GW1--03318_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORI) forinrom)Il1scONL.YT ._..�..__.... _�_._ -
This form can be used for single or multiple wells
I.Well Contractor Information: _
Mitchell Dean Cook 14.WATER ZONES •
• , FROM TO DESCRIPTION �""-'
Well Contractor Name r.•(t �%/ft. __.__._--_
2043 A ft, ,3.,,. ft.
e
NC Well Comtactot Certification Number IS,OUTER CASING. for multi-cased wells).OR.LINE if applicable)________
FROM TO ERTHICKNESS T MATALDennisHolland Well Drilling Inc. �t: it. {mAMF!
1 '
.Company Name _.-_ ,..-l-_-_.i l_. __..,�_�.___ -•._ - _INNER CAS N;OR;TUBI6 sCi 1.4„,. ,.2 t ' p ir.c.
(geothermal closed-loop) . _
FROM TO DIAMETER THICKNESS MATERIAL -
2.Well Construction Permit ff: /, ,,,;Z ft, ft. in. ,
List all applicable well permits(i.e.County.Slate, Variance,Injection,etc.) --^ + ,-,._-.________.._ _�_. __
ft. ft. in.
3.Well Use(check well use): IT.Sl:-RRBN -�-^��"`___.'._,.in __T
-
Water Supply Well: "-"'`- - i i 'ro DIAMETER_ SLOT size_Tuic .i ss MATE:RIAl.
OAgricultural LiMumicipal/Rlblic ft. it.^-^- in.
--
(11Geothermal(l'leating/Cooling Supply) 7 sidential Water Supply(single) ft. R in.
�T —^^T
Olndustrial/C:onnnercial I(Residential Water Su))I 18.(;ROUT _ _ _ _ __
Supply FROM TO MATERIAL. EMI.I.ACEMENTM E71lOD&AM(IUY1
GLTi:anon__ ,fr. ,, , ft.
Non-Water Supply Well: - .aS �:_.."`1t e _ __:_..t 19,5- ,Pt,.941
['Monitoring ± -
DAt ixi,ction Well: -uifer Recharge [:]Groundwater Remediation .1-9.SAND/GRAVEL PACK(inapplicable)
• FROM TO MATERIAL EMPLACEMFTITMETHOD
[]Aquifer Storage and Recovery 1:1Salinity Barrier ft. - ft
°Aquifer'I'est OStorntwatcr Drainage,
°Experimental Technology 1:3Subsidence Control
20:DRILLING LC)C mesh additional sheets if OM neceasar„YL-� _.____ _ _
°Geothermal(Closed Loop) LlTraeer FR To __DKsCRIPTIOl eolor,hardness,sail/rotk iipe tin siuiat-
C°Geothermal(Heating/Coolin¢Return) GJOther(explain under 821 Remarks) __ rt. _ - ft. M^ _ _-_- _ N, _.-_
- V l ft. ft
4.Date Well(s)Completed: G 05-ice /.2.'/Well Inn V 1<-________.__. .---ft. .— --ft.— .�_�� _.— �•
Sit.Well Location: ---_ r_ __ _ _ _ —h. fa
Facility/Owner Name facility Mg(if applicable) ft. It.
,p
Physical Address,City,end Z.r 21.REMARK] _ � -_„Jr �i „T --v.;'-:i+-!_4 —
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: --A^
(if well field,one lat/loog is sufficient)
350 .2.6/. l>1-.5 U 9 ._..t.t9:5 1. 54,0 Pr7 w .1M.Lte.;:ic?l.L_. -(chit_.._ ,P�.__.. 6.5—/
Signature of Certified Well Contractor Date
6. Is(arc)the well(s): Il),Prfmancnt or °Temporary
By signing this Jotmt,/hereby certify 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: DYes or IfINfl- copy of this record has been provided to the well owner.
If this is a rcpuu,fill out known well construction inlornrmion and explain the nature of the
repair under 101 remarks section or on the hack 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
A.Number of wells constructed: 1_ _____ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the stone construction,you con
submit one form. SUBMITTAL.INS•1•LICTIONS
9.Total well depth below land surface:- .2,5 S _(ft.) 24a. for AlI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-i a 200'and 2@/00') construction to the following:
10.Static water level below to of casing ft, Division of Water Resources,Information Processing Unit,
P g �' _ '' ' -- ( ) 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"�"
11.Borehole diameter: 6"
(in.) 24b. For I�rlutiQn Wr•.Ils ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this fonts within 30 days of completion of well
12.Well construction method: ROtary _�.__ ___ construction to the tollowing:
(i.e.auger,rotary,cable,direct push.etc.) T_
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:„� _ T_ ^� 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Sufp y&1n1ection Wells:
13a.Yield(gpm)._._.,50 _._____..____ Method of test:__._-,_____.__.__.�..._..___ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H&.,M.._,._ ......_.. Amount: 12-.. , well construction to the county health department of the county where
constructed.
Revised August 2..01:1
Form(iW-1 Nottlt Carolina Department of Environment and Natural Resources--Division of Water Resources

Q10 eft
J Macon County
o� ;S Public Health NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
�tl � a�
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Nicole Esmon LOG# 120223-P OSWW# 120323-S
INTENDED USE Single-Family Well, Residential PID # 6587397378 ACREAGE 1.75
LOCATION 6890 B son Ci Rd
DIRECTIONS 28N,to #6890 on L. Gravel Drive just past a wooden shed.
Permit Conditions
Well shall be constructed incompliance with all NCAC 2C Rules. ,
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
Bryson City Ra r
Well to be
.f.M, . abandoned
ray'
W.
�t-.0 15
•
*,.,0,r Well Area
,,� ,..; (5 x 15,E i 5
Ex. House
Driveway
4 61'
m 1P 1 S!
, ti
t iO.
N
+ o
,
.04 -'1_
Barn
\,, ,.-7 I"
— — 11 S
This permit is valid for a period of five years except that it may be revoked at any time if it is deterrnined 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]
Issue Date: 12/6/2023 Trevor Justice, REHSI 3294 �' / --- _Authorized State Agent