GW1--03754_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD
Ihis Corfu can be used lbr single or multiple wells For Inteniql Use ONLY:
I.Well Contractor-Information:
Mitchell Dean Cook
Well Contractor Nam,
2043 A
NC W ell COlar"clOr Certification Nuinticr
Dennis Holland THICKNE
'R W,
Well Drillinq, Inc. ATh
'4 lit,
t.
Company Narric IT .5z?lf
51
(0411 vi;iul" =l
.! I
2.W01 Construction Per lift H: FROM .—J E :R THICKNM MATERIAL
,
List all applicable e.11pe.rits(i.e.Canarrc, ff. in.
--0ly,
5
,jan, C.T
3.Well Use(check well Ilse): ft. ft. in,
aCCt'Sv5m
............ 7
apply Woll.,
fyn
D I A ki E7h,a SLOT THICKNESS 77.RIAI,
LLF!h
ClAgnculturfil ENuniripal/Public
(Heating/Cooling Supply) 041UFsidontial Writer Supply(single)
01ndustri'll/C011ranorcial 1.1 Rusidential Water-Supply(sharcd) 5*11.1 1.., A,01
FROM_ T
AN—Uffl—
Non-W t 7Supply—Well: ­--------
CSMonitrning (.:!Recovery -41
n.
—2-1
OA(luifar Recharge
00roundwater Romediation fg,
ClquiferStorage and Recovery L0 .._
r 08alinily Barrier .. .. _�jATFFL1&l,___ EMPLACE51 ME!nlOD­­
UAquifer Test ft.
El8t0rillwater I)naillage
C)I.-,,xl)eriinetitul'reclujology fr.
Usubsidence Control
(:!Geothermal(Closed Loo . ff. ..........
- I at c Val FU`1C.,3 'racer-G FROM 1MLCRIMON c l An-"
cotherinal(licatilIPJCooling Rcturn) (explain tinder#21 Remarks)
4.Date Well(s)Completed:(n
91-aj�- Well Lim IVIA
fin,Well Location: Z
­
M—
FA.
) 7 E7,0
_-T:-I-.3-Z
l"Ruility/0%Ynor Nanic
Facility ID#(if applicable)
ft.
Physical Address,City,and Zip rt.
75-3'/.2 3Z.11 FT
coulay
Parcel Identification No.(PrN)
.5b.Latitude find Longitude In degrees/minutes/seconds Or(ICCIn2al degrees:
(il'wcll field,one tat/long is sufficient) 22.Certificaflou:
N --2
Signature ofCcitified Well Coutroctor Date
6.Is(are_)the well(s): F44"JEFmatlent or,
By signing this form,I hereby rorlify that the welift)inns(Were)constructed in accordance
with 15A AICAC 02C.0100 or 1.5A AfC11C 02C.0200 Well C listruction Standards unitthof a
7.Is this a repair to an existing wcll: UYes or &QN a COPY qj'lhis record has been provided a the well owner. 0
If this is 0 repair,fill oul known well cons[ruction information and explain the nafure of the.
repair under#21 remarks section or on the back qffhIsform. 23,.Site diagrnn e
'i or additional welf dtails;
8-NI'MI)el'Ofivellseons(ructe(]; You may use.tire.back of this page to provide additional well site details or well
constilletion details. You 11111y also attach additional pages if necessary.
Fur multiple injection or non.%varersupply u,clis ONLY with the sane construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ;?
24a. for AIL&e Well: Submit this lbrin within 30 (lays of completion of well
For'alulliPle We*All all depths ifdiffereat(example.3@200'anY2-(�:FOT) colistructioll to ill('following: I I
10.Static Water level below top of casing: (ft.) Division of Water Resources;Information Processiag Unit,
ffvvater level Is above rasing,use 1617 Mail Set-vice Center,Raleigh,NC 27699-1617
11 1 Borehole diameter; 6. 24b,fiojjWU.!jqZ&PIL s ONLY: In addition to sending the form to the.address in
_
12.Well coustruct-Ion method: Rotary 24a above, also submit a copy of this form within 30 clays of completion of well
(i.e.""gas.rotary,cable,direct push,etc.) construction to the following:
Division OfWlltCr ReSOUITC.S,Underground Injection Control Program,
FOR WATER SUPPLY WFLUS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(glum). ......... Method of test; Air lift 24e.For W�atcr SMjLAj_IrCec.(iou Wells:
_ _ I
Also submit one copy of this Form writhin30 days of completion of
13b,Disinfection type: H.& H
Amount:.12 Oz. well construction to the, county health I cle'partment of the county where
constructed.
FOMI North Carol n n DePai later i I or HInviron inen t and Na tura I Resources--Division of Wo ter Resources Revised August 2013

ote
Qt �r
•m Macon County NEW WELL CONSTRUCTION
; Public Health CONSTRUCTION AUTHORIZATION
'd • a' PRIVATE DRINKING WATER WELL
r Highlands Vineyard, LLC • 051323-P • 052321-S
Sin le-Family Well Residential ' 7531247485 26.86
• • 3954 Flat Mountain Road
3954 Flat Mountain Road Highlands
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale
PL
i
dr,
G
\\ve �0
O•
y°4 Approved Well Area 5'x 10'
RV �GPS 35 5'22.533 N
wky . 111' 83 14'17.103 W
Clean out connection
PL Previous permitted not drilled well
Log #031319-P
— -- — --- -- -- PL-- — — —
N
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: 5 23 2023 Charles Womack, REHS 1300 Authorized State Agent