GW1--06936_Well Construction - GW1_20231027

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W,I__ ______CONSTRUCTION RFC_(YRll -- -.- .
•flu-form can be used forsingle or multiple,wells for linen:41 Use ONLY:_ ��� -- "-
1.Well Contractor Information:
Mitchell Dean Cook -••'- -_ , . �_-_____ . --�_
^ ��1� r"-�-•"'- ._. - _ ~� ' :. t. L ;.. 17":y ^Y �
_FROM __T( _OFSCRI70NL_ "''•' "' -WetI Contractor
2043 A It...._ _ _•.___
Ni`,Well Contractor Certification N� G/+� rt. J .., ft.
Number l �...,,., .
()P.nfIIS Holland Well ,FROnr ,30 -=( ,s iErs...ls;�Y.() IICKN isfajstilMAT R�<:rr`sr>:i ,.^
Drilling, Inc.
I —.— ..__ DIAMF I'F:R ITIICKNESS MnA—hR1AI _^
Company Name __ _..� _— ___ �l file y� ti r' m .2_ /-vc
• - x116 1'NNrkRn_C;MtN(r,()li'1'-1:1}3ING' eo'Ihowm e`' m.
FROAt _To _ {R elFctoCKNE p)w_ [ A:`:;#'; •
2.Well Construction Permit tl: - DIAMF.TOR THICKNESS MATERIALList oil applicable well genius(i.e.Coun fit• fit• in.
County. Vm•ianro,/7 jerrion,ru:.J __,___-
3.Well Use(check well use): ft. ft. v ;rr. - -
k-iW
7.7
FROM_ _f0'�" .. ....a_:..,:.;:.
_ _ OIAMFTFII,I 340T.S1'!.R_ RIICKNFSS �tATtR1AL-
f_IAPriculnual CJMunieipal/Public �rt• 1 - file' in._ '
°Geothterinal(Heating/Cooling Supply) C1`dential Water Supply - rr,-` __ ._-ft._.__ _.. in.j '"- ^ ----
OSI I I Y(single)
❑Industrial/Cgmmueitll
("1Residential-Water Su ir18.?R)i!tg.'1
fff;;;L---)Ir'f•TI(ii1I1011 _ _ "—_ ) .—•FROM —_ _-_I'0_,_.. _____MATERIAL. _,RMPLACFMFNTMETIIO&MOUNT
Ivnn-Water Supply Well: -_._.--_-__.--..._...�._ __.__-...--__.-_- ,_`4' fit. r -file /rnn; XX J
G'C �G�-f tub -�711 si S 1.f/ -•C 9 UMonitoring HRu ovl;ry fl_ .-___-tr.
Injection Wel�l _'"' -� _.._.__-_- $ �_..�_ _ _ ' 1 z. -..:./V.%r �y .i'
ft.
(.]Aquifer Recharge • _ .
GlGroundwater Remcdiation 1;9rSAtNn/,5)0Eg _ t..._.:., ' 57.
[7Aquifor Storage and a Z.I=AGfC rf e t7 lib r':%`4: ' ` _ _._
g Recovery °Sal nity Barrier -FROM__ TO..•..-.. TE' �� ''MP �� i s:O7:i
_ h1ATERIAI. ,:~�''FMPLACF.AIENTMF.'I7ipD,�'
C1Aquifer'fesl ft. rt.
C:]Stormwater Drainage --- __ __ _ �_
Cif xpi rimwual'1'cthnolagy (:JSubsidencc Control ft. ft. T - - -- .
I.1 it atlte .....-
Rlla (Closed Loop) mccr O'.i.ill.Rlt 1..kli711;.6(C.:(etfii&tUdd•IIIIlij8N9I1Pe f 44,iiga• ll.17`.e •
F71a To DES(_RIP]_ION.coles.b ant atsnsoiVroek l e,grain e;ze�c.y.1_•0 eotherntal(1-leating/Coolin Rcturn). I:Other explain under#21 Remarks ft. ft. 1
ft. file r '
4.Oate.Well(s)Completed: (U--jn•-,2 3;: Well ID/I. ----- ft:"------- .._-_._..__._'.__..___-_.___-._.______._.._._.___..-____-.._
Se,Well Location:
ft. fit. i, ,,,..,' "� T _.. .4,- -
facility/Owner Name. -•�'��'�-•'��.�.'� _"'"-' -:-•—..._----- kl
a
Facility ID/I(if applicable) _.__..___...._...__ i__.._.__...__..� .. _
fit. ft. j• __...
