GW1-2023-02609_Well Construction - GW1_20230410

_v_g Ii.CONSTRIJ.CTION 12ECORll --__
-Thus form can be used for single or multiple.wells for Internrl Use ONLY: -- -_�.
1.Well Contractor Information: I
Mitchell Dean Cook _�^--�
----- ___ _�. _ _ _ES RIPT: ,,; r `yte .:i' } . ...
Well Contractor Name ,_FROM_TO_ DESCRIPTION
2043•A �3S•ft. � , , ft. _
rt. rt. i
NC Well Contractor Certification Number .1IS,-01J1.YR S -(,A 1NG{for.oitltt cast•tlswelle�l)12(1i1NFk�t[t(i�f�)7icktile);`.
Inc. •
FROM TO -- DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling
Company.Natnc - - .__ _ �/P'a ��/G
. i 16 11Y1 igi o.4i N..ORhI'(•))11`.r(9� Wilieiiiiii liA4d^IO "':F :._.gi.
2..Well Construction Permit#: 22-P FROM 'IDDIAMETERTHICKNESS MATF.RfAL ---
List all applicable well permits(i.e.County ,S'trrlc, No,lam:e.Injection,rtc..)---...__._._.___.-_- -�^- ft,� -_T- rt. ' in. --
3..Well Use((heck well use); ft. ft. inn. '- T__
Water :"17:.5.<RF)FNr_"' ,F7. - - - _, t 'r' 2;<i .;�-.�--
Supply Well _.._..-.-_._.. ` ;;.;.;�.., s
__FROM _,9O . _ DIAM ET ER SLOT SI?.F• THICKNESS MATERIAL. -
C1Agricullurnl DMunicipa!Pith lin ft. ft. ro.'
OCieothermal(Heating/Cooling Supply) residential Water Supply(single) .- rt. ' -`-ft. �'-ina.T
Dlnd is '
ommercial . 7• :g..I<.:-
CaResldenttal Water Su ;1Rs�Rn.U.f`:!= ^� ---
Supply(shared) �.. r., -s ;;� z�;r:< .:,,<- :.«
~•._._.FROM TO ._: as:onc
LIIfrIlatipfl TT—_A_'- MATERIAL EMPLACEMENT MFTt10D;&AMOUNT
Nou-Water Supply Well: '"" Q ft. fr.
Olvlonitoring [:)Recovery 3 �i� -..-ft. QQ
Injection Well; - .-_____.._._._. - _:. �Ai �- �ji�-+ /tl�n���.._
fr. ft.
(.]Aquifer Recharge C1Grouctdwater Rcmediation ^13 S //,G1;AVE;Ii?(K ifia 1 l'dable''.
DAquifer Storage and Recove (�
Recovery C1Sulhlity 13arricr Hamm TO MATERIAL EMPLACEMFN ME'[HOD
lJAquifcrTcst ft. ft. __._..
UStonnwatcr Drainage ---___ .__
ClCxperimental'feclutoln ft. ft. -'
Technology [)Subsidence Control
I likcuhennal Closed Loopitcer) II0:1)1U1,11 N(j,OTi;ntiacliraaiuon•�al+'stiVetasf(ne issary) :
PROM _ TO nos RIYfiON-Icolor_hardors�soiVroek y�rein sin,ctc.�._
, -DOcotherntal(Flcaling,/Coolits [:)
Return) Other(explain under#21 Remarks) ft. ft. _
Completed:O fr. ft.
4.Date Well(s) �07$.2j Well 1DH�46.. :._ ....-._---- .----_••-_------- �;_,-. ^_.-
Sn.Well^Location:l1 ((�� •
----ft.- - ft _ s. �_'--__
Facility/Owner Name Facility IDII(if applicable)
. ft. ft. I __-_..
Tao sq/ GA SU,rn rn a t' d _�- __ __ ._— • _ _...' « . ..
Physical Address,City,and Zip
21 I2FM.4.RN
Cotmty Parcel Idrntiticnlion No,(l' ) _—' ---__. -._. _-....___
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: ^�~ T-T ._______..._.__�._'..._.._
(il'well field,one lat/long is sufficient) l2,Certification:
•
� .$� / 'O$' N 5".3a ' �' - ' '�' i
Signanue ofCenified Well Cootrnctor Date
6.Is(are)the well(s): FtTPcr'maucnt or OTemporary
ny signing this form,l hereby ramify that the well(.)was(were)rotsnucted in accordance
-- with 154 NCA(.'02C.0100 or/.54 NC/IC 01C-.0200 Well Construction Standards and that o
7.Is this n repair to an existing well: DYes or o copy of this record has been provided to the well owner.
Olds is a repair,frH out known well constructions h formation and explain the nature of the .
repair under1121 remarks.section or on the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Nurnher of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the scone construction,you can
submit one form. SlfI1M ITFAL.INSTUCTIONS
9.Total well depth below land surface: /D05 . _ _ -•(ft•) 24a. For All Wells: Submit this limn within 30 days of completion of well
For multiple wells list all depths f different(example-3(tJ,200'and 2@100') ~ - construction to the following:
10.Static water level below top of casing: 3.$' • .(ft.) Division of Water Resources,Information Processing Unit,
limner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699 161'1
11.Borehole.diameter:_ _ (in.) 24b. For injection Wells ONLY: ill addition to sending the form to the address in
ROtary 24a above, also submit a copy of this torn within 30 days of completion of well
12.Well construction method: ___ - __ constntction to the following:
(i.e.anger,roraiy,cable,direct push,ate.) —_.__.-._�
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: T^ ---TT 1636 Mail Service Center,Raleigh,NC 27699-1636
Iaa.Yield(gpm)._.._L__ Air lift 24c.For Water Su ply Re Injection Wells
..____:�^. Method of test:.__.__._.
H & H Also submit one copy of this form within 30 days of completion of
I;lb.Disinfection type: _ M H Arnow' .._....7._________;:_....____,..:__12 oz. well construction to the county health department of the county where
__ _T'__ __ __._. _-___--__ constructed.
Form(1W•I North Carolina Dep:uIntent orEnvirnuncnur r and Natural Resources--Division of Water Resoccs Revised August 1017

Q<otect• .
` m Macon County NEW WELL CONS IRUCTION
° Public Health CONSTRUCTION AUTHORIZATION
r ;
�," a' PRIVATE DRINKING WATER WELL
APPLICANT/OWNER ��/ '--"-"'�
�S/A . .. 7i _ LOG# IO - OSMAN
INTENDED USE � / Z f- T2-2 -- PI D # r `,a, �5,• ACREAGE 4i31111 •
LOCATION .iL.j%rf /J_/,Y/W/WSGl -- —
DIRECTIONSgext_ �� � - ---
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable ° I
Diagram (Not to Scale)
w
7. -ar .
/ 4e7-12.-/ .
Ply
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1, ,S S-eftilW>
.2-5 MI2u-„,;....s...„.,.....,. 17 -5 /1-- Mf)( le __________ ---------
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I•
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 MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRA .ED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP tNSTA TIO . QU STION ?( 8) 349-2490
Issue Date: //A1—',::77x2._._
' orized State Agent