GW1-2023-02608_Well Construction - GW1_20230410

WELL CONSTRUCTION It I�is form can be used for single or multiple wills C0 .11j)
Pot 111tanurl Use ONLY:
L Well Coalractor Information:
Mitchell Dean Cook 7�
Well COUIrfictor Nome M 0 DESCRI MON
2043 A Tft.
ft.
MIN
smmv Arft(0 V Wlii
NC'Well Contractor Certification NumberQg,
R'
Dennis Holland TEj: 11 E&9 MATERIAL B-:__
Well Drilling, Inc.
ft. -ft. in.
Company Name
V SUM
2.Well(*,'01iStrucjjOU Permit#: FROM DIERE R I ICKNUS MATE
ft, ft. in.List all applicable well pur"Itij(i.e.;County,State. Variance,Injection,etc.) ---------
3,Well Use(ebeck well use): ft ft. in.
m ,.m
%
T
DIAM TER Iq SI7,.E, IC FSS MATERIAL
E, RT
I.JM111liCipaliPublir, in.
DOeotherinal(f feat'118"CoOl i 119-Supply) El Residential Water Supply(single)
`77—77 i,0 111d list Fill l/Coln-inercial klr�csidential Water SuPply(shared)
- 11�i—I MATERJAL. FmPL MENTMET110 &A OJINT
Nrin-Water sit
pPly Well..
limonitorilig CJRecovury ft 16 ft-
.......
DAquiflor Recharge 00roundwater Ronledimion .... ZKM if;
fJAquiI`er,Storagc and Recovery 08alinity Barrier TnERIAL
LJAquifer Test ft.
08tormwater Drainage
DExperimentol''rechnology USubsidence Control ft. ft,
(:)Geothermal(Closed Loop) C]Tmcef
LCoolie G othermal(1-1011tillRi" g.Return) 1:10ther(ex)lain wider 921 Remarks) ft.NROM _10 ft. .!�ardotm 3oll.frockly- ra�ln Am c I c
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4.DRte Well(s)Completed: 03 Well 11M Ft.
Ft.
So.Well Location:
AX-aW2 ­Fi - ----APJL_7L, ,%-X-__A _
V
Facility/Owner Name Facility ID#(if applicable)
Physical Address,Cily,and Zip ft. ft,
Comity
Pnrccl Identification No.(PrN)
Sb.Latitude and Longitude In degrees/ininutes/seconds or(lechiial degrees:
(il'wrli field,one lat/10118 is sufficient) 22.C'erlifictition:
350 1 f r I—
*26 " /7 '
N -W
Signature ofCortified Well(onractor Date
6.Is(arc)the well(s): Wermanent or ol'oulpor-al-y By signing thisforin, !hereby certify that the well(,)was(were)constructed in accordance
with IJA NCAC 02C:0100 or IJA NCAC 02C.0200 Well('OnstructlonSiandai'dT and that o
7.Is this a repair to an existing well: OYes or 68iV0 copy(V*ihij record has been provided to the well owner.
li"his is arepair,fill 0111 blown WO11 c0lish-uction it forinallon and explain the nature of the.
repair under#21 remarks section a)•on the back qfthisforin. 21.8ite diagram,I or additional welf details:
B.Number of wells constructed: You may List!the back of this page to provide additional well site details or well
For multiple injection or non construction details. You niny also attach additional pages if necessary.
submit are farm. -water supply wells ONLY wilt[lie sauce construction,you can SUBMITTAL.INSTUCTIONS
9.Total well depth below land Sul-face: (ft,) 248, E1qj_AIj ftefl�.t Submit this l4rin Within 30 days of completion of well
PO)"Illilliple wells list all depths if(lifferent(example-3@200"and_2(,:Di0_F)______ constrlictioil to the following:
10.Static water level below top of casing: (ft.) Division of Water Re.jourc'6,Information Processing Unit,
ffivater level is above casing,use 1'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"
(ill,) 24b, _F&Ujqg.,QtjqL_WPMs ONLY: In addition in sending the form to the address in
Rotary 2.4a al)ovt,, also submit a copy of this form within 30 days of completion of wall
12.Well construction method: construction to[lie following:
(i.e.ImBor,rotary,cable,direct pllslt,etc.)
Division of Water Resources,Unde,rgrotjnd Injection Control Program,
FOR WATER SUPPLY WFLUS ONLY: 1636 Mail Service Ceut6r,iIRaIcigh,NC 27699-1636
13R.Yield(gplll).-.3 Method of test: Air lift 24c.For Water Supply&lulection Wells:
Also Submit one copy of this Form within .30 (lays ofcollipletion of
13b.Disinfection type: H & H Ainouut:.12 oz. well constructionto the County health,I
department of the county where
--.Z-J constructed.
Vonal Gw-I North C.Firrilinti Deparitnom Of Il"IlVirOLID10119 allil'Nature I Resources--Division of We[or Resotircos Revised August 2013

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a 19 19�: "�C?a���:� /,/�� C;ONSTRUCI-ION AUTHORIZATION
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PRIVATE DRINKING WiffER.WELL.
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Polmit Conditions
Well shall be construci:ed ldcompliance with all NCAC:K,Rulc!s. r oa
Malntaln minimunt setbacks as applicable.
Diatgarn (Not to 5cale)
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Thin i.1crtnit is Valid for a period of t`otmr VC-NUS excopt that It may he revokM,,at any Cline If It is det u enlne d lhel:ntliere has brrn m act a aterial Change In any factor
fircumstanco u11°n vrhlch the permit L Isslwd. wall location,InsL•:,Ilatlon,and protec-tlon must pim sleto rogulaticns. nio well shall br.Insper.ted anil approved by M1 con county
I%ubilr.I IcaRh Iwora It Is put Into use:. the loeallon of the well Indicatod by f4C1'I I Is to provlde;prouxtlon ffoln poaalhlr:sourer;of c:OnlaminotI n. How volume(vrall yield)Is NOY
quorantn.ed at any site by MCPH•
A WEI.LI-IFAD COMPLE EON INSPCECRON MUST HE AV11ROVFD 131'_fTORE..FINAI.POWI R J GRANTS .)1j f IL',Wl'.I.l.Is PLACED INTO
5!:RV1CI'.. PLi_A.iE SCNF:r)l.1Ll:A VJL'.L1.F11AD INSPECTION AI=1 i:R f'11h1P IN`i:l"ISLI. �C iI ija N31?i3):'d/bJ F/d�3fD
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