GW1--00978_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
Mitchell Dean Cook 14i:W.ATERZOl S.,. •- + '. '
FROM TO DESCRIPTION
Well Contractor Name `,� 611L4 3.?J-i ft
2043 A ft. ft. I
NC Well Contractor Certification Number :15.OUTER_CASING;(for.mititi-cased wells)ORsi 1NER(iliot libable): . .
FROM TO DIAMETER THICKNESS l MATERIAL
Dennis Holland Well Drilling, Inc. ft. ft. .r fin. I
I,
Company Name 36:INNER GASINGOR3�UBING(eethBrmal:elosed Ieop);..' . ":. • ..
1 DJ�a 3' p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: //ll ' ft [t �� in
List all applicable well permits(i.e.County,State,Variance,injection,eta) Q ri m ��
ft. ft. in.
3.Well Use(check well use): 17.SCREEN .. : - • w .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mu nicipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply ft. ft. in,
(Fi g1 g pp y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) r18::GROUT•
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation • �ft. . ft �r
Non-Water Supply Well: d �iy71`4°°•°Ga" .Z - _`" D es"'-"/1
❑Monitoring ❑Recovery ,,s, t fa 243 i ft. L2,,,x�ri `v /D12-z�,l'h1
Injection Well: _ - -- _. ft. _ ft. - -
❑AquiferRecharge - t7GroundwaterRemediation ,19.SAND/GRAVEL.PACl (ifapplicable)... . _ . _`.'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Starmwater Drainage - -
ft. ft.
❑Experimental Technology ❑Subsidence Control• 1
20.DRILLING IAG(attaefi<.sifditienaisheets.if lecessary) . -
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
• ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft, ft.
• ft. ft.
4.Date Well(s)Completed:0/z2.3 1:24'Well ID#
ft. ft y. lam"'e"'a 'o �^
• 5a.Well Location: ft. . ft. . '.-r.- .,IL+i v
J 4 3. 1 ) Cie. -2j Ll.- ft. - ft. h td tl1 024
Facility/Owner Name Facility IDli(if applicable) 2 - Y.
c.7 G ft. ft.
(�
a O ,40 1'fr/l, i r J,L?q - k7 Q4' ft. . ft. j ►f1f;ilKL'Lci:if P,u'..::+.:,y:Ur3.
SOG
Physical Address,City,and Zip j �J��1/ �!J�( 21.REMARKS � �� `
�4! 2
/A a 4e7n ((/
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) •
W / �'',,�
�e�� oZ,�•J�.•Igf yN :�'��03 /,� 'T�4`-'� el r.-23,-'-?..•-;,L
Si elute of Certified Well Contractor .. Date
6.Is(arc)the well(s): manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
_� with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to.an existing well: ❑Yes or ��S1Vo copy of this record has fieen provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .5-r (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:
I
10.Static water level below top of casing: 7e (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 Injection Wells ONLY:; In addition to sending the form to the address in
Rota 24a above, also submit a copy di this form within 30 days of completion of well
12.Well construction method: ry 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 _Air lift • 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) /a • Method of test:_
Also submit one copy of this form 1 within 30 days of completion of
13b.Disinfection type: H & H Amount: 1 2 OZ.' _ well construction to the county hl alth department of the county where
constructed.
. I
Form GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013

Qiote,i,
w to Macon County
o
s Public Health NEW WELL CONSTRUCTION
°•a , el CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANTIOWNER Clear Sky LLC C/O Keith Jones LOG# 101223-P OSWW# 101123-S
INTENDED USE Single-Family Well, Residential PID # 6586666088 ACREAGE 0,79
LOCATION Lot 12 Country View Farms r Location
DIRECTIONS Take 28 N to L onto Clear Sky Drive property is at the beginning on the R
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 25'from building perimeters and 50'minimum from septic system components.
(Not to Scale)
• - N
4. 11 C26q 967 •ji4) P*'.•
•//8,
ii8,:ligtram,
Alit'
Ii-'8,
f S
TA .. �ry \al
S/T
i, w-°00 ..._,�s ._,, '00 ` 5'Min IP
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- %r„° .r aai 27' , •
IP
t a Y a.' a v
: .
,rU ;•,:4.;s...• • , co N 'roposed
:f r -
�,`•V:t 14 3 :edroom
'z' 100' aI-
ui
N
\iS.1I 28'(25'Min.) J.
�1 61' ~Ssrso. � i'
Box 141- ?,a• 45'
— - -, --- l-1 I _
•
•
4430„0 1,9,
Permitted r"�it
Well Area IP
(15'x 12')
101223-P)
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]
i
Issue Date: 10/23/2023 Jonathan Fouts, REHS 1979 4uthorized State Agent