GW1--05174_Well Construction - GW1_20230818

WELL CONSTRUCTION REC'ORI) --
This Corm can be rued for single or multipleT wells - For Iutermil Use ONLY; ^�� ""'�"�
I.Well Contractor Information:
Mitchell Dean Cook . T —�
'`ird'I g.0.4 ES2; :i�,:.,y ';<•Sfi't'li: -�;-x, .,,::.:.7.;;r•...:
N'ellConh'acUrrNnmc —�_ _-- — __FRCcOM _ _TO_,A OHBCRIP170N f" s'a ...;'r:::^:
2043 A -__ _ _ .____—__.____._.__
NC Well Contractor Certification Number
'--_.mber BLS' ;IS r Ay )st(10...,— -
...�� �;'...:..11'{.f3(fgXiuiul�iiicti9et11;we r<Q rClilN��.'k'i(fi :;c�•';'-,.•..:::.....:.:
•I!Rom � To .1�.): :.�jlLfcablc);��; •..r.�;,.::�;
Dennis Holland Well Drilling, Inc. -— ft. �• — DIAMETER THICKNESS MATERIAL _^
Company Name
- _ d6� ft S i ro. 6 ��C
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ttlu�i)•(Ntli OMIllb OR09I)[NOS'(p�go•'I Mitltcl'oi'e4 1'oOp7) F .. .. t
2.Well Construction Permit r#: a FROM _ TO MAME.rER__ THICKNESS MATERiAL_._.—___,
List all applicable well pennhs(i.e.Coen 92_7_.,2-z S— (t. ft. io. — —
ry,,Sane, Vm•Iance,In jecsion.elc3— ----._.__-.__...._.._......._.__�-_--.......__,—..._.._....--
3.Well Use(check well use): ft. Ili.
{>fIl/5.(�iiiTN ,fir.; -- 74---i-,-.�:----;r,
Water Supply Well: _...__ _�_ _ x.._.... '-'._•,A' :.,,a,r; K;s+:.
FROM 1'o �'., ii.`r•r.•ICi,x;::-.-t�n..�,cr s`}:AFL_.
DIA�lFTER SLOT THICKNESS AtATF:RIA I^
ClAgriculhrral f_7MunicipaVPublic ft. ft_ in.
°Geothermal(Hcating/Cooling Supply) L'Plosidential Water Supply ft. ft. -'^in, - -"----'••-
Qindus c' pl Y(single)
Industrial/Commercial _
("1Residential.Waters's18iRO:IlI> ""'"supply shure<1 -,,J7 `,.: „a�- ,,.� ,; :�i�:': n!`>:,a;: ,:;r.>r:
0111i(lltti011 FROM _TO_meµ_,--M:TE : ,F,MPLACEMENTMETH0 R&AMOpl`r_
Non-Water Supply Well: _ ___ _ __..., _ t.
_._ ,pv7�'�cadl
_OMonitoring �3^fL �� ft. / '
CJRet overy - ohr —OC feis�,injection ell: — ecove ---- -_.-___ ___ • 'rL_.. ______R, -'� "_
f.7Aquifer.Re
charge c OGroundwater Remediation WATT fat. t. a.•. ;4 „,--?7!. :
• C°Aquifer Storage and RecoveryFROM ..A
FIf;.P l:C?l. ef.p ll a Iy %;s: . :^i `:; , r::,,
t_)Stfllllity I3atrirf --•-- .-_...._.._.._ MArEFifAI. EMPLACEh1ENTMF,'I7icD�'•-_
CJAgtrifer'fesl ft. ft._
ElStorntwater Drainage . _ ___ -
TechnologyC113xperimenfulft, ft. '--"
°Subsidence Control
C°Geotller»al Closed Loop) 20 1)RiI siMiSlh<i'(s?nits'c8`itiddiliunals hecfs'"if'else' mm" -" "
racer
FROM• T(.> _ nE,S(:RiPT1ON colors canthem,soiVrock Iyfwagrain size,etc.) V
OGemthernaEHeatil Coolin8Return) I:JOther Cox>lain under ti21 Remarks ft. ft.
