GW1-2023-01547_Well Construction - GW1_20230209

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information: /
Mitchell Dean Cook M TO %l.:.n'': �'.I lr<"ii�1.':'t'::i::T..:• :tr;"iYi,:i��t.�::.i.:...:
:;aj4�!`'t1�R .17r7E'S• , :5,...,:.,+:i°:i�.
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FRO ,DF;SCRiP77 0N Y I
Well Contractor Name
ft. 'f"
2043 A- ft. `t.
_'_ -"'•• 'c�ell�'i(�''� t itf:� t, e:•,a:•,t , ' '
NC Well Contractor Certification Number , I NRt(�AS71VG1%({oYiintihtnc3�`d: )i.Gi ElY, efitiT',="��`.:T`.`:'•i
FROM TO - D1AMF.TF:R � �THICKNESS MATERIAL,
Dennis-Holland Well Drilling, Inc. ® •ft. ft• i S'DR�-.a1 G•
Company Name '�7 ,tu}t;CASINIrU1t Pilo G `eotlierm'ii;C! ed-l'o'.o` i%is
FROM TO DUMETF.R THICKNESS MATERIAL
2,Well Construction Pe rmit#:,/�„ ���,,2^_� _ _._� _T ft _ft.
:.List all applicable well permits(i.e.County,State, Variance,injection,etc) -
ft. ft.
3.Well Ilse(check well use):
Watel'Su )I WCiI: T FAOM TO _ DIAMETER �SLOTSI2F. TH1CYNESS MATERIAL.
ply ft, ft. in.
ClAgriculhtral riMunicipal/Public -
qGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. �rt, in.
;:fl? :ai'.•�',•ti,':i:`ii�;`?�;jw.iit;:; :£i>t'T� i?air�ti�i':e:?•
❑htdustrial/Commercial OResidential Water Supply(shared)
FROM -TO MATEKIAI, EMPI,ACRMEIYf MF,THOII&AMOUNT
Olrri ntion D r ft. 3 At ft.
Non-Water Supply Well: ft.
CJMonitot'ing i.7Recovery -
Injection Well: r ft. ft,
0Aquiter Recharge ElGroundwater Rrmcdiation i9i5A#InIC)iAYEI':iPAGKCE':a�•':rr•:;;,,'+:';;•:;<
FROM 'rp ATERI MATERIAL. EMPLACEIIIN:TAtE'l'HOD
OAquifer Storage and Recovery Malbtity Barrier ft. ft.
OAquifer Test 08torniwater Drainage ft - ft.
OEix eriniental Teclutolo ❑Subsidence Control
P gY i201:111tt1 ;INf3a1a11i'atfaCfituddilioAel?s&cefi tiflu'cesse is<;'`.I o s%i;:;::: :'2 r`•
00cothermal(Closed Loop) C_)'I'mcer FROM TO DESCRIPTION eolorihardne so Nck l grain size etc.
(]Geothermal Hearin Coolin Return 00ther(explain under 921 Remarks) ft, ft. _
4.Date Well(s)Completed: 'P 11.1 Well IDII ft. fL
_
I
Sa,Well Location: - -ft. ft.
vny
20
Facility/ caner Name Facility IDN(if applicable) `- ft, _.ft �ifli'cji w:r';�-�I
c �� 7 ft. ft. --�._ s�tder�luv� IT
Physical Address,City,and Zip
_ eke,r,tlL�
Canty Parcel Identification No.(Pi I)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/loug is sufficient)
J _ r N � J Date
Signature of Certified Well Contractor ,
6,is(ikre)the well(s): Ofrmauent or []Temporary By signing this jonn,l hereby cert01 that the well(r)was(were)constructed in accordance
with 1 SA NCAC 02(:'.0100 0+•1 SA NCAC 02C.02.00 it!e/l Constructlon Standards find that a
7.Is this a repair to an existing well: oYes or �If Pti copy of this record has been provided to the well owner.
If this is a repair,fill out known well cons°ucrion information and explain the nature of the 23 Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the bock of this page to provide additional well site details or well
nstruction details. You cony also attach additional pages if necessary.
3.Number of wells constructed: co
For multiple injection or non-waler-supply wells ONLY with the same corstntcdon,you can SIMMITTAL INSTU(TIONS
submit one form.
9.Total well depth below land surface: _ (ft.) 24a. [tor All Wells: Submit this form within 30 (lays of completion of well
For multiple wells list all depths if differmu(example-3@200'and 2@100') construction to the following:
Division of Water Resources,Information Processing Unit;
10.Static water level below top of casing: ,_��� - (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"F"
11.Borehole diameter: 611 (in.) 24b,For In'ccti9n,Wells ONLY: hit addition to standing the form to the address in
24a ahovc;,.also submit a,copy of this;form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
-- ' 1636 Mail Service Cetiter,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: j
Air lift 24c.For Water Su ty&Inlectton Wells:
13a.Yield(gpm) O-____.___. Method of test: -_�__._� Also submit one copy of this form pwitltin 30 days of completion of
well construction to the county health!department of the county where
13b.Disinfection type: H __ _.� Amount: Qz�.- - constructed.
Revised August 2017
Form CW.I North Carolina Deperlment of F,nviroument and Natival Resources-Division of Water Rei.:reos

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Macon County
Public Health CO NEW WELL ��UC�ON
RUMO'N AUTHORIZATION
PRIVATE DRINKING WATER WELL
05052-2-P Ex.
Sing.le-Family Well Qa!Y Residential
161 McDonald Road
Permit Conditions ~
Well shall be constructed in compliance with all NQ\C2CRules.
Maintain minimum setbacks as applicable, including 50'from septic systems and 25'from buildir1`9 pe'rimehers
Honor madhghtofway.
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Diagram (Not to Scale)
eel
Power
Pole 9
Neighbo At
rs Drive CIO,
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 ract 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 or 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.
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«WELLHEAD COMPLETION INSPECTION MUST 8E APPROVED BEFORE FINAL PUWER �
lSGRANTEDRTHEVVELLl3PLACEDlNTO
SERVICE. PLEASE SCHEDULE AVVELLHEADINSPE370N AFTER PUMP INSTALLATION. ��WESTI��WS?[phone]
Issue Date: 6/23/2022 Jonathan Fouts, REHS 1979 Authorioed 5yate,gent