GW1--04286_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORll ---_------- --
This form can be used for single or cnultiple walls for Intctnsl Use ONLY: •
1,Well Contractor Information:-^� _
•
Mitchell Dean CookI. iAoty ESt � �yr.- ,t;;` r 4 :. . .s ;,:
.,
- FROM TO "DESCRIPTION "'-
Well Contractor Norse
ft. ft.
NC Well Contractor "" � ..-.._.__
ontractor Certification Number °'15'�0 7lN•Ri+(` s `r"'"' a ,
�,,.,,; .U,_(< •fbc(in'iu �1tY lie c.E)12:GIN .,`�>'",;'�'
fiiick�'." µe�' FI(i t[»"7f<:h)�1�:..,.: .�,;,::
FROM TO .( ., ..)r_ ;.; ---. .._-
Dennis Holland Well Drilling, Inc. DIAMETF:R 'T THICKNESSMATERIAI ^_-_
n. ft. in.
Company Nam m ��""Name -
('6,iROCW.(1.•;VA j(rt)1201).DA (g olli_e nlifi'lbr gl-i8 g,?i,•:r:r;`'.' ^;- •
FROM 'IO DIAMETER THICKNESS MATERIAL" .
2.Well Construction Permit#: laf 7„� Q _) ,ft, verj, . _- - _ ___._
List all applicable well permits(i.e.County,State, Variance,Inj;Uwn,etc.) ___-.._ '7 /
3.Well 67
3q+rt. . fb - _ ib .i _�` - F
Use(check well �c?U n
:ti'7 S:(RFi' ;.h:;; - - ;: t,;i .. :..--1:q.' -•-
S ewe ATERthl, `'i
lister PPIY WCi1: T • FRpM_ TO UTAnt'R_PER fiLnT.S1T•F, THICKNESS 11tAT{RIAL
°Agricultural f.7MunicipaVPublic ft, ft. in.
DGeothennal(Heating/Cooling Supply) &31tesidentiai Water Supply(single) ft. ft. in.' ^' "'
°industrial/Commercial LJResidontial Wate Supply(sturcd) iaE_ 0- :f, .. ':': R ,p.r a:r f:.,a.: ,n .Pp_:;a
•:i ,; .,-a7L
FROM _TO , _ MATERIAL . EMPLACEMENTMETIJOD,&AMOUNT°Irrlgallan
Non-Water Supply Well: �" /F , fr. T _fr.� ��p ,2
°Monitoring (°Recovery - �• ft- U' ft. ea2,,/ 14
/)�
Injection Well: -' - --•- �
ft. ft.
7Aq ifar Recharge
°Groundwater Remedintion 7.WS /•
Aar A Rif pifro g T: ' :=:";"`:j' ; ;-- 1 ;[`.;. ::.
FROM TO MATERIAL EMPLACEMENT°Aquifer Storage and Recovery Dal bity Barrier
,,,..
°Aquifer Test °Starntwater Drainage ---• - _
•
Lli..xperimentul Technology (]Subsidence Control ft. R.
!2(!vi Lt%N(l',g at Gdiit oa
iglieYn 4§ %-x `''vv
r�st*:;.; r:Ccothermal(Closed Loop) [.\\ acer FROM TO UFSCRIPJTbNAtolorLherdocu s(lUrockrype�greinsiu,c(c)"T•
°Geothermal(Heatin,/CoolingReturn) [°Other(explain under 421 Remarks) ft. It.
4:Date Well(s)Completed: —_ __.--,.,,_ - _ _ r _• ..... T
P .,.✓% -4W-;.�3Well 1D/l.-_�// �j
Sn.Well Location: - ..-__._.-_._._ __..._ __ �O`� _ _
/v.is ft. ft.
Facility/Owner Nmnc __•„_,_ __ - .L
Facility
lDN(ifapplicablc) - ----- ..-..--_-----.-- s=�-,:...F..�.^�;:;�c J'i;�?._..__.
ft. M ft. ~�tti`a"iFt�a� yt
if�l"Pia .6',- P.a?e Z..6, _.�... -._D4 WQI23OG__--._..-• _
and'Lip -' � - ft, ft
Physical Address,City, _
County Pared identification No.(PM) '
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field,ono let/long is sufficient) 22, C.ct It ttea on,
95'0:91.-_'a.,5• N &c' l, `0 7 ,' .__-.w ..2 -, Ae f, .._ 2:__I �f _
Signature ofCcnified Well Contractor Date
6.Is(are)the well(s): Eaklintauent or °Temporary
Dy signing this font', I hereby r6,fy that the well(s)was(were)ronstracred in accordance.
with I SA NCAC 02C.0100 or 1.54 NCAC 02C.0200 Well Construction Standards ond.rha a •
7.Is this a i•epait'to an existing well: °Yes or kr.3fTti copy()Phis record has been provided to the well owner.
If this is a repair,frli out known well construction information and explain the nature of the
repair tinder 12/remarks section or on the hack of 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
8.Number of wells constructed: _ _ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ON/,Y with the sane construction,you can
submit one form, SUIIMTTTAL INSTUCTIONS
9.Total well depth below land surface: .9• C> __ _,,�' �(ft,) 24a. Itar,-,•,;,,All Wellg: Submit this form within :10 days of completion of well
Parntuirip/e wells list all depots if different(example-.?@200'and 2®100')......'- construction to the following:
10.Static water level below top of casing: ..5 �__,(ft.) Division of Water Resources,information Processing Unit,
limner level is above easing,use"+'• -•--- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole.diameter:6N _ (itr.) 2411 For Injectjn Wells ONLY: lit addition to sending the form to the address in
ROtr7 24a above, also submit a copy of this form within 30 days-of completion of well
12.Well construction method: ry _ constntction to the following:
(i.e.auger,rotary,cable,direct pasts,ate.)
-'
_ • __ _ Division of Witter Resources,Underground Injection Control Program,
FOR WATER SIJPI'1,Y WELLS ONLY: _ _ - _ _ - 1636 Mail Service Center',Raleigh,NC 27699-1636
13a.Yield tin •_,• Air lift 24e.For Water Supply&Injection Wells:
(p, ) lq��,_-,-,_--,- Method of test:_Air
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: _� OL. well construction to the county healtii department of the county where
--- _ constructed.
Point OW-I North Carolina Department of Pitvirot utcnt and Natural Resources--Division of Water Resources Revised August 2011

Qt°LQ��
A•m Macon County
ti r d Public Health
°a • a'� NEW WELL CONSTRUCTION
• CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Juan Carlos Jimenez LOG# 101722-P OSWW# N/A
INTENDED USE Shared Well Residential PID #. 7513903523 ACREAGE 6.93
LOCATION Maple Breeze Ln
DIRECTIONS River RdLtake Lonto Maple Breeze Ln,First Left at a Gate
Permit Conditions 314 , 0
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well shall he a minimum of 100'from Animal Barn •
Diagram (Not to Scale)
• litre -
?co
Animal
Barn
•
>_100'
38: , >_100'
MI 4 .'' f ► 1F-eed
We•
ll Lot_!
aJ Aera 20'
20'
•
3
0
N
•
i U
i a)
i IL
a) - -
•
�
a)
i t3.
i O
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: 12/20L2022 JeremyPless, REHSI 3157 '�
��!�—_�:;�-�_ �uAuthorized State Agent