GW1--03493_Well Construction - GW1_20240612

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WELL CONSTR.VCTIPN RECORD �---- _
'Otis form can he used for single or multiple wills For Intenug Ilse ONLY:'
1.Well Contractor Information:
Mitchell Dean Cook 14.WATER:ZONES —.
FROM ~ TO _ Dl§CRIPT'IDN — -..._
Well Contractor Name I ,ft J ,ft ---.�-. .__.
2043 A ft. �'ft. --
NC Well Cnmractor Certification Nurnlur 15.OUTER(:ASING.Sfor-multi cased wells OR:LINE If air__------
Dennis Holland Well Drilling, Inc,
FROM _TO DIAMETER' THICKNESS RIAL.___ b• f•,: /09. ft 6;/ in, $, _.
Company Name IC INNER CASING-Oft ZUBEGIReothermal.elossid7loo
FROM TO DIAMETER THICKNESS MATERIAL --
2,Well Construction Permit It: _ fr. ft. in. — ——
1 list all applicable well tennits i.e. � f"^'coon e....__..._..___.._-.. ..,
1 ( Cmurry,.Stole, Vnriarce,Injection,ear..,) _-. _
. ft. ft. +in.3.Well Use(check well use): _....__ .,_.___.�,-
I7.SCii15 -
^Water Supply Well: ________
.FROM 'rO-T" DIAMETER SLOT SIZE THICKNESS MATERIAL —
DAgricultural 1.7Mtusicipal/Public T ft. ft in.
__^
(ICleothernal(Heating/Cooling Supply) 7 sidcntial Water Supply(single) ft. ft. Tin. -'
°Industrial/Conunercial °Residential Water Supply(shared) Ig.GRUU1 mm-- --"--'"
FROM TO MATERIAL ante. — , I ft. .Y. ft. r?y�9
Non-Water Supply Well: �" !T` ___ P Y 7/ .�. _
DMonttoring I,RP.CUVety ^�,�T� y--„
t injection Well: '_'—...___.__._.-__.'__--- _.`._._._..__.—_-- tl, ft.
°Aquifer Recharge OGrounclwater Remediatiun 19,SA_ND/GRAVEL PACK(iCap Ifcable
(lAquifer Storage and Recovery 17SRIinity Barrier • FROM TO MATERIALI. EMPLACEMENT METHOD__
H. ft.
❑Aquifet'lest OStorin water Drainage - ------ —_
ft. ft.
(lExperimental Technology °Subsidence Control ,
.20;DRILLING LOG.(attach additional sheets if necesk L. —�
°Geothermal(Closed Loop) °Tracer FROM_4— TO DPSCRIPTION(color,harderos,soittrettk we,grain size __
°Geothermal(HcatingCooling Return) Bother(explain under#21 Remarks) ft. ft.
-�-L _ L F
4. Date Well(s)Completed: r _ Well UM /V - ;
ft. �' ft. -H-t fci—t— A Sa.Well Location: ft. ft _ — —Mitt iV 1 2 202`t ^
2 oh - ti-i L ,.._L_.Joy 4._ ft. ft. r
.__....__.._.._..._._ -.__._..............-._Ir./if,;,ii�1fl,. ._ :.. _ ..1`a�._.._..._Facility/Owner Name Facility lDN(if applicable)
fr. fr. D'fiCa3L.�t�r
Physical Address,City,and Zip 21.REMARKS ��__..._,_.__ __ —
_. _ -L------
- ____. — IA/g_.r -L �� ___.__.__.__._...
County Petrel Identification No.(PIN)
___
Sb.Latitude and Longitude in degrees/minutes/seconds ordecimal degrees: 22.Certification:
Orwell field,one Iadlong to sufficient)
/
.g,5.4. a Is i '/ye, . ,r&'a,. 1a I 9ae '' w _A6 t .1-4;:4_ ►/1__. aa..___ e...,ge'. vs_sa �a .z 17e.
Signature of Certified Well Contractor- Date
6. Is(are.)the well(s): l ..Befmancnt or °Temporary
fly signing this form, I hereby rerun,that the wells,)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: (1Yes or I$No- copy of this record has been provided to the well owner.
If this is a reputr;fill out known well consinrction irijornation and explain the nonar of the
repair under 111!remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the hack at'this page to provide additional well site details or well
S.Number of wells constructed:_1__ -___ construction details. You may also attach additional pages if necessary.
Far multiple injection or non water supply wells ONLY with the same construction.you can
submit nrte/iron SUBMITTAL,INS•I'(ICI'IONS
9.Total well depth below laud surface: 3 Q.. r (ft.) 24a. for_All Wells: Submit this form within 30 days of completion of well
Fin multiple wells list all depths if different(example-.t cr 200'and 2®/00') construction to the following:
10.Static water level below top of casing:
�•y ______^_(ft.) Division of Water Resources,Information Processing Unit,
lQ._-_
lI water level is above casing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
6° 24b. FoLjpjcrtion Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: _(in.)
24a above, also submit a copy of this limn within 30 days of completion of well
12.Well construction method:_int`� - a)nsuuction to the ti>Ilowing:
.�..________
(i e auger,minty,cable,direct push,etc.) —._
_ Division of Water Resources,Underground Injection Control Program,
TT T 1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
(gPm) •
Air lift 24c.For Water Supply&Injection Wells:
13a.Yield _..__ y. _.____•.__. Method of test:_ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,M,. ,_M._...._.._..._.. A mount:•12•, z..._..._._.._._. .....
well construction to the county health department of the county where
.—_.._--.___.,, — constructed.
Recited August 201 J
Form UW-I North Carolina Department of Environment and Natural Resources••Division of Water Resources

Qtoteo�
• A •�+ � m Macon County
1830 Lakeside Dr
Franklin,NC 28734
J Public Health (828)349—2490(Office)
o dit'd J (828)349—4136(Fax)
WELL CONSTRUCTION AUTHORIZATION
Owner Zane&Helen Talley WEL 030224-1 SEP Ex.
Location 115 Ed Henry Rd PID 7448160929 ACREAGE 5.0
Directions From Highlands take 28 S to R onto Clear Creek Rd to L onto Ed Henry Rd
Design Single-Family Well Permit Type New Construction Expiration Valid for 60 Months
irt
V I
m
N co ®Dry Well Location
CIO
3m
(1)
(5`
ea
P�
.(4Q •
\ •Utility Pole
115
150'
42'\111. ®Proposed Well Location
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, 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.
May 29, 2024
Issue Date Jere less, REHS 3157