GW1--05175_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORI) - -- ----- ----
This form can be used for single or multiple.wells For Went?!Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook _
• :FR wATFR rONFb
____'�_.• .___.__— __.___ _—._..._.. _ FROM _ '1'n .DESCRIPTION t«.:...�...._...
. _....
Well Contractor Name e^�� ft. ft—^ �����
2043 A 3i,'ft. / ,ft. • __ _
NC Well Contractor Certification Number .)i5 n,All GAS7N(,(formulthc8scd wef��),O I)INF (t[p'' i'llesib)e :+
FROM___. TO _ [DIAM FTFR_ TfltCKNESS MATERIAI
Dennis Holland Well Drilling, Inc.
ft ��3 , ft. l� „ in, ., �
__ _._. __ "),Z.
Company Name
�— 16 TNNEIt(sASiNG 01ZiTUDING(P,eottiertnal.cliised l6.op�
FROM T oT DIAMETER R___... THICKNESS MATERIAL
2,Well Construction Permit#: t i gg ) "� -----
d_ mil ,� . _ ft. ft. . in.
List all applicable well permits(i.e.County,State, Varitvrre,It je,ition,etc.) - ---.r _ — -- __. T_
ft ft in
3,Well Use(check well use): m _
�17 SCRSFNt. :._..r� . I J
Watet'Supply Well •------------_."—___._-._._. From Y Tn'---- ^V DIAat ETtR S[oT SIZF; THICKNESS•' MATERIAI
[_lAgrieulhural IDMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) fJi dcntial Water Supply(single) _ ft. rt. in.
f itdustrinl/Commercial [:!ResidentialWaterSum)I .Jig -11-al T.
Supply y(shirred) FROM TO MATERIAL w F•MP1 ACFME TMETHOD&AMOUNT
[.1lrrignllOtl _ __.__._.�T___._ _ fi. .,-�
Non-Water Supply Well: -_ _ —_ - 4_' '�-•---" ct:l/1ePe11/_ .-2 :._, •yc7 AL,-_-" `.
[:!Monitoring (7Recovery _...__ ^_ -_, h' ; ft. . �,.c, ./_� W ...�c"!� .:.4
Injection Well: ft• ft
t.7AquiferRecharge °GroundwaterRcmcdiation 19 SAND//G1tA 11:i 0K(ifer t Ij iih1e) t
°Aquifer Storage and Recovery °Salinity13arricr FROM _To______ MATERIAL EMPLACEMENT METHOD__
°Aquifer Test LiStormwater Drainage - --• - -- — _...—.-- .__
ft. ft
L°Experimental Technology °Subsidence Control _ T-
i':20.DRIliI#IN(r I(1(s(atfech'adldrtmonal sheets if ogee ssery) :,, ` __:
I.1Gcotherrnal(Clotted Loop) 1. rtucer FROM __TO _ _ DES(`RIPTION color hardne emUrock type,grain size,etc.
OGeothermal(Ileatin Cooling Return) [7Other(explain tattler62l Remarks) ft. —ft.
fr. ft.
4.Date Well(s)Completed:r3;:C'-0/_,2 Well IDH __f d.e4 .___— ..._.-----irr-----
__s__..__.—_._
—
Se.Well Location: _-___._ ___ .ft, ft, e rP '
Facility/Owner Name Facility lDU(if applicable) — _.._..__._, _AUG.1__$_2 3_____.__.
ft, rt.
4—. �e r✓� )rm)i. 4,e, .r4. %L > rL ft. n1lat� ��
Physical 4c dress,City,and Zip _ _ ?y21FRFM11iC'llK, :-• M-_^_ _w _• �__-• _—v �_ ..., —�-
Cory Parcel Identification No.(P/N) _
wSb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
Orwell field,one Iat/long is
sufficient) �> y y �j _r
� �5 �? r L'f. �e_... N r3J a�,,P , •✓���"^1�._ ._.__W ..,,,— .,�.t,.;-�-`r-J:c4 i 1.... 'µ 4- f `� r -�
��_�.•�'• Signature.ofC:crtified Well Contractor , Date
6.is(are)the well(s): fA1'crnranent or OTcmpo•aiy
By signing this jirrm, I hereby certify that the well(,) was(were)constructed in accordance
�� irirlr I.SA NCAC 02C:0100 or l•1A NC.4C 02C.0.200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or &No 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 of the
repair under tI21 remarks section or our the hack o/'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; 1 _ construction details. You may also attach additional pages if necessary.
For multiple injection or non-tvmer supply wells ONLY with the same construction,you can
submit one forum. SU13M1'17AI.INSTUCTIONS
9.Total well depth below laud surface: ti,e•5:_e______mm-_ (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of well
Far multiple wells limo!!depths if different(example-3®200'and 2@/00') construction to the following:
10.Static water level below top of casing:_... 74 ' �._ �_•(ft.) Division of Writer Resources,Information Processing Unit,
II writer level is above rasing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: S
Rotary (in.) 24b• hotIn(r.clion Wells ONLY: hi addition to sending the form to the address in
form 24a above, also submit a copy of this Co within 30 days of completion of well
12.Well construction method: __T� _ _ cunStnrution to the following:
•
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONI.,Y:^^ _ �— — ��^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield im Air lift 24c.For Water Su ply&.Injection Wells:
(g1 )___,; G�l._______ Method of test:________ —_ Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: H -.._—_-�• Amount:.�?C.•__._._._.___ .____ well construction to the county health deportment of the county where
_ .,.— _._._•___ . — __-__:.=w_ ..-_ constructed.
Revised August 20t3
Forms OW-1 North Carolina Department oflinvirounueut and Natural Resources.-Division of Water Resources

Qtote . may
may t 7
' Macon County NEW WELL CONSTRUC I ION
E ( Public Health .mot CONSTRUC.I ION AUTHORIZATION
°.d i 'ieyL.1 ) PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Jimmie H. Roberson LOG# 032121-P OSWW# 035521-S
INTENDED USE Single-Family Well Residential PID # 6562955894 ACREAGE 3.59
LOCATION Off Eagle Point Rd Lot 9, Eagle Point
DIRECTIONS 64W to L on West Old Murphy to Lon N.Jones Creek Rd.,to L on prd Farm Rd to L on Eagle Point Code 2.433 to lot 9 on right. _I
Permit Conditions
Well shall be constructed incompliance with all NCAC 2C Rules.
Mzilfltain minimum setbacks as applicable.
Diagram (Not to Scale)
Eagle Point
•
Iron Pipe III"1.'
p'O'O
Z$miCar eC
'Ed Dr .
Propos
House e. 100'
$ 1fip front
. an62%ter.
IePa
x N
� l3rr"l.5'
Fd gropes
1pe
9/P Ao� N
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: 4/23/2021 Charles Womack, RELi5 1300 .. ._._....__._Authorized State Agent
.. e