GW1--01258_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 14.WAT:ER`J.ONLS ._. • I
FROM TO DESCRIPTION
Well Contractor Name . 3sJ77`ft* 3'$j r it
2043 A . 75,'•ft. ?,.5.,:,ft. I
NC Well Contractor Certification Number 15.:OUTER CASING(for multi cased wells)°OR LINER'(if applicable) •
FROM TO DIAMETER! THICKNESS MATERIAL
Dennis-Holland Well Drilling, Inc. a ` ft. •,2.5' ft. 6• icr 'in. S/,.P-.2/ P V'
Company Name 16 INNER:CASING ORTUBINC`Oeothermalclosed-loop)i.
FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: 0/0 / a a -/47 ft. f. I in.
List all•applicable well permits(i.e.County,State,Variance,injection,etc.) ft ft. in.
3.Well Use(check well use): a7.'SGREEN w _
Water Supply Well: FROM 'ro DIAMETER I .SLOT SIZE THICKNESS MATERIAL
❑Agricultural °Municipal/Public ft. ft. in.l •
❑Geothermal(Heating/Cooling Supply) 7R'sidential Water Supply(single) ft. ft. in.
I_
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:GROUT. . ., 1 : •
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation "
, ft. s ft. rr, _ /n
Gr 3' /1�..•7,47.,,.�, .2 4v ✓ /a,.s.y/li
Non-Water Supply Well: , ft. , ft.
❑Monitoring• ❑Recovery -5 ..BLS /.rs, ,;,,,, .1- ..2 - 4 A.•-•,-,f-x/
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ."19:SAND/GRAVEL PACK(if,'applcable) ..'.' ..: :'•7-,,, . .' • ..
1 FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier • ft. ft. I;
❑Aquifer Test °Stormwater Drainage
ft. ft. I
°Experimental Technology ❑Subsidence Control
20:DRILLING''OG`(attach-additional shects:ifnecessary)', - •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock typet3rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 4,4,-O.`;-24+W ell ID# A/•A. i
'ft. ft. ,.,. ,n ya,r, ;:•.....Sa.Well Iocatinn: ft. ft. bd. D
C ISM�11....f. V 7—
)
1J;/2 fr,r? )7,-/ c.:Gl m,=1d- • tliil ,-.)..•,), .1 --S ft. ft. FEB 2 9 2024
Facility/Owner Name Facility IDII(if applicable)
ft. � ft.
ft. ft. ifR'flrlR'ii:'it; fn ..+vca m:4
Uta
Physical Address,City,and Zip 2t:REMARKS ! �Ql
/JA rx,..<t., 7•5 5z //l, J•sS ? .
County Parcel Identification No.(PIN) 1 '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if welll field,one llatflong is sufficient) -
-4_T t 6(q 3 tt N 0-06-4-0 w /,�:.ei 'Ep 4-.e' 1t1r 1..' ,,.2. 6..`.5.--...41.--1-,e04
Signature of Certified Well Contractor ), ' Date
6.is(arc)the well(s): file re manent or ElTemporary By signing this form,i hereby cert fy that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ,No copy of this record has been provided to the well owner. -
•
If this is a repair,fill out known well construction injarmation and explain the nature of the -
repair under H21 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: &- 'S i (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 rr 200'and 2@100') construction to the following: I ,
.10.Static water level below top of casing: 3' (ft.) Division of Water Resoui.ces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ceniter,Raleigh,NC 27699-1617
6"11.Borehole diameter: (in.) 24b.For Infection Wells ONLY: in addition to sending the font to the address in
24a above, also submit a copy of th+is'form within 30 days of completion of well
12.Well construction method: Rotary 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
Air lift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) • _!_ Method of test:_____ •-- Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type:-1-1 & M_. __ Amount: 12 az• well construction to the county health department of the county where
— constructed.
Form C1W_I North Carolina Department of Environment and Natural Resources•-Division of Water Resources urces Revised August 2013
t

NA,��L L 1-
<otc!
:. =.: NEW WELL CONSTRUCTION:
- nt Mcan Cou:niy
I.o" ' CONSTRUCTION AUTHORIZATION
-
d P:ublrc He I:Ch
o, ,o • PRNATE DRINKING:WATER WELL
APPLICANTJOWNER .�..►i�\d4:•, o. C' ,:„�. •. i��•,k C�. oe S W# oip:,2.. S
LOG OSW
INTENDED USE :::$t�1. �t- r..t1IrJ t-tl. Le�-�tti
P I D # (� ACREAGE �j i A'
LOCATION S.. i fink_ ('r:e►4 4-h'�L. ' :i.l G 2 y/
•
Permit Cond►tons
We11 shall Cie constructed.in compliance with alt NCAC 2C.Rules
Maintain minimum::setbacks as.applicable
Dia ram Not to Scale
.. •.. ,,,�ovf'r+i <va,.x1 �o SL e
o eke N
. f
•
-This: ermit:Is valid.for.a eriod of five y ars except that it,.may be revoked at`any time IF rt is determined that there.has been a;material,change in any fact.or
"circ msttance u on which the. .' _. sissued...Viieii location.installation,.and:protection must meet state,regulations.The well shall be':inspectedrand approved by Macon County
:::-::;:.•i:..•:.,...•..........:...!..........f:..:'•:
.Public Health',before i.t is put.tnto'use. Thelocatlon o.the weh indicatedliy MCFH Is.to'provide protection from possible• '....sof cant ruination :Flow volume(well yie.. NoT.
.•.;
..::--..:-:•.:..::.-::..:.•.-.-..;.::1•.-::...!:..-.:.':-"-..•-:.....-....•..:.1.:;-...-.--.-..::..-.......:......'...,..:.....:....'.::...-'.:-.:.•.-:....:....-:.....,:.,:.:...........y..-...".......,1......-...,-
:.guaranteed at any.site by MCPH
A:WELLHEAD COMPLEfION'INSPECTION'MUST BE:APPROVED BEFORE;FINAL POWER IS:GRANTED;QP THE WELL:IS PLACED INTO
SERVICE PLEASE SCHEDULE: '.WELLHE AD INSPECTION AFTER PUMP INSTALLATION QUESTIONS?(828)3 9,2490:'
. Issue Date ::Z.
i g Z Z s Authorized State Agent
r