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Home My WebLink AboutGW1--00977_Well Construction - GW1_20240209 WELL CONSTRUCTION RECORD For Internal Uso ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: - _Mitchell Dean Cook >...1.4.1ATERZONES ! • . FROM TO DESCRIPTION • Well Contractor Name /'•4 'ft. .n'ft. • 2043 A !� ft. rE ft. I 1 NC Well Contractor Certification Number 15.-OUTER(ASING_(for multi-cased.'wells)'OWItINER<(Ifiap.licable).:•` . FROM TO DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. 0 ft. .7n ft. �' to PVC Company Name - 1.6:?INNERCASING OR TUBING;(geothermal{cioo-sed loop)':..; - .. . FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#:O//4,•2 4 •'/ fc ft i in. List all applicable well permits(i.e.County,State, Variance,Injection;etc.) ft. ft. in. 3.Well Use(check well use): 1.7.SGREEN v.. Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft ft• rn. (single) ft. ft. in. ❑Geothermal.(Heating/Cooling Supply) residential Water Supply ❑Industrial/Commercial °Residential Water Supply(shared) 18:GRoU C FROM • TO MATERIAL • EMPLACEMENT METHOD&AMOUNT ❑Irrigation ft. ft. r p Non-Water Supply Well: � .5 . /poi•'t%0.1,ae ..� --.rel y,$' 'le nSS'</ ❑Monitoring ❑Recovery ? .,- ft. 26 , ft. 0.o liej.1,,,,,,+' / 60 fo:4 9s,Adf Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation i.14:SAND/GRAVEI;'PACIc(f applicable),-. ' " . • FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. ❑AquiferTest ❑StormwaterDrainage ft. ft. ❑Experimental Technology ❑Subsidence Control 2.0 DRILLIll( IO.G;(attach;additionggheett•ifnecessary);-: ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) - • ❑Geothermal.(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. ft. ft. • 4.Date Well(s)Completed:121 Well ID# *-/,4, ft ft. i F t"e>--. !" " �� arm ' e 5a.Well Location: + //may ft. ft. ' r,."`p".,?LZ 01 t "�`Y el�/ 4 Ed -G Pt A n� '�1"%. . ft. ft. 1 t 3 O tF. 2024 Facility / caner Name • Facility ID#(if applicable) f. ft. 36 6t R�,sef. 4,'_ 4 ft. ft., i7S�LiA'm et'i!P,rn�ea.P�(!"� Physical Address,City,and Zip Dwed_ 3 06 .1e... °/,-4 rz4-274 774i3 ) County - Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: • (if well field,one lat/long is sufficient) 3.54' //, 2 ',44.,E N ,g ' .: 0 `/9e�." -w ;fig e .,r 'G o/-4'd-2d2 ' Signature of Certified Well Contractor ! Date 6.Is(are)the well(s): permanent or ❑Temporary By signing this form,I hereby cen fy that the well(s)was(were)constructed in accordance with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or 'I'4o copy of this record has been provided to the well owner. if this is a repass',fill our known well construction information and explain the nature of the repair under 01 remarks section or on the back of this form. 23.Site diagram or additional well details: You may use the hack 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 injection or non-water supply wells ONLY with the same construction,you can submit one form. SUBMITTAL INSTUCTIONS . , 9.Total well depth below land surface: X:6 4. ' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: 10.Static water level below top of casing:- Sa (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" (in.) 24b.For Infection Wells ONLY:!In addition to sending the form to the address in Rotary. 24a above, also submit a copy of:this form within 30 days of completion of well 12.Well construction method: construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 m t Air lift • 24c.For Water Supply&I jection Wells: 13a.Yield(gpm) /O a _ Method of test: _ Also submit one copy of this farm iwithin 30 days of completion of 13b.Disinfection type: H & H __ Amount: 12 oz. well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 C otec am Macon County 1830 Lakeside Dr EI' Public Health ( Franklin,NC28734 828)349-2490(Office) d (828)349-4136(Fax) WELL CONSTRUCTION AUTHORIZATION Owner Tracy and Ed Jansen WEL 011424-1 SEP On File Location 3661 Rose Creek Rd PID 6577477430 ACREAGE 2 Directions 3661 Rose Creek Rd Design Single-Family Well Permit Type New Construction Expiration Valid for 60 Months Well Driller Cert# - Shed ,c oqco / • / a.�c%, . !/ •\o / a a� / • o= Cu � ' / t..W% •/ as `u teol rlr ! s/, 0 50'MI O P [_� Ex. .,(Or nelt Dry Well • - - Diagram_not to scale_ _ ____ - _____ _ _ __ __ _ _-- __ -_ Permit Conditions 1) Well shall be constructed in compliance with all 15A NCAC 2C rules. 2) Maintain all minimum setbacks,were applicable. 3) When well and pump are completed,contact MCPH for inspection and water sample collection. The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking with appropriate governing, bodies in meeting their requirements.This permit is subject to revocation if the site plan,plat,site,or intended use changes.All rules in 15A NCAC 02C Well Construction-:: Standards are incorporated by reference into this document,including any subsequent amendments to those rules,and shall be adhered to.Please contact MCPH for inspection when well head and pump installation are completed and you are ready to apply for connection to power. Any person abandoning a well must submit to MCPH Form GW-30 upon completion. l; January 25, 2024 deliZ- f i/1, - Issue Date • Chaz Allen,REHSi 3258