GW1--03091_Well Construction - GW1_20230428

W.b;I,L CnNSTRUCTION RF� ,CORI)
'Ihis form can he used for single or multiple.wells For Interngl Use ONLY:
I.Well Contractor laformatiou:
Mitchell Dean Cook
Well Cttontracctor Nam, ---- FROM TO;..- nF.SCRIPfiON 20
�'fit. _.-_..._.. ...__._... �....
NC Well Contractor Certification Number a$'nl 7?Hlts(? $N.G r tt `. tl l�N) is
a !� oc;uiul'(i �J;�.dfsYei�s'C() .fi,.• 1'C$6 a d: ::;:.t?k> :_FROM TO r..,`•...:.'
Dennis Holland Well Drilling Inc. f _ DIAMF;fF;R_ TFlIClOrES9 MATERLIL --^_
Company Namc - — fL .�� io,
+16,ffllljtt`(rYSllVlr(3�2}T(1T{ 1G' a'dilie'inulcl'w'edSliiil"
�j FROM _ �.�
2,WP.II C'oustructiou Permit H: LJ _ DIAMF;TBR 7TtlCKNF,, MATF;RfAL
Lisrall applicable wr#perruirs(i•e.Coun ��� y-r-^-'._. .__.-_._._�,-_ ft. �� "ft� r., in.
ry, yInfe. Variance,Injection,etc) _L� _ _- -,^_ �C� i ✓� r
3,Well Use(check well use); fit. ': fit.
ater Srlwi,:7,,..:C
W pplyWCII:
-- T 5 F,k! r..; '';4,:.: .. sr -r.•..
FROM_ 9't)'
DIAMETER �SE.OTSIT.F, TlIICF:NFSS MATERIAL
—
t_lAgriculturnl C;1Munir.ipaVPublir, ft. ft. tn. '
00tothennal(Heating/Cooling Supply) 03't2''�dential Water Supply(single) - ft. -ft. -" in.
CSI "-
01nd IS l,ttll (`ll/
Crci C1Residarttial Water ;rlN ( t. U:I' .;' ::: „?:>: tr.,. ,i ::,,as :> -..i
Supply � .__._ .,.�;
%..FROM - TOT.. `. ,,�_....�.�i , ,�... .,rr:za,:.
MA�fFNIAh F,MPI,ACF,MFNTMFTNOD&AMOI1Mf
Nou-Water Supply W ll�' " _ R. fr.
0Monitoring T(JRecovery - hM
Injection WPII: _ ._.._.... _.._.._..fl.• .-- ff-"
0Aquifer Recharge
00roundwater Ro. _ ntcdiation g1;9%S� D/,�A•VE•r'AGYCi'�,e~ :a:.�� �"'�^--T•
f_lAquifer Storage andltccove -�-•.. ,�,.[ �iLP 61bj ��^ ;; � ;;."'�"%;t:slt;°i'"�r�;...,�;'.•
Recovery L'1Sulblily Barrier FtiOM T(1 _ MATERIAL. , ,:ii:iFMPLACEAIF.M ME'(7IDa
LJAquifer Tesl ft.� 'ft. - _._
L1Stonuwatcr f.)r�linage - ....._..... ,
ClExperimentul Teclutology 03tibsidence Control (L T fit•_ ---- -.-_
1:1GeDthermal(Closed Loo i20:31JRt111Niy[ :(sr affn`etifthiaifo'n heo s fin
P) (.J•1'mcer I ce94e s„,_ ..c;...:.;:e.,; •:.:!g;r..;::,::.:::
(7Geothermal Iiealin�Coolie Return [lUther(rxplain ImderN21 Remarks) FROM TO irF^tiCRIPlIUNLoIo_�hardncs ,oturoeke ,ru,,,;u
q,Date Well(s)Com leted: n. - ft._ _ ,__�_� •� __�„r�---
P C2 'WellIDN Cj .4
fit, fL --
Sn,Well Location: _...� _ •
115el ZA y2._.__ ._ x4A) _T ft. _ fit.
