GW1--03089_Well Construction - GW1_20230428

WELL irl T&UC QQNST�QN RECORD
1 rn Use OWN:
FOlrucan�hcusc rorsingleorml;UIT1171I.-IN For totem
I.WPII C00tractol,Information:
Mitchell Dean Cook V F
_Mitchell
Coll�tlactor Name -4liom­r ft - DESCRIU�V! N
ft.
2043 A
ft
NC Well
Contractor Certific-ation Nunabor
T " -
Im6RihUri IMgar FRO
TO
ILM E ER %I�. E MATFRALDenni8 Holland Well Drilling,ling, Inc.I 7, in.
--
Company u FROM T
—­--
2.Well Constructiou Permit N:
List all applicable will perm ADIA E F, MATFR1AL—
........ ft.
"j(""'Colloty,-*(ne, Variance,It!icolion.air.)
3.Well Use(check well use):
F;
Wall Slimily Well.
OM T Z&
bAgricultural r"I Milli inipavPub]1C ri. to. L.qj_.E THICKNESS MATWVRI I..
7
00-thermal(Heating/Cooling Supply) Ll Residential Water Supply(single) L in.
ClIndustri'll/Cominercial L41(e'.'sidentiul Water Supply(share() 7.7 77777-5
Q-1imp FROM
,ation MATERIAL PLA FNTME
Nou5Wn­ier,SllPply�Welh —­­--- !I
0mollitoring
(JRecovely
Injection --ft.
L�l .tl —7-7
DAquifor Recharge 00roundwater Reniodiation Rii, ip; k" -77=­
T) MATER] 1,
ClAquifer Storage and Recovery (08111blily Barrier EMPLACEME
LJAq u ifer'Pest ClStOrnlwatcr I)nijllage
gY 08tibsidence Control TI,
0(jeothermal(Closed Loop) C.lTracer
FROM TO D&4CRIPTION(rolo ardnt 3011trock lyfittat
under821 Remarks) Ao"t
4,Date Well(S)Completed:<Yj4 Well IDjj -1 16— 166--4 V
So.Well Location: ——---- 2023
Facility/Owner Name Facility IDN(iflipplicable)
ft.
ft. ft,
Physical Address,City,and'lip
"M
ti­"E
coolay
Parcel hirtitificalion No.(PM)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(irwell field,one lat/10118 is sufficient) 22,certiricaHoo:
35"" 4
N 25' SP
W
Signature of Corlified Well Contractor Date
6.Is(are)the well(s): or 1.11'emporary
By signing(his form,/hereby certify flint the svell(s)sias(wrrc)constructed in accordance.
with 15A 1VCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an exisdug well: OYcs or =LFtNo copy ql'ihis record has been provided to ilia well owner.
If this is a repair fill out known wet(ronst)uction inlormallon and explain the nature.of the
repair undow#21 relharks Section at-on the back of
Illisform. 21.8ite diagram'i or additional welt details:
You May UNC the back of this page to provide additional wall site details or well
S.Number of wells constructed: 1 (1101131111clitill details. You may also attach additional pages if necessary.
Fornitilliple,injection ornon-warersupply ivells ONLY with the sanle ca construction,you n
submironeforin. smimrrrAl,INSTUCTIONS
9.Total well depth below land surface: '24a. jeat�,All Weill: Submit this form within 30 (lays of completion of well
Pal'Inulliple wells list all depths if different(example-3@200,al?Y2C�jO7) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
11vi,aler level is above casing,use 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(ill.) 24b, WX,11,.j ONLY: In addition to sending the form to the address in
12.Well construction method: Rotary 2.4ft above, also submit a copy of this flullil within 30 (lays of Completion of well
(i.e.lltl8cr.rotary,cable,direct Intsil,etc.) C011SIRICti011 to 111L 11011OWill6l:
Division of Water Resources,Underground Injection Control Program,,
FOR WATER SIJPI)I,y WFLLS ONLY: 1636 Mail Service Centel-,RRIcigh,NC 27699-1636
13a,Yield(gilin) -14 Method)d of(,,,: Air lift 24c.For Water Su !X&In ection I Wells:.
13b,Disinfection type: H & H Also submit one copy of this Form�within .30 days of completion of
Amount:•12 oz. well construction to the, county health department of the eounty where
constructed.
Form CFW-I Noilh Carolina Department of 13tiviro n men t aulf No liva I Resources--Division of Water Kcsourcos Revised August 2013

Q�pSe�P
`4 *m Macon County- W NEW WELL CONSTRUCTION
ova Public Health W `l CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
8
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
,f
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 fad 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 volurne(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL-ROWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INS AL ON. QUE ONVS? ;orwed5tateAgent
349-2490
Issue Date: /"