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Home My WebLink AboutGW1--03317_Well Construction - GW1_20240603 WELL CONSTRUCTION ItKORI) For Internal Ilse ONLY This form can he used for single or multiple wells I.Well Contractor Information: Mitchell Dean Cook 14.WATERSONE "�"� T FROM ^TO —__— DESCRIPTION --___—_--_--- Well Contractor Name —/GtN_ 2043 A rt. O a. NC Well Contractor Certification Number 15.OUTER CASINGlfor multi-eaa�ed•wellaI OR LINER if appliuble)_ FROM TO IMAM ETTFR THICKNESS 1 MATERIAL. _ — Dennis Holland Well Drilling, Inc. �, rt• • rt. ,• i°- �I i MATERIAL Company Namr.___-- , ^��- •� -� -16,INNE ..4.2 G OR�TUB�G(geothermal c -loop) - I L I �'�,,, 't J FROM TO DIAMF.TER THICKNESS MATERIAL 2.Well Construction Permit N:_, �_�_Z.,.-._.._.1 _.____.^... ft. ft. in. Lit all applicable well permits(i.e.County,Stare, Variance,Injection,etc.) -- — — — _ _ — — R.^ ft. +i°. 3.Well Use(check well use): 17.SCREEN-� _--, Water Supply Well: -...._.._^_'-~ _ ,FROM TO �__DIAMETER SLOT SIZE_,_TIIICICNESS MATERIAL.� ft. ft. in. __.. °Agricultural ❑Municipal/Public ft. in. __�_ --_-- f.1Geothennal(Heating/Cooling Supply) 7 sidential Water Supply(single) ft. •,T,. OlndustriatlCommercial °Residential Water Supply(shared) 18. ROUT 1 I Y mom ''f0 M_ATERIAL. EMPLACEMENT METHOD&AMOUNT Oki:SHOD Non-Water Supply Well: �` '� _ _ _ il3L:?104_.2_:ramr`" S.__.e4.w,/,a� rt. : it• , , . -.4— A,-'7!_,e-e/- , °Monitoring (]Recovery -..._-- I! �t'1+ -sue- J� Injection Well: �� `� ft. ft. — -- UAquifer Recharge °Groundwater Remediation 19,RAND/G1tAVE1,PACK RimplicableL�,_ -... FROM TO MATERIAL EMPLACEMENT Mmini)— °Aquifer Storage and Recovery E./Salinity Barrier ft. �.ft. OAquifetTest C]Stormwnter Drainage ---T ft. fr. -- ----- --_ (]Experimental Technology °Subsidence Control 20;DRILLING LOG irach additional ahem*if aeceasaryl _� UCie.OtllCllllal((dosed Loop) ['TracerFROM TO_ DESCRIPTION_Acolors Aardness_soil/rock we,train siu a-__• °)Geothermal(Heating/Cooling Return) °Other(explain under 821 Remarks) ft. ^� ft. ^- w�^ _ VA 4.Date Well(s)Completed: e. G/J;L 9- Ii Ho /v' [ _.._.__._..._. ft. -�..-ft.T__'-__^_ ._------ _• Sa.Well Location: —ft. -_ ft. - -__._.. /• arc 40 n�. -115'ir• . !_1C11.�a. ft. ft. _. Facility/OwnerNamc Facility ION(if applicable) -- rt._ ft. -�:..,\,.y,..t i! ....LI — 14, /r,yta. ) ..�__--�' cl_D144 __ ._.n.____ _IL _ii11.u : [f17.4 _ _—._ Physical Address,City,and"Lip 6,6c'gA)3 21._RE:MARKS V___-„_-.______.__ ___ _._.___ County Parcel Identification No.(PiN) `____—TT__-. ----- Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (it well field,one Iat/long is sufficient) Signature of Certified Well Contrectnt Date 6.Is(arc)the well(s): Ij).PeFlmanent or f.3Temporary try signing this firm, I hereby certify that the well(s)was(were)constructed in accordance with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: (]Yes or Rest0 copy of this record has been provided to the well owner. If this is a repair,fill out known well construction information and es plain the nature of the 2 i Site diagram or additional well details: repair under 11l remarks section or on the hack of this form. You may uset back this page to provide additional well site details or well 1 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 sate construction,you coat SUl3MITTAI.,INS'1•UC"1•iONS submit one foray. ..._- _..._..._9.Total well depth below land surface: LLD, ' _ _ .(ft.) 24a. Fqr All We•Ilg: Submit this form within 30 days of completion of well Far multiple wear list all depths ijdijjerea(example-r�zno'and l�lua) construction to the following: �_(ft) Division of Water Resources,Information Processing Unit, 10.Static water level below top of casing:,._: Q _._____.- _- 1617 Mail Service Center,Raleigh,NC 27699-1617 if water level is above casing,use"4" 24b. For lniection Wells ONLY: In addition to sending the form to the address in 11.Borehole diameter:� _(in.) 24a above, also submit a copy of this form within 30 days of completion of well Rotary constuction to the ti)Ilowing: 12.Well construction method: • „ , _____.-.___.--- (i.e.auger,mtaty,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, ----- 1636 Mail Service Center,Raleigh,NC 27699-1636 FOR WATER SUPPLY WELLS ONLY: Air lift 24c.For Waterer Sups!),&Injection Wells: I3a.Yield(gpm)...6 __________ Method of test:__, ..__._..._._.__..._....._ Also submit one copy of this form within 30 days of completion Of i-i & i'i 12 oz. well construction to the county health departtnent of the county where 13b.Disinfection type:._.___....._....._.._..-_.. Amount:._._.._.... constructed. Revised August 2013 Form OW-I Notth Carolina Department of Environment and Natural Resources-•Division of Water Resotures 1/t rcr . \m Macon �- O U rl t y 1830LakesideDr .1:/i ' Franklin,NC 28734 Eo e jc� P u b I i c Health (828)349-2490(Office) .d �' (828)349-4136(Farr) WELL CONSTRUCTION AUTHORIZATION Owner Crai r&Laura Doolittle Location TBD Golden Grove Laura-.Doolittle __._._ WEL 121323-P SEP 122323.5 Directions Take 28 N to L onto Snow Hill Rd to L onto Rickman Creek Rd to Red Oak Rd to L onto Golden Grove2803 Drive ACREAGE 3.2 Desi.n Single-Family 9 y Well Permit Type New Construction _ Expiration Valid for 60 Months 211'225' 145' 194' __s 1 1 sir ( Septic Repair 1 is NI I Area 1 m n n MIS 15' 175'x40'i I 1 I in 1 I I I Proposed I I 3-Bedroom I . I 1 i in ti a a ,r, �. y 4 a ' , i lie d IP • • 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. Including but not limited to 25'Min from Buildings and 50'Min from all components of Septic System 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 it the site plan,plat,site,or intended use changes.All rules in 1SA NCAC 02C Well Construction • 5'fondants 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 C,W-30 upon completion. • • February5, 2024 - _Ca ... .+ Issue Date Chaz Allen,REHSI 3" 25g I i i i I