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Home My WebLink AboutGW1--01390_Well Construction - GW1_20240304 • • WELL CONSTRUCTION RECORD For Intem:J Use ONLY: This form can be used for single or multiple wells i • 1 1.Well Contractor Information: 14;.vyATER'I.ONES': l Mitchell Dean Cook FROM TO DESCRIPTION 1 , ft. %ji.. ft. ^� Well Contractor Name • 2043 A L5:5-ft. J R. 15.0UTER"('I for•multi-eeted.weUs)OR LINER(if'ap livable) NC Well Contractor CertificationNmnber FROM TO DIAMETER THICKNESS MATERIAL {t ft. ,' in. .5. ' 2! /0 1/G Dennis Holland Well Drilling, Inc. [3 lo�:Z •'•165 INNEROASING OR:TU DIAMETER ETERhermal to xN S8• MATERIAL Company Name � FROM TO ft. ft. ia. 2.Well Construction Permit#:G3A2 I. �-a�._} -/ in. List all applicable well permits(i.e.County,State, Variance,injection,etc.) ft. ft. 3.Well Use(check well use): _I.7 SCREEN . v FROM TO DIAMETERJ SLOT SIZE THICKNESS MATERIAL' Water Supply Well: • ft. ft l'i ❑Agricultural ❑MwticipaUPublic ft ft ;la, ❑Geothermal(Heating/Cooling Supply) esidei tial Water Supply(single) • ls.GROUT ' ❑Industrial/Commercial C7Residential Water Supply(shared) FROM TO MATERIAL/ ) EMPLACEMENT METHOD&AMOUNT �,,ft. ft. ./4„, aw .,.Lij y,,'`s' %?1i i/ad ❑Irrigation ��d^ ft. ft. f c f Z_. .. Non-Water Supply Well: 3 , rwr • ❑Monitoring ❑Recovery ft. ft.Injection Well: 19.SAND/GRAVEL-PACK if'a .licalile . ❑Aquifer Recharge ❑Groundwater R.emediation FROM TO IMEM1111.110 EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier it. ❑Aquifer Test ❑Storntwater Drainage ft. ft. • ❑Experimental Technology ❑Subsidence Control .20:DRILLING LOG:attach additional sheets•ifneeesse ❑Tr'acer FROM TO DESCRIPTION color,hardness,soil/rock , rain size etc. ❑Geothermal(Closed Loop) • g, R. ' ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. ' 4.Date Well(s)Completed:D,�.-�-7-� ell ID# A ./.4. ft. ft. ft. ft. Sa.Well Location: Facility II)8(if applicable) {G _ ft. Facility/(hvncrNatne ft. o A 20LY i ft .-2L:REMARKS: Physical Address,City,and zip • `. 1 Ot-Pfia':lE;l ?r^/,'3ft„`'+�,,y U7i3 /(/Ic*G�rC� ' Farce)Identification No.(PIN) County Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: (if well field,one ladlong is sufficient)- ��jjyy�� //J/f //� /> _.� - L,b 3.5� '' N S'3's..L3' t.J- W Lam/ �. Darr. U� l� ----- Si;,mature of Certified Well Contractor 6.Is(are)the well(s): la$trthanent or EITemporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 7.Is this a repair to an existing well: ❑Yes or �� 23.Site diagram or additional well details: If this is a repair fill out known well construction information and explain the nature of the repair render 1121 remarks section or on the back of this form. You may use the hack of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. S.Number of wells constructed: � For multiple injection or non-water supply wells ONLY with the same construction,you ran SUBMITTAL 1NSTUCI'IONS submit one form. 5' ' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well 9.Total well depth below land surface: construction to the following:. Formultiple.,yells list all depths ifdiJjerent(example-3@200'and 2Q100') Division of Water Resources,Information Processing Unit, 10.water level above level below top of casing: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 /11.Borehole is casing,use•"+" 24b.For Inicc lls ONLY: In addition to sending the form to the address ii 11. diameter: 6_- -- (in.) 24a above, also submit a copy of this form within 30 days of completion of we Rotary 12.Well construction method: construction to the following: (i.e.auger,rotary,cable,direct push,etc.) - Division of Water Resouices,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699 1636 FOR WATER SUPPI Y WELL$bNLY: " Air lift 24c.For Water Su 1 &In section Wells: 13a.Yield(gpm) _• -- --- Method of test:_____.-.----•--- Also submit one copy of this form within 30 days of completion of well construction to the county health department of the county where Amount: 2 Qz__. constructed. 13b.Disinfection type: _ M --- - North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013 3vi_. Macon COUnt.00teep ' 1�� + 1830LakesideDr y • Franklin,NC 28734 o Public Health ZM �r I (828)349—2490(Office) o a 407. { (828)349—4136(Fax) WELL CONSTRUCTION AUTHORIZATION Owner ' Linda Lampkin -WEL • 021424-1 SEP. .. Ex. Location 200 Cedar Hill Rd .•'PID; 6582530289 • :ACREAGE.. 0.45 ' Directions 441S,R onto Addington Bridge Rd,R onto S Skeenah Rdt L onto Cedar Hill Rd to#200 Cedar Hill Rd Design' , Single-Family Well - Permit Type -'New Construction ` Expiration Valid for 60 Months J i N rk Ale E y" -, ,,,,,''.�edO(" — ,. S / \ I. % . 1 i 041 Fx H, aiouse 41 1 Well Area ,a0 ft ,. , (• ,- ,‘••' 31 411111614111111.— —.3 ae `' —^ �� 43� Dry Well y [ itt oTo aband be oCa, p" Ex- -rport >50'to septic ,� M [ 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) Existing well shall be properly abandoned in compliance with all 15A NCAC 2C rules,and a GW-30 submitted to MCPH. 4) When well and pump are completed,contact MCPH for inspection. 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 i5A 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 FormGW-30 upon completion. - e 1,g r r February 20, 2024 v l,„.,_.Of=a„,...O6 ;��11Issue Date Trevor 3usticHSi 3294