GW1--05177_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD •
'this form can be used for single or multiple wells For Intent al Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook aarw snE' t riEss;: >:; ,; <:;;.,;:,; :!..o.
. —FROM " TO' :� ?,:�:: :,,r., >s'..�...._r r;= sr `:i
DESCRIPTION
Well Contractor Name -
2043 A " �Q ft. 171 . ft.
rt. ft.
NC Well Contractor Cenification + 'r 'tcation Number �!.$:rOU',7!N;Ri`CsASYN.G�k�fgx.mu7ii�,casFd)we1>e:?Y.(11ZtIdNEggrp'`, I461'e tVA'01? .��T
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. ft.
Company Name
II'7k of)ierinahaavi:dz3oop`')'Wfl4 =,Mg.
FROM TOT DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: el 7 a.2 ,• -P
List all applicable well permits(i.e.County,State,Parlance,injection,etc.J -_��_.___-' -__..�.: f t, 2 .. �ii . la. .Sa?a) PI'G '`f,/
(" ), , ft. 1/1,P'ft. in. �g s- / / y6
3.Well Use check well use " m
Water Supply Well: ...
:':;.: ,•_.,,•: .,:, ::c:.,::
•.-FROM �TO: DIAMETER SLOT SIZE THICKNESS MATERIAL.<•
ElAgricultural f_7MunicipaVPublic ft. fi7 in, -
°Geothennal(Heating/Cooling Supply) DResidential Water Supply(single) ft. -'ft. . io.M
°Industrial/Commercial � Supplys"8` 't_%'.'T?J • :,:
3'1.$,-ty...��i ;»i. ;;,fix,
�H'Zesldential Water shored .• -...... ��: ��=`£'scii;, ,r;; :,z„�;:•
(shared) FROM TO __ 'MATERIAL. EMPLACEMENT METHOIT&AMOUNTT
Oirri_ration
Non-Water Supply Well: . -
__Q • ft. ? r ft. /2��fQNgl 2_ Ad"�i, _,
CJMonitoring ORecovery 'ft: ,, ' ft. ©�' � ` , �y-."A
Injection Well: "� j
tL ft.
•
(,7Aquifer Recharge 0JGroundwater Re _<mediation �<•9%�ANI��i�A�ETs?RAG`Ki`itie' •�c"b•�i~ :.{<
• DAquifer Storage and Recovery __ ( PEu a 15:::.% : >^ MPL` E T` `THOD
i7Sulbtity 13arrier FROM TO MATERIAL EMPLACEAtENTME'THODJ '
ft• ft•
DAquifer Test DStorntwater Drainage
DExperimental Technolo ft ft.
gY C]Subsidetue Control •
20.illR11 :1001lhZs?alfneli`t�ld o alb" •,: lt...
°Geothermal(Closed Loop) 0Tracer d ,." . ( CRI ON iciilol,`ardnas,se•" :`:r;'•;:.,.• .size, tc.) .
FROM TO __DESCRIPTION(tolor�hardneu soitlrotk type,grain size,eat.)
, °Geothermal(I•Ieating/Cooling Return) GOther(explain under#21 Remarks) ft. It. •
4.Date Well(s)Completed: o 5,—Q 3Well ID// 67 SJ 3a.12 S - _- ___ •
ft. ft,
Sa.Well Location: ••---•- --__ _ _ � ._•__
_ft. ft. r
• Facility/OwnerNatoc Facility ITV(if applicable) ---_ --•-• _, _ _� ____.._ tnir
Physical Address, y p
Y 5a,(it,road Z.i ir'k+ri#'i0;Z:r1 [,cf !t�>a n.n 1 t a
Ph
•
Art -t c,a h 73 G , t 9 a,53' .2. r ' l -
County S t __. _ _
Parcel Identification No.(PIN)
Sb.Latitude end Longitude In degrees/minutes/seconds or decimal degrees: _ __
22.Certification:
(if well field,ono tat/long is sufficient) J
19 ram _,` N � 1�C��' W '''f —''�2. n•P"c2._ -20a 3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): manent or DTemporaty '
By signing this form, I hereby redly that the wells)was(were)constructed M accordance
with ISA NCAC 02C.0100'or i.SA NCAC 02C'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or Lst . 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/121 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. SIA3MITTAI,INSTUCTIONS '
9.Total well depth below land surface: 1,9©_ (ft,) 24a. hor All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3@a 200'and 2®100') construction to the following:
10.Static water level below top of casing: ' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" - On. 24b, For Injectt�t n Wells ONLY: In.addition to sending the form to the address in
Rota 24a above, also submit a copy of this foal within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield* m �' Air lift 24c.For Water.Supply&Injection Wells:
(gP )__ D__�-_• Method of test:_________ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount:, Off• well construction to the county health department of the county where
"� " ` -__, constructed.
Fort GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013

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.Q otect �``
• d m Macon County
7� Do�.,l'f(ten'
c ——`,'._.. NEW WELL CONSTRUCTION
�° r ,� Public Health � CONSTRUCTION AUTHORIZATION
.d a' PRIVATE DRINKING WATER WELL
tYtv1.c ` f'—
APPLICANT/GINNER Airmcknoliq Ong,p eM LOG# o-DZ.tt...p OS1NW.toieSat-s"
INTENDED USE Skc,<<!+ wL‘l PID # Sd8 tti4s3c.- ACREAGE
° AtLOCATION
M.�a Ci.,..tL Q.,N —�--
DIRECTIONS i't ;ewe{- 4,0 clop {1.4zq __C.4k‘) Zed
Permit Conditions 3�'Ok 4..V..iM t O bo I\4.-4 fte. , •.
Well shall be constructed in compliance with all NCAC 2C Rules. ik ,,t.,,IN S^b' ( en ( l srt�e.e.
Maintain minimum setbacks as applicable, 1� r �s r t`'°'"� `tt°
w 4i*-r.
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Diagram(Not to Scale)
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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 Qa THE WELL IS PLACED,4NTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP IN ALLATION. QUESTIONS?[phone] ,A;'
a
Issue Date: I 6 !?a Z'Z tithorizect Sr.te Agent
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