GW1--01391_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i l
This form can be used fir single or multiple wells i I
1.Well Contractor Information: -
Mitchell Dean Cook :'14.WATER-ZONES.': ' ; -
FROM TO DESCRIPTION
Well Contractor Name 3 6s ft ,ft.
2043 A LOe
, . 9,It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)`OR.LINER/if ap 7icablc)
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. ft. in.
Company Name ' 16,'INNER''CASING OR.TUBING'(geotherniaLclosed-loop) .. .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: c11 j/a 4E'-i _ a : ft. i e , ft. 6.; ,' in. 543/ / piy�
List all applicable well permits(1.e.County,State,Variance,Injection,etc.) ��"
• //c) , ft ft. y _ in. rT
% � G . S te/3.Well Use(check well use): 17.SCREEN q o
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipaVPublic ft. ft. to
OGeothermal(Heating/Cooling Supply) l idential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) •18.GROUT i .:
FROM TO MATERIAL EMPLACEMENT� / METHOD&AMOUNT
['Irrigation
on-Wat r 4 ft. ft. D.7c-f/q=/ „c•�.L7��F�� A9'��,/ ei
Non-Water Supply Well: J! ) J
°Monitoring • DRebovery r> 1 ft. 0 % ft' ikceb �11//tT.r- .Giq tiyy)/9e./
Injection Well: -" ft. ft.
°Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEI.PACK(if applicable).. -
FROM TO MATERIAL EMPLACEMENT METHOD J
DAquifer Storage and Recovery (-.]Salinity Barrier ft. ft
°Aquifer Test DStortnwatcr Drainage ft. ft.
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°Experimental Technology DSubsidence Control
'20.DRILLING'LOG'(attach additional sheets if necessary)
OGeothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION1color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft.
ft.. ft.
4.Date Well(s)Completed:O.:.2-2 7 y7 Well LD# /t/; /l •
ft. ft. •
SR.Well Location: /fs ft. ft k 1-c't k-P. . it---Y,,i
l3�1ete.---•f N 11' - L.-e1 /ncji e:i Ai /4 , ft. ft. A.x- 3.L- k S•... .!
Facility/Owner Name / Facility IDt1(if applicable) - ft. ft. . MAR J) A2024
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/a tr.�e' . G l e,,e:// le,--.1, ft. ft.
Physical Address,City,and Zip e � >
21.REMARKS Incf ;i'rn�' e n r:%=*` ++ 3
A/I a c:,,e°,07 6.58.76• Cf gam/ CiddC u' '
County . Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ^
(if well field,one lat/long is sufficient) �� i
35`' I5 " 1-/„ N �r�,`, -� 'ef, w 4 J i -'24
Signature of Certi ted Well Contractor Date
6.Is(are)the well(s): )( errs anent or ClTemporary By signing this form,i hereby cert/lY 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: I7Yes or Ri'415 copy of this record has been provided to the well owner.
if this is a repair,ftl!out known well construction infa•ntation 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 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
9.Total well depth below land surface: :J ' (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@l00') • construction to the following:
10.Static water level below top of casing: )Sill ' (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
Rotary24a 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
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: H &M,__^____ Amount:•1 2 Q�• „_______. well construction to the county health department of the county where
"- constructed. i
Form OW-1 North Carolina Department of Environment and Natural Resources•-Division of Water Resources 1 Revised August 2013

Qtote .0 ,
M �� •m Macon County ,,1830 Lakeside Dr
Franklin,NC 28734
° Public Health (828)349—2490(Office)
o r ). (828)349—4136(Fax)
a al
WELL CONSTRUCTION AUTHORIZATION .
Owner Robert&Janet Marcie WEL 011124-1 SEP 012224-1
Location TBD Cowee School Rd PID 6587686980 ACREAGE 2.89
Directions 28N,R onto Cowee Creek Rd,R onto Cowee School road, L onto Gravel drive for#412 and#416,go to top,property on R across#416.
Desi n Single Family Well =Mil New Construction Ex.iration Valid for 60 Months
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N IP{-., :�:..._P/1 125' IP
® �._ P/L 1.25' IP
wNil6 e \ Well Area O1 Q s^uu:.-r, ,...,,,-:0
(10'x 10'x 10') 2
1��, Proposed Proposed 3 BDRM ' i
S \\ Garage House(68'x 46') tl
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\\ Prop.Porch)
/ zn
ST ST
0,' c:\
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\ a Je1y Septic Area
r- ; 1 1
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'',, ` f Septic Repair Area % y •
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'. �GrdV -Slit b i 'i
i el'R ank '
U: d'C/ r i
4:�
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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, and home is ready for CO, 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 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.
February 23, 2024 L /60,__
Issue Date Trevor Justic REHSi 3294