WELL IS PIACEf3 Ifl[i O'
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