GW1--03461_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
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FROM TO DESCREMON
Well Contractor Name , ft. 1 1 M
2043 A ft. � ft.
NC Well Contractor Certification Number KRiG'SYPLfS f•fkti imu7ti cif1 e "51�t.'II�E 7 if4" "'6ie :w'''•"`.?;{;a •;
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. D r ft. ft. ,, i°• _� �vG
Company Name
.E`ItG••'A�fN_lr..`:�1�`�t1131N ; i!'U 'fi�li>e°`1$se11z ".%�sr;';iz;'""s"•y�;'a. "°.
r FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#:aLt,2/ z�L y- //S�;� _ fr, ft.
List all applicable well permits(i.e.Coun%State, Variance,Injection,etc)
3.Well Ilse(check well use): ft. fr. inip
'17:175'RI$k ,-s r- f. .'. ; i3„ �`�1,. y�..: .sy...k.,..;j:...:.. .•.
Water upply Well: FROM TO I :DIAMETER SLOT SIZE I THICKNESS 11lATEAIAI,,3`
❑Agricultural OM/unicipaUPublic ft. fr. in.
❑Geothermal(Heating/Cooling Supply) GaR sidential Water Supply(single) ft, ft.
❑Industrial/CominercialSupplyCR si ntial Water Shafed) -ti R.U�'"�::.;:' ,v :;::' azt;;�:�^»<.; .�',.,.::•:....;ss�.
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FROM TO MATERIAL ry 1 EMPLACEMENT MFTHOII&AMOUNT
❑Irri atl0tl ..
Non-Water Supply Well: 6 r ft. 3 ft. lisy� !>laoS Pcs /�
❑Monitoring DRecovery r ft. 2-0, ft.
Injection Well: fr. ft.
❑Aquifer Recharge OGroundwater Renmediation fla' i Ali is
❑Aquifer Storage and Recove FROM TO MATERAAI, EMPLACEMFNTME'THOD
Recovery C7Sulhmity Barrier ft. fr.
❑Aquifer Test ❑Stornmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
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❑Geothermal(Closed Loop) 01'racer I3ROM TO DESCRIPTION color,bardnt3h pollfrock lyfg,graina1w etc.
❑Geothermal (Heating/Cooling Return) ❑Other explain underN21 Remarks) ft, ft.
'
4.Date Well(s)Completed:cmH- ,2 Well IDN , ft. ft.
�
Sa,Well Location: ft. ft.
� eAle
' By A / -, fr. ft, MAY I Q2 Z3
Facitity/Owlier Name Facility lD#(if applicable) —
ft. ft.
I� RIJ. ft. _ ft fm► ,.a r, r ..
Physical Address,City,and Zip
Comity Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:(if well field,one lat/long is sufficient)
��� Signature ofCciti6ed Well Contractor Date
6.Is(are)the well(s): frlTermanent or ❑Temporary
By signing this form,/hereby rer•t6 that the well(s)was(ware)constructed in nccur•dnner.
with 1 SA NCAC 02C.0100 a•I.SA NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ' !zJ'IVo copy of this rerord has been provided to the well owner.
If this is a repair,fill our known well consir•trction information and explain the nature of the
repair under#21 reinarks.seerion or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: lam S_ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa'multiple wells list all depths tfdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1.2 5 _ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater•level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6a (ill.) 24b.Eor Injection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
_ Air lift 24c.For Water Su &Injection Wells:
13a,Yield(gPm)___1?I Method of test: i
'�� Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 2 OZ. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Enviroumcnt add Natural Resources-Division of Water Resoru,ces Revised August 2013

if -plap�pfl,�r
The Jackson County Department of Public Health
'k 538 Scotts Creek Rd.Suite 100 *Sylva, NC'28779•
Tel: [phone] * FAX: [phone]
{� Shelley Carraway = __
DIRECTOR =
Shelley.Carraway
Authorization to Construct
Reference Number: Permit Number: 2021-22124-9-11508
1 PIN: 7489-0076765 Application Date: 11/5/2021
-- Owner: --- BEGERRA­j-MIS-T-Y — ----City: - -CLERMONT-FL - - -
Address: 921 S MAIN AVE Zip Code: 34715
9I Lot Number: BULL PEN RD
3,Service Type: IP/CA/ OP/Well Permit Bedrooms: 2
Directions To Site: Bull Pen Rd.
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t
Initial SYstem l'y`pe. I174=25�0%-REi?OETtUA« -
- S
.A Distribution: D-BOX OR STEP-DOW[ S f.
Minimum Grade level: I•I _ { �
Nitrification: 400 SQ FT
i� Pump Tank Size: t
ti T stem Repair S p y Type: IIIe-PPBPS .'•,�f
Septic Tank Size: 1000 GALLON 3
I,I Water Supply: PROPOSED WELL
Attached drawing not to.scale. Do'not fill over proposed septic area. Install I�
drainiines.level and on contour. Stay 10' from any property line. Stay 10' from any ! �
water line. Stay 100' from_.any drinking water spring. Stay 50' from any Well. Stay
--- ---- ---15--' from a basement cut.. Stay 15-from-any-cut-bank 2'or greater.-Stay-5-from any--'.
i.l foundation, including decks. Stay 50' from all surface waters. Stay 9' on centers. f
Ia t
l
INSTALL A 1000 GALLON'S/T',,FEEDING 16W OR DRAINLINE 36" WIDE AND 18"
Remarks:
!i� DEEP ON LOW SIDE. = 'i
SYSTEM ADEQUATE FOR 2 BEDROOM240,GPD MAXIMUM.00QUPANCYi4 PEOPLE €�"' -.-
THIS PERMIT EXPIRES ON:-11/22/26
Fee: $680.00 _ R__4Pti.
EHS: l/i",-�kl P Date:
.;.. Da e:
Signature: :
J,