4.Date Well(s)Completed:o ft. ft.
�'/O �-?Well 1PH -/ �_. _ _ ,r.:__ " � °�_.__
Sa.Well Location: __tr. _ft.-
/ ___ Q I I �QT L _...-____.._...--
Faeilily/OsntcrName Facility 11)11(if applicable) ___..._-- _._-•.--__.r.._.__..._-._. -....-_---.�.. ...-----•_-
rt. rt. inform-Win?rrscs®aing f lnf
Physical Address,City,and Zip —��'_'_" —
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C,eutty Parcel identification No.(Pict) _ —' _ __ ._ ...�. _._— ___ _
Sb.l atitude and Longitude)n degrees/minutes/seconds or decimal degrees: - _ - - --'� _-___ --__.----
(if well field,one let/long is sonnirient) 22, .et(I icattou:
' • ", N- �3's,..
.3J�_� ...� _ os
Signature ufCertified Well Contractor Date
6.Is(are)the well(s): .t )anent or []Temporary
By signing this form,I hereby certibi that the well(s)was(were)constructed in accordance
with I.SA NCAC 02C.0100 or 1.5,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or LZFPdo copy of this record has been provided to the well owner.
If this is a repair,fill out mmown well construction information and explain the nature of the .
repair underll2/remarks.section oron the back o/'this fonn. • 23,Sitediagramoradditionalwelldetails:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: _____ crntshucliun details. You stay also attach additional pages if necessary.
For multiple infection or non-water supply we/is ONLY with the same carstruction,you can
submit one form. SL173ML'1"fAL INSTUC:'i'IONS
9.'I'otal well depth below land surface:"ICJ_-$-M _ ..(ft.). 24n, [iorWll Wells: Submit this form within 30 days of completion of well
Fo•multiple wells list aldepths ifdifferou(example-3(rr1200'and 2@I00') �� construction to the following:
10.Static water level below rep of casing:� � (ft.)
Division of Water Resources,Information Processing Unit,
I waterlevelisabovecasing,use".i." ' 1617 Mail Service.Center,Raleigh,NC27699-1617
11.Borehole.diameter: ttr, 24b, Forrllnje. tr n We11s ONLY: In addition to sendingthe form to the address in
Rota► 24aabove, also submit a copy of this•form within 30 days of completion of well
12.Well construction method:_ y_ ___�_ _ - construction to the following:
(i.e.Huger,rotary,cable,direct push,etc.) ��-"_
— Division of Water Resources, nderground Injection Control Fragrant,
FOR WATER SUPPLY WELLS ONLY:•
1636 Mail Service Center,U Raleigh,NC 27699-1636
13n.Yield )nl _•_ Air lift
24c,For Water Supper&Injection Wells:
(gl ) 3.__._,.-_____. Method of test: .-_ __ _ _ •--- -
H & H r - Also submit one copy of this form within 30 clays of completion of
13b.Disinfection type:_-__ Amount:,1 2 OZ• well construction to the county health'department of the county where
a -
I:om1 OW-1 North Carolina Denartmont orIi,ivirnoment and Natural 12rcnuran.r._Division of Wnrrr Rasnunas Revised Auvust 2011

ote
ate, Macon County
s d Public Health � � ��
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NEW.WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Otto Bundy LOG# 091722-S OSWW-A 120322-P _
INTENDED USE Single-Family Well, Residential PID # 6587396324 ACREAGE 2.21
LOCATION :-6890 Bryson City Rd, Franklin NC 28734
DIRECTIONS 6890 Bryson City Rd, Franklin NC 28734 ~V
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as'applicable, including 100'minimum from all septic components. •
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• - Diagram (Not to Scale)
Bryson City Rd - --�
i`e 1 Gate
ose°a
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inoo qp,• 120'
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Lp0 40 a t4.
cn
35'
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Qp S
-air I%S�Q
a~ea:h' Proposed 2 BDRM
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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 OR THE WELL,IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone] •
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Issue Date: 12/19/2022 Jeremy Pless, REHSI.3157 -`_.Authorizec/StateAgent
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