GW1-2023-01519_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD For interval Use ONLY:
T rru his.fo can be used for siugle or multiple wells �II
L Well Contractor Information: E
Mitchell Dean Cook
bROM TO I DESCREM,ON
Well Contractor Name ft. fL
2043 A ft. fL
NC Well Cont-ractor Certification cationNmnber (NWYNf3foiilm` ti��'GI1vYPlIa'tiQ�t.'1N tit;.' , 1"fret:•._.:..............•
PROM TO I DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. . 0" fL ft, 6„ io. _z1 j�tvc
Compau m y:Nae-
i167r .>✓K_CASIPIIr U1tiTl113I1!1(`:� e'otlieinal;clbieSXo'ti` 'ii`. „'�' .:
o FROM TO DIAMETER THICKNESS- MATERIAL
2.Well Gotistr,'_ticfin Permit#: j'>�O S ft. "ft. in.
List all applirdble wellpermits'(i.e.County,Vrate,Variance,,Injection,etc)
ft. ft. i in.
3.Well Use-(check well use):
Water Supply Well: -' FROM I TO !.; DIAMETER SL:�: L OT;:,',•:SI F. THICKNESS
I THICK KNESS MATERIAL;if},'%�iti7d• A
, A1,
0A Agricultural CJMunicipal/Public fr. ft. in.
Meothermal(Heating/Cooling Supply) qKsidential Water Supply(single) fr. re,. in.
i:' iJ: '•iyc' ,i1t•.?:..v _ ,y4'.,:; :�',Ar4: .`li:_'`.".Y,%'+'
171tdustrial/Comm
ercial C3Residential Water Supply(shared) FROM TO V Y MATERIAL. I F..MPI.ACEMENT MF,THOD.&AMOUNT
C1lrri atio11 , ft. 3 . re,. ` `
Non-Water Supply Well:
_
❑Monitoring URecovery. 31 ft. ft.-
Injection Well; ft. ft.
DAquifer Recharge 00roundwaterRemediation ;i7. +Ptl�Kt t'=a It�ab e.< -,:,:, :,r� a•s;:6x
❑Aquifer Storage and Recovery 08alinityBarrier FROM ft. ft.TO MATERIAI, EMPLACEMENTMETHODa'
❑Aquifer Test OStormwater Drainage
DExerimental Technology ft. t...
P gy L7Subsidence Control
C1Geothermal(Closed Loop) C71'rncer rR�R tlilt3sLh s(y(i atfac
OM TO DESCRIPTION color bardnM saillnick type,grain size ete. '
(Geothermal Heatin Coolin Return ClOther explain tutder421 Remarks)J f14
ft. ft.
4,Date Well(s)Completed: p/M./6�,23 Well ID#.__��1,� fa ft.
Sa.Well Location: ft. ft.
re, "" ', ;'
Facility/Owner Name FneilityID#(if applicable) --
ft. ft. FEB 0 9
r=ooh ft. ft.
Physical Address,City,and Zip Y
'2�1�' �'ii�;;�>:.: .. .,.,..mow,.
..i '�i�C� _',:ii�:.�iYT: .i/:-is:`��':af7."��zF.xer:✓x..,�.Y.Y,ti�':�...
70—S 2 21DLd i6:
Comity Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
, tt
W -
- a-a3
��� Signature of Certified Well Contractor Date
ItI 6.Is(are)the well(s): Krmanent or OTemporary
_ By signing this fonn,1 hereby rertfv that the well(s)was(ware)constructed in aecordanea
widt'15A NCAC 02C.0100 or 1 SA NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: •-ClYes or wdo copy of this 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 under#21 remarks.seclion or on the back ofthisform. 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 multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well.depth below land surface: &3aS' __(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells list all depths ifdiifferenr(example-3@200'and 2@i00') construction to the following: I
10.Statie-vater level"below tbp of casing; Q (ft.) Division of Water Resourc6,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For In-jection Wells ONLY: Ili addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.nuger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection.Control Program,
FOR!WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
138.Yield m _ Air lift 24c.For Water Su &In'e Wells:
(gp ) Q Method of test: 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 health department of the county where
— constructed.
Fomt OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201.1

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EPA' A I LE�
's Macon County IMPROVEMENT PERMIT and CONSTRUCTION AUTHORIZATION
Public Health ON-SITE WASTEWATER
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center •IS "lowside G 11 ,,q 1 evo
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The Issuance of this permit by Mesh In no way guarantees the Issuance.orother permits. The permit holder is responsible for checking with appropriate governing bodies in
meeCng their requirements. This permit is subject to revocation if the site plan,plat,site or Intended use changes. This permit is subject to compliance with the provisions
of the NCiaws and Rules for Sewage Treatment and Disposal and to the conditions of th permit Construction and Installation Rules NCAC.1950,1952,1954,.2955,.19-A.1957,.1958.and.1959 are Incorporated by reference Into this permit and shall be met i
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