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Home My WebLink AboutGW1--03320_Well Construction - GW1_20240603 WELL CONSTRUCTION KECORI) For Internal Use ONLY --._...-__ — 'Otis form can be rued for single or multiple well~ 1.Well Contractor Information: __ ._._-.__ _..-.-- --- ` -� 14.WATER%ONES --- -------- Mitchell Dean Cook FROM TO _- DESf.R1PI7ON -----• Well Contractor Name _ _�_ ft. rt. -_+T, �^ 2043 A D. rt. - _ -- 15.OUTER CASINQifor multi eased wellaZOR.LINE i[appliubleL_-___.__ _ NC NC Well CutaractorCenification Number FROM .TO DIAMETER THICKNESS 1 MATERIAL. Dennis Holland Well Drilling, Inc. v ' fit. ` ft. de '' i°' -a/ ''�G= Company Name. w __ - 16:INNER CASING OR:TUBfFIG(gcothsrma c need-1eo I Y FROM TO DIAMETER 'THICKNESS MATERIAL s O J+ I // ft, ft. in. 2.Well Construction Permit q:_,Deb- '.J_ ..__...._--- --... _,_ — -- (.ist all applicable well permits(i.e.Cony,State., Variance.,Injection,efc..) ft---�' ft. in. 3.Well Ilse(check well use): 17.SCREEN „_ % --- — -! FROM _'r0 _ MAME *: *SLOT SIZE THICKNESS MATERIAL. Water Supply Well: fit. ft. in. °Agricultural °Mtuticipal/Public _____ -- ---- - --T--` - � °Geothermal(14eating/Cooling Supply) Alaalential Water Supply(sing ft. fit. in. le) __ _ — _ - C Dltrdustrtal/Coinnuercial SI etrttal Water Supply(shared) l&GRUU7'- ,----__-r--- FROM MATERIAL T F.MPLACEM ENT METIIUD&AM OU(VT 1 °IrO...11 iotl _-_ eft. - rl. eg-en !(j.. " .),. 5 ,/47!/•• , -+ Non-Water Supply Well: •. . r ft. r ft. _�y�� °Monitrn'ing UReeovery T _�_• fit. ft. `� A ° . Injection Well: -- �� []Aquifer Recharge ClGroun(Iwater Renrediation 19 SAND/GRAYEI,PACK(ir p�ic blc� � FROM TO MATERIAL _ EMPLACEMENT MFTNOD °Aquifer Storage and Recovery °Salinity Barrier ft. ft. - �_� _ -- °Aquifer'I'est l'lStonnwater Drainage ft. --'^' rt. °F.xperimental'1'eehttology I:J3ubside.nce Control 20;DRILLING LOG(quash additional sheets if°eceasatm•l_��_ �_ QGeodtennal(Closed Loop) (]Tracer' FROM TO DESCRIPal sheecolor_hcrduss,361400i 1w,O'+in size,12,0 •- fit.- ..fit. °Cieothennal(Heating/Cooling Return) OOthe.r(explain under H1.1 Remarks) •_.-._..._.___- ---.--- -•- ft. ft. �, _ _______„...._ 4.Date Well(s)Completed: c _ Well IDd _f V (L' ._ -. • -n. ---___-ft. ft ,...ems SA.Well Location: fit' „r ----- - rt. 2jLill 4 Facility/Owner Name Facility Il7U(if applicable.) - ft._.__._..__...._.._ft. IT,`); . ,i'. _ ;'s- r�. _ -- rt. ,— Cam: C � - -- t/off /N tN 1�. ea��t , r�.y_e - --— ---- ---_-__ -----. Physical Address,City,and lit :REMARKS �_T__. _ ---- County Parcel Identification No.(PIN) __T „- „ - --«_.- Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (if well field,one tat/long is sufficient) �� S�4 S=_/Z. r r ., . _ice- .3 6 w �J�_t c:A_�LL__.1, 'aeLL.. G_ege D ea- Signature ofCertifed Well Contractor 6.Is(are)the well(s): IOBefOlanetlt or fTremporary fly signing this final,/hereby certify that the,we/I(s)was(were)constructed in accordance with 1 SA NCAC 02C.0100 or I SA 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 au existing well: []Yes or K}No� If this is a repair,fill out known well construction injor•mation and explain the nature of the 23.Site diagram or additional well details:repair under p21 remarks section or on the hack of this form. You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. 8.Number of wells constructed:_1 _______ For multiple Injection or nor-water.supply wells ONLY with the same construction,you can SUl1MITTAI..INS'1'UC"190N$ salami one form. ,5 __(ft.) 24a. Col\II Wells: Submit this font within 30 days of completion of well 9.Total well depth below land surface:_��_ _-_-....--. - constriction to the followinli For multiple wells list all depths ifdii different(example-30200'and 2@l00') Division of Water Resources,Information Processing Unit, 10.Static water level below top of casing:_____. ...,a,• --- ___(fit) 1617 Mail Service Center,Raleigh,NC 27699-1617 If water level is above casing,use"+ u 24b. For lnjcc_.tion Wells ONLY: In addition to sending the form to the address in I1.Borehole diameter: 61 (in) 24a above, also submit a copy of this form within 30 days of completion of well Rotary construction to the tbllowing: 12.Well construction method: _, . _ -- (i.e.auger,rotary,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 Water SuP.E!X d'InjectionWells: 13a.Yield(gpm)_.__I, .� test:Method of __......______.___._...--•-- Also-submit-one. copy of this form within 30 days of completion of I-1 & H 12 (�z, well construction to the county health department of the county where I:ib.Disinfection type:•__..._....._._..._._..._. Amount:,-._.r... _....._..._._.._._..._._- constructed. ----`-�--�_ Revised August 2013 Form OW-I Notth Carolina Department of Environment and Nauual Resources--Division of Water Resources LUicc1 ( hm al- i- ) 't-610 q- qq0+- lotect ' 1830 Lakeside Dr `� •m Macon County b',b 'AUIo � Franklin,NC 28734 tit PubIic Health1.,-- (828)349—2490(Office) 01.11 /} l q\ts-/- ) (828)349—4136(Fax) c. • WELL CONSTRUCTION AUTHORIZATION Owner Chmar 5 Investments,LLC WEL 020524-1 SEP 020924-1 Location Hedden Cabins Lot 1 PID 7541039569 ACREAGE 1.20 Directions Take Flat Mountain Rd to R onto Hedden Ln to end of Rd Design Shared Well Permit Type New Construction Expiration Valid for 60 Months 0 N ifil .1--- 444 1�' F d) vow 4.(+. Line(362.91') Property IP ' '•'\� 4, %6� . . 26 (_5_ , (145')100'Min-----► S/i. 41, �```9^d�i^,``' 1 We11'5, /`. 9 .� is, Ra • ��2S' p .yin vIr- ti . oti ) 0 PP pr AA 3. rp00 SO I/ �ooSery II% � S, , k ` pro / ti/io %, / • 0hS.y, c Ip6 ou opr9 i.rnN(196.99 ) 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. March 28, 2024 LI,, Issue Date Chaz Allen,REHSi 3258