GW1--03753_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD -- ---
Iltfs form can be used fbr single or andliple wells For Inlennll Else ONLY:
I
I.Well Contractor Information: _
Mitchell Dean Cook :ra:wA - NFS{
.: �set ii:t_ '�-�- 77
_..._� FROM _ TO :-_=:,'�,:2_:'.•!'...r.... ........ _:a�.::;t: _'." .:,;
R'elI Contractor Name, ��—! DFSCRDvnON
ft. : ft. -
2043 A n: —
NC Well Contractor Certification Number 15ONE 1ZE' ` r"'*^,
G�11Y4 to .uiultrcascd�w`cus�()11NF,t rf`i'7Jc 6j�cZ ,
Dennis Holland WeII Drilling, Inc. RROM - TO--- - _DIAMPTFR- TFIICKNESS MATERIAI
-- -_-�— Q ft eft in.
Company Name } i - ---r- r
OR"I'l)L3IIY(y eolh'e'•ii]el;clbsod5l'o3"''t+
2,Well C:onstructfou Permit ff: /40 0 5� FROM_ Dtah1F:TF:x THICKNESSMATF.RfAL_
List rill applicable well permits(i.v.Connry,,S'Irrre, Variance.Injection.etc)- -___._.___._-
3.Well Use(check well trse): ft. ft. in. -`
Water•�ISIIPPIY Well..
__
"
DIA IFTk(i St.OT SIT.F._ I'Fi IC.'KNFSS MATERIAL
_
LIAgricultural CJ Milli iaipaVPublic fl, ft.
0(le0thermal(1lcating/Cooling Supply) (LKc-- tial Water Supply(single) -fr." T"-rt. —"— in. ------_.__
(7lndust rill l/Commercial -"-
J sudentiul Water Supply R- ;t 11 shurc(J
(71rri�flho❑ FROM_ TO _•_•�_ MATERIA[, F,MPLACF.AIFNTM1iFTTiOD&AMOUNTT
Nnn-Water Supply Well: fr. , ft.
_Ghlonitrn ing (.]Recoveryft' R
^— _
�ft. ft. -- -
DAquifer Rechari;c FIGroundwaler Rcn}cdiation -.1,9..' SA`Nn%G AYF i'P'' '' ":•• _. �,..�,. AGK rr`a'Lij111'c�'iiftle
C1Aquifer Storage and Recovery 08alblily Barrier Fi(OM •_ TO — MATERIAL. — EMPLACFMFNTM1IF R10D --
0Aquifer Test fr.- ft. -
ElStormwater Drainage
1:113xperimentul Teelmolo
gY (�Subsid(:nce Control
(:)Geothermal(Closed soiUroc matr
Loop) [:1'1 zi20 llRli Ir;IN(r[O( (etfaofli6d'dlirogel sheets rftriece se]y�`�
racer
r FROM TO hFS(:RIP'170N_ , k t ain sin,etc. __
.[:)Geothermal lieatin Cooling Return) [:)Other explain tu}der#21 Remarks) colo-r�^�hardness
rlc ft. ft. ___ _----
4.Date Well(s)Conti ted;Q S�� ' 3We11 1DN 4�p ---- c -�h—,_ _
Sn.Well Location:
—.fit-. -__.__•fir.- _� .2-����
7 ;7 1
Facility/Owncr
Facili
Natnc ,__..-•,,�1 +�T C-l�v�: (�f"i T
ty iDN(if applicable) -- -- ......
--..---
n. -ft.
Physical Address,City,and Zip
County Parcel Identification No.(PFN)
.b.L,alitudc and Longitude In degrees/minutes/seconds or(IeeimRl degrees:
(il,well Geld,one Eat/long is sufficient) 22.Cerlificaflon;
Signature.ofCeni6ed Wcll Contractor Date
6.Is(arc)the wells: aPe.rmauent or'
(> 01•ernpnr•ary
0y signing this form, l hereby rerr fy that the well(,) was(were)constructed in acrurdanrr.
ndnh 15A N('AC 02C.0100 ur 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: I._)Yes or C51NIr- copy(f Ihis record has been provided to the well limner.
6(this is a repair,fill vel krlori'n well ronsnvc/ion Information and explain the nature of the.
repair under#21 remarkssection ar on the hack gfrhisfurm. 23.Site dingran)or additional well details:
You may ustt the back of this page to provide additional well site details or well
8.Number of wells constructed; conslnuclion details. You may also allach additional pages if necessary.
For muhiple injection or non-watersupply wells ONLY with the same construction,you can
submit uaefur'"• SU7IMIT'TAL_INST'UC TI_ONS
9,Total well depth below land surface: � �-• _ _ ft, 24a. For All Wells: Submit this Jimn within :10 (lays of cola lesion of well
POrnturnple wellslirr alldeplhslfdifferent(example-3(@,2200''an`1Fi 100') _"--T-( ) construction to the following: y p
10,Static water level below top of casing: _ C� (ft.) Division of Water Resources,Information Processing Unit,
/fsvater level is above casing,rise"r" - "— 1617 Mail Service Center,Raleigh,NC27699•-1617
11.Borehole diameter: 6" (iu.) 24b, For Inj_r.ction Wells ONLY: In?ddition to sending the form to the address in
Rota •24a above, also submit a copy of this form within a0 (lays of completion of well
12.Well construction method; Rotary _ construction to the following:
(i.e.ringer;rotary,cable,direct push,etc.)
_ Division of Water Resources,Underground Injection Control Program,
F'O1(WATER SUPI'I,Y WEI,I,S ONI.,Y; 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(PPm)._. te
Air lift 24c.For War Su111iI�Rr injection Wells:
..__/_..DQ..__---.___. Method of test:
H H Also submit one copy; of this form witliin 30 days of completion of
lab.Disinfection type: Amount:• OL. well construction to the county health IdeIparttnenl of the eounly where
constructed.
Form GW•I Nmih Carolian Deparlmcot of linvironmcnt and Natural Resotuacs..Division of Water Resources Revised August 2011

'm Macon C O u n t y NEW WELL CONSi-RUCTION
C, � Public Health CONSTRUCTION AUTHORIZATION
- l�ul1��-sue PRIVATE DRINKING WATER WELL
iML,—amil)L.L4le -PC
• �'� God- A� 'tn•ler5ec�orl of ro�a�����,�4-
Petit Conditions
Well shall be constructed in rompliance with all NCAC?.0 Rules.
Maintain minimum setbacks as applicable.
Diagram(Not to Scale)
so' ~IN
j?r �a I r .Area
j Pro
?a use
47
1 y
VY, y
3. VV
t51 ISr
�o i r2
This permit is valid for a period of five years except that It may be revoked at any time If ft Is determined that there'has been a material change In any fac or
the p_-rnr is ism ed. Well loc3t:on,Installa'lon,and"protet-tlen must meet state regulations.The well shall to lnspe`ted and approvei by Macon Cciity
F•e^r:t is P+fit irta use.,11:e la-=ton or the well L.dlc2ted by j-XPrI Is to Provide protection from-possible sources a contamination. now votume(wall yieia)_is a;o'
P EADCOi i?Lc iTrt:. INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
`= rt_FkSE S_FiEDUI r A VJcL-HEAD INSPFCTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]S
L1a=. I I/'t/p('� faJ�0f7•'t'rJ.S:`jCt'/ia.�.il:
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