GW1-2023-01750_Well Construction - GW1_20230223

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WELL CONSTRUCTION RFCORD --_- a_
'Ibis form can be used for single or multiple wells for lntcm:rl Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook • ,:,Q;,,Y
ATER: .i,;,
Well Contractor Name - _ _FROM TO DESCRIPTION-� -- ' ` >' 'T:
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NC Well Contractor Certification Number 1S plillaR tASIIi)G for.mtly_carsetlkwCllt ifiLle1(7.; i ittgjillcfeble).
Dennis Holland Well Drilling Inc. `RD"' TO � -
_ DIAMFTF;R� THICKNESS MATI;RL41
Company Nam, _ �q ft. , ft.. - J' in- f
K _ D ' 11 J id 1/�
16 IhNI R(`AS11y(OR TU$ING eothocinal(closed lb$
2.Well Construction Permit t#: d F FROM ""
9 j 7 L9� !0 DIAMF,TER THICKNESS f MATERIAL List all applicable well permits(i.e..Comm �G• C t -----•-------- ft• ft, in. -"-
ry,•S'ratc, Variance.Gje<sion,etc.J
3.Well Use(check well use): ft. ft.
- �in --
Water Su )I Wcll: __ _. _ 1..7 5OREENiT �:):," -. -'.::.,
ClAgriellltiral DIAM FT 560T SI7,F, rli THICKNESS MATERIAL
[:iMunicipaVl'ublir, ft, It.
i o.
CJCieothermal(Heating/Cooling Supply) l:7 'icntial Water Supply T" - _.-_ _�- _ �____:
csll !! y(single)) ft.� ft. in.
❑In(lustriol/Comntl:rcial sm,Ic -"
E)Re ' '
slier t :Sg,tIaI ,',Cs
Water star •• :.<,:;:
Supply �) R,;,U;7:�;�: .,,.
°lrrigntioll I Y(shared) FROM TO __ ? ;:'r,:.;'' 4;r.: f.
MATERIAL EMPLACEMFNTMFTHOD,&AMOUNT-•
Non-Water Supply Well: _ _ d fr. 3 ft.. " `wJ9 ,�
DMonitoring
DRecovery ,^ ' ft, i ft.
Injection Well: - __ --- m-_� _e �?l._. L� r�, .. ..
Tft, ft.
DAquifer Recharge C1Groutulwate:r Ransediation T'
f- -.1,9iiSiktcl1S%Cy iA'YE 4fACK�(7 1'lld".11 C:`'%;;r.."::: P i` :iF';:
_)Aquifer Storage and RecoverytROnt TD 'a Z...... ..:..'..r.....::.:. .....:.r.:;: :% ?'
°S[tlirrity I3arricr _F - _ MATERIAL MATERIAL. EMPLACEn ENT METHOD
°Aquifer Test tr. fr.
OStormwatcrDrainage —
C1Experimental Technology C7Subsidenee Control ft. rt. -
°G t rmal .. ,
e)the (Closed Loop) :20t.:1W INf;'�l•cie attach;d r• '" ' ..
P) °Tracer S ii�honalsti`ecf`a,if?iiq�cvser 'i:
FROM
°Geothermal Heatin Cooling Return) f:70ther(explain wider#21 Remarks) ft. ft.
TO_._.. DE:SCRIPTIONWolorzhardnes eon/rock type,grain„re cir.1V_
e
4.Date Well(s)Completed:4� /d ft. n. 5-.�f"�rt n;•,:! ,
. Well IDII ',�/g: .._ _____..__ "-----ft:--_�-..-.- .__�.._.-_..--.._._.___�' -.' .-z w 't no" ' -•
Sn.Well Location: '
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J • / CaG� : c go 5..7•.,L -5. ft. _. f`__.��..__ .Rr.�.._jT-sr D
Facility/OwnerFacility/Owner a1J Facility Ina(if applicable) — _ - — _._ __ '1 . f�_C ^-• -
..-n t C,4,,ry -, r
Li
i-ta r,a'G; is 1 yc __ ___-__._ _ _.__... __.__-._._._..____-._.._.._.__._.--_-•
Physical Address,City,and Zip ft. ft.
2t 1tFMA�RKS
County
_� __._
Parcel Identification No.(PIN) —--— - --
Sb.Latitude and Longitude In degrees/r»itiilteslseconds or decimal degrees: � - - "�"-'-----•--•--•-
(it'wcll field,one lat/long is sufficient) 22,Certification:
aJ_ fJJrG' l5_,9__'c (____.; N e3
6.Is(are)the well(s): rmauent or C7Tempornty Signature ofCcnified Weal Contractor Date
By signing this form, I hereby rent that the'well(s)was(were)constructed in accordance
- - - • with 1S4 NCAC 02C.0/00-or 1.14 NC/IC 02C.0200 Well Construction Standards and that a
7,Is this a repair to an existingwell:
L7for or iIAFD'- copy sJ'this record has been providrrl to the well owner.
/f this is a repair,fill aa(krrammr well construction information and exploits the nann•r.of the
repair under 1/2/remarks section or on the hack of1hi,s form,
23.Site diapragi 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: constiuction details. You ntay also attach additional pages if necessary.
For multiple lryection or non-water supply wells ONLY with the snare construction,you can
submit one form.
SU11M17"I Al,INST[1CTIONS
9.Total well depth below land surface:_ ...0.5 _ (ft•) 24a. For All Wells: Submit this form within-30 days of'completion of well
For multiple wells list all depths ifdiffercnt(example-3 cb200'and 2 a;100'
C C ) construction to the following:
_. f® _.(ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:-
Ifwater•level isaboverasing,use"r" "' 1617 Mail Service Center,Raleigh,NC 27699••1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
It.Borehole diameter; 6" __ (in.)
Rota 24a above, also submit a copy of this form within 30 days of completion of well
_ ry construction to the following:
12.Well construction method:
(Lc.auger,rotary,cable,direct push,etc,) "'
Division of Writer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WF.I,IS ONLY: �.__ -T_ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm)____, ./?.______-_-. Method of test: Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of-this form within 30 days of completion of
13b.Disinfection type: H H Amonut:.12 oz. well construction to the county health department of the county where
L --• ..-____._._ _._..._-._ _ constructed.
Revised August 2013
Form GW-I North Carolina Department of Environment and Neon]Resources--Division of Water Resources

Qtoeeet
m Macon County NEW WELL CONSTRUCTION
o�d iii' a Public Health. • CONSTRUCTION AUTHORIZATION
a' PRIVATE DRINKING WATER WELL
APPLICANT/OWNER 7 ,/ -r"��� LOG# t)f�U .-POSWW#boSV.-.5'
INTENDED USE . -1/}1 '7/i�IL'--, PID # • ACREAGE
LOCATION i), ' / —
DIRECTIONS - ; ,# O ^ n. e r
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. 0 i
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale)
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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 KPH.
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A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR T • +ELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIO. •? (t 2/ 349-2490
Illir Issue Date: --/ , , SI �� fri/I �t��'o� edStateAgent
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