FReility/Owner Natoc Facility ID#(if applicable) - --- ----- _-_ _—. f
fL M - _ _Ffl$FiPian. �'1�i.��^ al _�[I4�._--•---
64%. .:_.�.�'2.
Physical Address,(Ity,find'lip
County
Parcel Idrntilicn(ion No.(PfN)
Sb,Latitude nod Longitude In degrees/minutes/seconds or decimal degrees:
KINTll field,one laulong is sufficient) 22,Certificaflon: i
Signahire ofCetli6cd Well Coetraclor Date
6.is(are)the well(s): �maucttt ot• p1'cmpot•ary BY signing this form,l hereby certify that the we/I(s)was(ware)constructed in accordanc•r.
with I.SA YCII '02C.0I00 of-IJA NCAC 02C.07.00 Well Cvnstructlon Sandnrr/s anti flint u
7.1s this a repair'to an existing well: lJYes or rt' co this record has been provided to the svell owner.
Ijthis is a repair,fill ont known well camstt7tetion information and explain the nature.oj'fhr. copy o j
repair under#21 rernarks sectlal ar on the back of this form. 23,Site diagram or additional wel(details:
You may use the back of this page to provide additional well site details or well
S,Number of wells cousfructed: _ constilction details. You nrny also attach udditional pages if necessary.
For multiple injection or non-wnter.rupply wells ONLY with the scone construction,you can
submit one forrn. SU11MITTAI,I_NST UC_TIONS
9.Total well depth below land sulfate: __ _ 248, ,Pot ll Wells,: Submit this foim within 30 clays of completion of well
Far 111111 plc.wells list all depths jdifferea(example-3@200'and 2@/00') - constrliction to the following:
10.Static water level below top of casing:�� %J ^: (fit•) Division of Water Resources,Information Processing Unit,
//water level is above rasing,use ,.�, 1617 Mail Service Center,Raleigh,NC:27699-1617
11.Borehole,diameter: 6. 24b,j or W9.0it9n Wells UNI,Y: In adiiition to sending the form to the address in
Rota 2.4a above, also submit a copy of this firm within 30 days of completion of well.
i..Well rotary,cable,
rllethod:_Rotary constnrction to the following:
(i.e.nugcr,rotary,cable,direct push!,etc.) �-T�'�•��"
_.� Division of Water Resources,Underground Injection Control Program,
FOR V AT ER SIJPI'LY WFLI S UNI,Y: � �-�- � 1636 Mail Service Center,,Raleigh,NC 27699-1636
13a,Yield(gpm)._...,�7,o_........�_ Method of test: Air lift 24c,For Water Su r�1ly&Injection Welts:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H H Amouut:.12 oz. well construction to the county health d partment of the county where
constructed.
Porn GW I North(.'aroW,n 1)epwluionI of liuviroumcnI anti NahtraI Rcsouecs- Division of Woier Resol 's Revised August 2013

Qtot��t
o ,. Macon C o u n t y '' f S � NEW WELL CONSTRUCTION
Public Healthy h i I���1-�� CONSTRUCTION AUTHORIZATION
" • I PRIVATE DRINKING WATER WELL
rien • 091022-P • 094522-S
0246ZO
amil Well Residential • 6570865932weeta Lab Rd.Otto NCRd to R on Coweeta Lab Rd ast 2460 to next driveway on L '
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. ,.
" v
Diagram Not to Scale
Telephone
Box Ditch
Coweeta Lab Rd
G < C< < < < < < < Bank < t
�.
�1g t f 2460 Coweeta
................
Lab Rd
I iT 1 , 1 ' r�w r r r r r smog �>t
75
_tom---}— I. —>► 134'Repair �. t
120'�
24� 7 t
I � I Neighbor 15'Min. t
t
Driveway", ',':_' IPi ,q I . 'I Proposed
�.. . 1\ 2 BR Huse t
\ o t v
\ \V I t v
Proposed Drivewa/1
Proposed ,-
Well Area °a
091022-P
5'x 7' a
t
t
t
t
t
--PL — ---- -—
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 GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 10/24/2022 Charles Womack, REHS 1300 Authorized State Agent