GW1--06940_Well Construction - GW1_20231027

•
W.I L' Cn�RUCTI_0_N ItECO___RI)
this Enna can be used for sing___
ingles c or ndliplr.wells - L or a.ruTI Use ONLY:I.Well Contractor Information: i
Mitchell Dean Cook :ad•waTFR<'. IYE rs---- :-s= .,__.__.��.•'-'._.
Well Contractor ..TO 1.._ r.c::{„1:ilii5 i':`%;N.lk ...... �,......_--..rNamc • FROM �pFSCItIPT70N
fig _ f / _____--
NI.Well Contractor otCertification Number 5`n.ATIWAVRT
„ru ulli.4W0-=lUs1
UIrN ff;-iR e1>_: '
Dennis Holland Well Drilling, Inc. _FROM :TO
_DIAM_E7'F[i _ CfIICKNESS hfATERLA4
Company Name - - - _ ____ _.-___ ft.
_ft. in. __.. ._...
.1;6t'11�N1t):C A,Ryf' j
rtini!"97G(kgotliee6iirt ei1z15o 7-' _
FROM 1'0 K .,�,= ":,.
2.Well Construction Permit N: 6T_` •. +� ,,v �. ._ DIAMETER _211ICKNESS MATERIAL
List all applicable well permits(i.e.County.State, Vnrianu:e.Injection,etc. _ il's • ft. y » . is __.__
3.Well Use(check well use): • •
t� • ft. , ft. ��,,,, -'r►✓ — `
-Vi
ater SlSupply Wcll: __ ., _.—_ s ::,_.,,�:zL TUIC'::::-s ti;;; -MAT R?.0
FROM_ To 2:'.•'..-a`.°= oc:SI is;j Yl'I•?-Kii•=•... :.:.A>r! y..,IAL.
_ DIAMETER I'...SLOT SIlE 'R11(:KNE55 AtATtiR1A l:�
ClAgricultural f_7MunicipaVPublic. fr• ft. io.1
ClOcothermal(Heating/cooling Supply) CaResidential Water Supply(single) ft. It. __._-.._.in,
❑Industrial/Commercial
(JResidential-Wai>l'8; 13-01T 4. _
ter Supply)I (shared) _..
I Y __I
I.1Irrigotion FROM . Tpt"
...._ _,.___..__.. .•. MATERfAI ��F.MPhACF_MFIYTMt;Ti14p&AAIOUK/'-
Nnu-Water Supply Well: -_• ft. ^"ft.
(:1Monitoring [Mt:covery rt. ft.
llljecctionWell: -_..__-....__.._ ____.....-_-..-._._.__.............. .___,_-ft. .___-._.-ft.. ___._-..__.._-_r__-_-_-______-_.._.�_-....____.___._
(.7Aquifer Recharge
(iGroundwater Remediation .114;0'.. .N70.51; gil ,i ffr :777
::,�_ ;Z�._..,�?. ifea'' lie:. .,<.�:?.ti; - -
OAquifer Storage and Recover eftOM___TO MATE h:ti._ a 'r 'a�, _.
Y f_7Sulbtity 13azrit:r __ . . _MATERIAL. - EMPLACE/LIENTMF.TIIO01)�
UAquifer Test ft. -ft. .
C1StorntwaterDtainage -._-- _-__—_.-T-------•-
f_'1Gxperimental'feclu)olo ft. ft. i `-'
Technology L)Subsidence Control
Ll Geothermal
(Chased Loop) flI ICtf ;20iI)RL__•'_I.._...r I< v_(aic'?tiJd)tron a191iecaiffnr�e9sery) _ —'_rma TO DF.,SCRIPTIO N1 colo_ bartioe il/ro 71r&rain sin c_k_lI:Gotherma_(Hc t_n!TDoling Return) a Qther(explain under N21 Remarks) ft. n.
• ft. ft. I
4.Date Well(s)Completed: J4-I.•2 Well IDN / -- ._-_._..__._._
Sa.Well Location;
Oki -4-w%r r riftc9.444.5 - - ft. _ .ftn».¢�,;f•^ rsj f1T;,
_ _ _
Facility/Owner Name __ _.. _..__._ 1...
Facility IDN(if applicable) .._._—,._..._.....-_•--�.._._.___..___
Physical Address.City,and Zip ft` Ifh`0 ��* 7 1; Csr+:L,a r
�s - '.Zt lit]'M,AAtg. r 9.V..>•v' f,,r\'f --°i-�.1.a1.._..
•
�"r "ij'� ` ._.._...,�� ._........ • _....._....._..._...a_ ram,t'l,� a�+�'.!.` �._.__..
