GW1--04284_Well Construction - GW1_20230626

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3 'ELL CONSTRUCTION RECORll net tt,t�rn;ri Use ONI..Y:---_�M______-y^T_
This form can be used I'or single or multiple.wells '
1.Well Contractor Information: .
Mitchell
_Mitrhell Dean Cook •,14 \YA.GFRlQNES� ;;• ,^i::id;,7;;:- i;;, ,...... is:.:','.?:,,'
FROM TO DESCRIPTION
Well Contractor Name , dt. ' ft. I
2043 A eft.
NC Well Contractor Certification Number CIS).011PR(,15T Ci f Le mutii=ci t:a5vO4is2(')12xC INFI,(ff a cable) ,,-_'
TO DIAMETER THICKNESS MATERIAL _..
Holland Dennis Well Drilling, Inc. FROM rt. �� '-� rt. -•� • �-'-��-_
_
Company Name ;116 INNER C'ASr_V(__x(_)tfiNt3I1Y(3(ge'olfiermsl.clw'ed=Tb3,`.:• I ''
CIA_ __ _
p FROM_TI'O,mm_ _ DIAMETER THICKNESS MATF.RiAL _
2.Well Construction Permit Y: 0436 j', . '/ rt. ft. �� . in. / / ^�
List all applicable well permits(i.e..(:onnry,.S7ate, Vo•ianrc,injection,etc.) __..._. - 1�J _J .L _...7 K'! - +�-
/ :ft' y . ft' 6 G
3,Well Use(check well use): V .O/P�J __ v
Water Supply Well:— ~'��-�- - -'-' _FROM_-TO DIAMETER SLOT SI?.F 'mgC:KNES-8- •rMATERIAL
ClAgriculntrnl C3MunicipaVPublic
DGeothermal(Heating/Cooling Supply) fr3T sidential Water Supply ft. ft. • in.
I I Y(single)
f-llti 1 s g�:(_ c t t s�1 ., RC. :r�l, nut/Cr )U t..,ommerc a >;t
El (shored) ::,, '.:;„;:��; :;. '::��. ,.a'•::rt: ,i: ,.�� 1Ji''
FROM To MATERIAL. F.MPLACEMENTMETHOD,&AMOUNT
Clirrigution ,c ft. .., , ft.
Nnu-Water Supply Well: _ O _.. 3._....._...._:.._�..4-&�N 3-� �j_...��+`�, gpQ...
❑Monitorinl3 (:]Recovery __3;rt__a.L__r__ - �E,401 _� 4 .-- � l ,.
Injection Well: ""'"" -- -'-"--'- ft. . ft.
(.]Aquifer , '.' ;'i '?l:?'i"`tmm
1 RechargeC7GroundwalcrRemediation 19SANP/G)tAVFIi+PA41i( efirltbjei _
C°Aquifer Storage and Recovery I_)Srllinity 13arrier FROM_-TO���_MATFHIAL EMPLACEMENT hi E'1710P
ft. ft.
❑Aquifer Test CDStorntwaterDrainage — ..._.___... ..- — -T-.
CDExperimental Technology R. rt.(J a sl ence Control ,.,�..,..,.,-_... ,
10`iiIIIE j.(AllO i( tiac'iliddif o al#slre6ia.ffti Orlitiryi;�;':' ` ,:; :77::,r: ;_i;..:
EICteothermal(Closed Loop) L1'I'raccr „FROM _ T) DESCRIPTION(color pardon soiLlrecyjm,gyain size etc.) _
lJGeothennal(1•leatin8/Cooling_Rclurn) f:lOther(explain under821 Remarks) ft. ft.
4,Date Well(s)Completed:06:'/Z•• Well IDH �- -..-••---_._
fir
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fin.Well Location: -----
ft. •-^-----•h.-- _T._.__�. Jug---' 2O23
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C. //4.c j y /,P^e 11-•/1 e5G4e C.).1, . 54..L3•-s__ — ft. rt. .. �. _s^ r r v,� = , l:r
FaeiGly/Owner Name Facility IDN(if applicable) ft'.- .__ft Ceti' Jam:
Physical Address, a..�•. -y ss, and Zip "'•r- �
:'21?3REMAKK r
_ . �c15 GOn _ 7s;),5'S5'y. 89-_ .._Ve y.rq ..` __
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Canty Parcel Identification No.(PiN)
'-__ _--- _
Sb.Latitude nod Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification 1 T �^^
Orwell field,one tat/bng is sufficient)
, -5'3 /,2 , LJ 8 •__' N 9- d,Z.‘ U' '1 �' .�` „ ..et _G_..-..�-. ..—kJ
_ ^ __� Signature ofCcnificd Well Contractor Datc
6.Is(are)the well(s): 11111 rmaucnt or []Temporary
By signing this fonts, I hereby certify that the well(s)was(were)constructed in accordance.
with 15A NCAC 02C.0100 or 1.14 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: IJYes or 8Jd'Qo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature oJ•the
repair under 121 remarks.section or on the back 0-this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
I
8.Number of wells constructed: — constntction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the scone construction,you can
submit one form. SI111MI17AL iNSTUdTIONS
9.Total well depth below land surface: . •5.S ____,- _,- _�(ft.) 24a. ftor_; •All,Wells: Submit this form within 30 days of completion of well
Par multiple wells list all depths ifdifferent(example-3@200'and 2@100') conslrltction to the following:
10.Static water level below top of casing; v_� • - _,(ft.) Division of Water Resources,Information Processing Unit,
II water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"—_ (in.) 24b. For In'eetir n Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of ti)ii fora) within 30 days of compaction of well
12.Well construction method:___Rotary .•-^ �, -_ cettstntction to the following: ,
(i.e.auger,rotary,cable,direct push,etc.) _
Division of Water Resources,Underground Injection Control Program,
[OR'A Al 1 R SUPPLY WELLS ONLY: T_^ ._.__- nter
1636 Mail Service Cell*,Raleigh,NC 27699-1636
13a.Yield )m . Air lift 24c,For Water Supply&Injection,Wells:
(P>1 ) .3O•___ _-. Method of test:-._,-___-,_.-._-____•,_-__-__ Also submit one copy of this fort within 30 days of completion of
13b.Disinfection type: H $q H ___-_-T Amount:.1 2 oz•._ _ _ well construction to the county health department of the county where
__ ___. - T ------�.___._.._.__.._. constructed.
Revised August 2013
Rom OW-1 North Carolina Department of Environment and Natural Resources-•Division of Water Resources
Rom

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Qiotect ✓ U 5
`I �R, Macon County F30 16 ' Q "
o ,d Public Health
,� ' �� NEW WELL CONSTRUCTION
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CONSTRUCT ION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPIICANTIOWNER. Cullasaja,Fire and Rescue 0'_0"72---`-
--_.—___�.____.____ __.. LOG#. 030723 P OSWW# 022423 S
INTENDED USE. Single-Family Well Residential _ A 9.____..Y.._._c_....._.___._._.__...._...-----...--.--,__-- PID D # 15 2 5 5 5i8,9 5 ACREAGE -
I.LOCATION TBD EIli�ay.Rdr 0:6 miles past-Little_Ell�ay Rd on the R.
DIRECTIONS ...__.._..- - • . I
Highlands Rd to L on Ellijay -
Pemiit Conditions , Y
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as'applicable, including 100'rain from all septic system components.
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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 OE THE WELL IS PLACED INTO
SERVICE• PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. ESTI S? [phone]
Issue Date: '/412023 Josh Wilson, REHSI 3227 __., _______...___Authoiized State Agent