GW1-2023-02611_Well Construction - GW1_20230410

WELL CONSTRUCTION RECO.RI)
Ilus fonu can be used 17or single or multiple wells For Intemel Use ONLY:
I.Well Contractor Information: A -
Mitchell Dean Cook a:w',> I�/.EN 5 r— fv/ .k.;'f..)is'J4 r)"^.:wii;S' x.f L:i_ ::•a.......
FROM TO___ DESCRIPTION
Well Contractor Name eft. . fA
2043 A ft. ft,
NC Well CoutractorCertification Number :1S,;dn[)TTIrR( '$Tlt(4`focimtilti �J'kj,'`clls'.E�)N.> 't it" jfcOble�:..:...:.... ...........5. ». r...,:._.:.:
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. -- - —
Q ft ` ft,
Company Name '1'gill(1YE`RrC;•ASIN��b13:�11�IJ`IG"eo'fbeeiriii);'IaYedsl'��'• „rf.:`a>;;G;•:.� �-r--,::.-.
RROM T0� DIAMETER THICKNESS MATERIAL
,,. ,•
2.Well C'onstructiou Permit#: O7Q��,�-^/� - _ _ ft. — ft. in• -
List all applicable well perm/rs(i.e,Coirnry,.State, Variance,Injection,air..)
3.Well Ilse(check well use): ft. ft.
sf�t'S.GRF.-RIY:.:::,:T M1.; ,,v.;;;i' i ;:.•:;;:: :,:;s:...
Water SupplyWcll: ---_-._---------. ,,. -•�.. ........,:• ..:.,�;.�,,...:.i:;:•;:;�':;-y?icy-.�-.
FROM TO _-•I)IAAfETk;R -'µSLOT SIT.F, '11i1CKNFSS MATERIAL
OAgricultural LIMunicipaUPublic fr. ft. in.
❑Geothermal(Heating/Cooling Supply) bXc—qidential Water Supply(single) rt. �ft. in. -�
❑Industrial/Commercial :.$
C]Residential Water Supply(shared) R. D• ''{=' :::��� :�i<:;: .a�s�>' w�•;- :,.;.,
❑Irri atiolt FROM_ TO _ MATERIAL}V F,MPLACEMFNTMFTHOA&AMOUNT
Nno-Water Supply Well: Q' ft.
CJMonitrn'in ft. D. �� A
g f.JRecovery 3 '
Injection Well: �fr, ft,
'OF-Water
❑GroundwaterRemcdiation �;1,9..a5'.'NIS/.CykiAlE G`IC Ira`"tic` e" t _''
❑Aquifer Storage and Recovery 178RIlltlty BarrierFROM T(r MATFR1Ah� T EMPLACFM-K.NTMETJlOD
ft,
_ Tfr. -
❑Aquif.r Test ❑Storinwater Drainage
CIF.:xperimental'reclurolo ft. ft.
gY l7Subsidence Control
00e0thermal(Closed Loop) �20;�RIL1<1Nr�i1,�'cs?alfa`a kaiiitolaai?stiec'tefiftb`ce�9si�•';=? ';�'�;!=z:;��""�:i ,�; :ii;'": .
f_1 I racer FROM _TO DESCRIYriON color,haAat eolVrock lZpUrein eize cic.
17 f
Geothermal Heatin Coolie Return C)Other ex)lain(miler N21 Remarks) ft. fa
4:Date Well(s)Completed:03-/ Well IDN ft,
^T-rt. ^- _ _~ z iT�-"•^
i
— ft.
5n.Well Location:
�ft. �ft. tILJ
Job Facility/Ownc/rNValiane 7
Facility fapp , - I
__. ^i,-•fit '•( �.•--
ft
Physical Address,City,find Zip
_ M geoAA 6 65� _zf3
County Parcel identification No.(PfN) - —'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wcll field,ono lat/long is sufficient)
35� /o 'as" N FS -24T _ W 1y -
.Signature of Certified Well Contractor Date
6.Is(are)the well(s): ffiflermauent or 01'empor•ary
By signing this form,l hereby certify that the well(v)was(were)constructed in acr-ordonce-
' with ISA NCAC 02C.0100 or 15A NCAC 02C.02.00 Well Construction Slandards and flint a
7.Is this a repair to an existing well: OYes or t-1N i copy of this record iras been provided to the.well owner.
fthis Is a repair,fill out•knowm well construction information and explain the nature of the
repair render#21 remarks.section or on the back of this form. 23.Site diagram or additional well details:
ti.Number of wells constructed: 1
You may use the back of this page to provide additional well site details or well
coltsUuctiott details. You n)ny also attach additional pages if necessary.
For nwhiple Injection or non-water supply wells ONLY with the sane constriction,you can
submit one form• KiBMITTAi,BVSTUCTIONS
9.Total well depth below land surface.: p(ft,) 24a. For All Weill: Submit this then within 30 (lays of completion of well
For auhiple welis list all dcpr/ts ifrlifferent(example-3@200'and 2@)100') construction to the following:
10.Static water level below top of casing: 3,5 - (ft, Division of Water Resources,Information Processing Unit,
Ifwater level Isaboverasing,use"F" -"�" ) 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: 6" (iu.) 24b. For Injectign Wells ONLY: In addition to sending the form to the address in
Rota 24rr above, also Submit a copy of this form within 30 clays of completion of well
12.Well construction method: ry � constriction to thu following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SiJPI'LY WEI,IS ONLY: 1636 Mail Service Center,Raleigh,NC.'27699-1636
13a,Yield m D Air lift 24c.For Water Suppl &In'ectiou Wells:
Q;P ). 2.....__._-.______,. Method of test:
--�` Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health idepartn)ent of the county where
_- constructed.
o
Form GW-1 North Carolina Depatlinom of liuvirenment and Natural Resources-Division of Water Resoiuces Revised August 2013

�.Qso or
M a o ri +`6 ti ri t NEWWELL-CONSTRt9CTT:EIN
ti 6 Public Health CONSTRUCTION AUTHORIZATION
v .:a PRIVATE DRI IUNG WATER WELL
doh 8`�� L�r✓ � 0?0l ZZ"4p � 070822 5
Permit Conditions
well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. +
Plagram(Not to Scale)
a
Kiel —...,
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/ to 5 hl6o" Ff
Diry Wert s6,4e3 01&
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ry
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AM permit i5 Valld'fsr a perlod of five years except that it may be revoked at anytime IF It Is determined that there has been a material change In any fact or
circumstance upon which the permit Is issued. I{/ell 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 posslW sources of tontamination. Flow volume(well yield)Is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST 8E APPROVED BEFORE FINAL Po Elt IS GRR {1 O' THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP/INNSSTTAL ON, tI ?[phone]
', / t
' Issue Date: 9/z 1 �v22 � uthor/zed State Agegt