3 A ..--_._.._ ...-_.___.. .,---_ ...
..�... ��fC.��'.� .J-yF�� ram. .--_ _ .__. '_...�___..._._.__.._-_.__------------__._._-•._
Physienl Address,City,and Zip
-' fL ;^^ ��G,- t t
��/,/(� / ;'.2IYi2F,ivIA)ZIE :; ?i err:: .. ..:, .
Coi ty __ __..___._._._____.... __�__,:_.�._.__ __.__-
Parcel Identification No.(PM) (
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degl ees: �� �� _ ^ -_�-..... ...... ._-
Orwell field,one lat/long is sutliir.icnt) 22.Certification:
•
_ �.... . - __.-______W �,/. .tom-, 14 7 _ ..._,_ ._ .m.:-43.: .-
�- Signature ofCcttified Well Contractor Date
6.is(are)the well(s): YaPfrmancnt or °Temporary
_ By signing ehis.form,I hereby certify that the wrll(.sL was(were)constructed in aecordattc•r.
with ISA NCAC'02C.0100 or 1.5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes. or ,I/JAfo---- • copy of this record has been provided to the well owner.
If lids is a repair,fill out A7101591 well construction affirmation and explain t1he nmun•e of due
repair under 11,2/remarks.section or on due hack u/•rhisform.
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: _ ___ _ consnurlion Details. You may also attach additional pagesif necessary.
Far multiple injection or non-water supply wells ONLY with the same construction•you can
submit one form. S_If.1M1'I•'_.... INSI'IICTIUNS
�._ - --�(ft.) 24a ,I)r_(1I] Wells: Submit this fiinn within aU days of completion of well
9.'fotal well depth below lanil surface: j ' ______
For multiple wells lien all depths if different(example-3@200'and 2@l00') construction to the following:
water level below top of easing:
10.Static. ••••_3 _ (ft.) Division of Water Resources,information Processing Unit,
//water level is above casing.use"i" 1617 Mail Service.Gender;Raleigh,NC 27699-1617
11.Borehole diamctcr: 2.4b. For nje.clionWells ONLY: lit addition to sending the form to the address in
. ___ . (in,)
24a above, also submit is copy-of this form within 30 days of completion of well
12.Well construction method: Rotary _� construction to the following: t•
(i.e.uugei;rotary.cable,direct push,etc.) �— ---._,___ .
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ____. -_ 1636 Mail Service Centler)Raleigh,NC 27699-1636
1311.Yield lm _._.- Air lift 24c,For Water Supper&IfjeeUou Wells:
(8{ ) / :.-- Method of lest: submit _ ..
`-'"""' Also one'copy of this foam'thin 30 clays of completion of
H & H
13b.Disinfection type:____. Amount:• �_2 OZ• well ructeduction.to the county health department of the county where
—____ ____. _ ____...__...__ _..-. - constructed. i,
1
I
Form OW-1 North Carolina Dawn of'Environment and Natural Rea w
sures--hivicinn of wp,It,•s„nn•ec a ,ds .r 111101107n i t
pa

•.. otect
a .B n, Macon County
E Public Health
od ��o
NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
`,APPLICANT/OWNER. James S. Raby :°LOG# , 080323-P OSWWN# N/A
INTENDED USE Single-Family Well, Residential .PID # 7514526408 ACREAGE 66.61
LOCATION TBD Perks Rd
?[)LRECTI,ON$s Take Highlands Rd to L onto Ellijay Rd to R onto Higdon Rd to R on Perks Rd (Then First gate on L)
Permit Conditions
Do not Cut Witness Tree until issuance of COC Permit.
Weil shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. -
Well may only be used for one Residential Connection
Diagram.(Not to Scale)
- - _ future -- - - --_ - _ _ - -- - - -
Septic
Area
•
Future House
L---r---r----
i
,
i
f
. i
fp0
Existing Old Rd `r ,
r`` + �7- Large Poplar
+ 35' + Witness Tree
_ _ + percni�e a +t
i ++ we,X20� --- , 6,
• (20`
i
N
i
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: 8/11/2023 Chaz Allen, REHS 3258, C I �r-- Iv v�.-� Authorized State Agent