Coaaty _ ------. -._.-y.._
Parcel Identification No.(i'RJ) / �' - J e. i--_-_"
.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one tat/long is sufficient) 22.Certification:
..?..S-__?-4 i ,f N. ep-,..---',,R ,' w 2
I y i s -- -=
Signature.of-Certified Well Contractor Date
6.Is(are)(lie well(s): fi Permancnt or °Tempot'ary
- - By signing this four,I hereby certify that the-well(s)-was(were)•con.rtnrcled in ncrvrdma•r.
with/.fA NCAC 01C.0I00 or LSA NCAC 07.('.0200 Welt Construction Standards and that a
7,Is this a repair to Au existing well: 0Yes or EINO` 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 oldie
repair under 1121 reworks.section or on the hack of thi.r•fonn. 23.Site diagram Or ndditimilal well details:
You may use the back of this page to provide additional well site details or well
$.Number of wells constructed: conshiuclion derails. You luny also attach additional pages if necessary.
For rnuhiple injection or non-realer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INS'1'l1C PIONS
9.Total well depth below land surface.: P $e___-____-_____ __•_�(ft.) 24n ,File_AU Wells: Submit this fixin 'within aU days of completion of well
Pin mntriap/e we/s list all depths if different(example.3@200'and 7.®100') - construction to the following:
10.Static water level below top of casing:_ _ - ... __ (ft.)
Division of Water Resources,Juformation Processing Unit,
//wrner level is above easing.use"•i•" 1617 Mail Service Center,Raleigh,NC 2')699-1617
11.Borehole.diameter:_6 .. -__.__- (in.) 24 b, FnhInjectionWells ONLY: In addition to sending the form to the address in
Ronal Y 24a above:, also submit a copy of this ifurm within 30 clays of completion of well
12.Well construction method:_ -` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
._ _ _•
_ __ Division of Water Resources,Uuderj;roun(l Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: -- - ^� 1636 Mail Service Center',Raleigh,NC 27699-1636
• Air lift 24c.For Water_Supply&Injection Wells:
13n.Yield(gpm)_.._s'f'�._-,. __.____. Method of test: ---
"�" " Also submit one copy of this form within 30 (lays of completion of
13b.Disinfection type:_H H well construction.to the county health department of the county where
Amount`._1?_ oz.
••-----...__. �_._._._......__._..._.__...._ constructed.
Fans CiW•I North('ernlinn Ilnnarim,:nt ifI(n n virnmm�l and Nnnuol Recoun:cs•-Division of WulffResnun. Revised Auousi 2017
rs

•1 r (:ate :
5 0
JACKSON -777I5777
n•WW��rfmoal of
Tu411e HrPilh
The Jackson County Department of Public Health
538 Scotts Creek Rd.Suite 100 * Sylva, NC 28779
Tel: [phone] * FAX: [phone]
• Shelley Carraway
DIRECTOR
Shelley Carraway
Well Permit
Reference Number: Permit Number: 2022-22690-9-13092
PIN: 7611-70-9165 Application Date: 7/20/2023
Owner: WATTERS,THOMAS M TRUSTEE City: ST PETERSBURG FL
Address: 1361 SHELL ISLE BLVD NE Zip Code: 33704
Lot Number:_ __ LT2 REV FOREST RUN _
Service Type: Well Permit Bedrooms:
Directions To Site: Barkers Creek Rd to left on Rockdale Rd. to left on Forest Run Rd.
•
Well Depth:
Case Depth:
Grout:
Yield:
Contractor:
Driller:
Well Type: Drilled •
Well Size: 6 Inch
Stay 25' from any building perimeter. Stay 25' from creek, stream or river. Stay within property lines. Well
for single family residence,stay maximum feasible distance from any part of septic system or repair area, in
no case shall it he less than 50'. Stay out of power line right of way. Stay out of any road right of way.
Attached drawing not to scale.
THIS PERMIT EXPIRES ON 7/24/28.
APPROVAL OF THIS WELL APPLIES ONLY TO THE CONSTRUCTION AND LOCATION OF THE WELL. THIS
Remarks: DOCUMENT DOES NOT GUARANTEE YIELD OF WELL OR POTABILITY OF WATER. ATTACHED WITH YOUR WELL
PERMIT IS A SCREENING-REP_ORT_WHICH-SHOWS ANY KNOWN SOURCE OF RELEASE OF CONTAMINATION
THAT IS LOCATED WITHIN A 1000 FT RADIUS OF YOUR PROPOSED WELL SITE. THIS IS A GENERAL - —
LOCATION WHICH ONLY INCLUDES SITES THAT ARE IN DEQ'S SITE INVENTORIES, AND IN NO WAY
REPRESENTS THE EXTENT OF THE SITES KNOWN OR SUSPECTED CONTAMINATION. THERE MAY BE OTHER
SITES THAT ARE NOT COVERED BY DEQ'S AUTHORITY THAT COUNTY HEALTH DEPARTMENTS WILL WANT TO
CONSIDER. DIRECT ANY QUESTIONS TO YOUR LOCAL COUNTY ENVIRONMENTAL HEALTH SPECIALIST
REGARDING SPECIFIC KNOWN RELEASES OR ANY FURTHER WATER SAMPLING THAT MAY BE
RECOMMENDED.
Fee: $320.001 1 ry Receipt:
�� - u
EHS: 1171m641Ae 2 ii q II Issue Date: 74 (/z 3
EHS: Approval Date:
Signature: Date: