GW1--03863_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD -- .,�
flue form can be rued for single or multiple wells For Interngl llsc QNLY '
1.Well Contractor Information:
Mitchell Dean Cook 14,WATER,ZONES '
• PROM_ TO --'DESCRlPrioN "------ .
Well Contractor Name _ ^
2043 A .77Q' 77 J, rt. --
NC Well Contractor Cenification Nrnnlacr 15.OUTER CASING/for-multi-cased walla OR LINE—it a Icable — _
FROM TO DIAMETER TTIICI(NESS._ 1 MATERIAL.—.-�—'•
Dennis Holland Well Drilling Inc. .L...
Company Nnror. 16,INNER CASING TOR TUBgfr
_FROM TO (6eothermal:closed-loop)
2.Well Construction Permit'It: — DIAMETER THICKNESS MATERIAL
Gt_ ../ .alone _.:-..Z._._.__...__ ft. ft. in.
Lit all applicable well penults(i.e.Cuuury,.State, Variance,Injection,etc) ----— — --___ _
3.Well Use(check well use):
Water Supply Well: _ .FROM •ff1— DIAMETER SLOT SIZE mien/ass MATERIAL
()Agricultural 17Mturicipal/Public ft. ft. in. '^"
flOeothermal(1•Icating/Cooling Supply) 7 sidential Water Supply(single) _ rt. ft. -- in. .—__
()Indust rial/(annmercial flResidential Wetter Supply(shared) 1g,.GRUU1'----R'�`
Cl irri.ati0,l_ nom __To MATERIAL EMPLACEM ENT METII(lD&AM(WKr
Nair-Water supply Well: ---- •ft.
_....1____., rt.
QMonitn W DRecovery ---1ft^ ' ft. 4.'s
Injection Well: -_____ _ _.- - - s�sri Jam" ..2. R �119 /�,i,,�ea�
ft ft
°Aquifer Recharge DGroundwatcr R.emediation .19.SAND/GRAVEL,PA(K'(if'NiLlicgtilej ._.7-7, -
()Aquifer Storage and Recovery T./Salinity Barrier d FROM TO MATERIAL EMPLACEMENT METHOD T_
ft. 'ft.
°Aquifer'I•est C)Stormwater Drainage -- _ __ _ _.__.-_. ..-_
t]F.xperimental'feelinolo.((Y ft ft.
IDSubsidence Control
°(ieolheflllal(Closed L.00 -20;DRILLING LOG.Artach additional sheets if necesYoaL,_
p) ClTracer FROM TO DESCRIPTiONJcolor,tintless,soW_r cch rrpr,vain tin,eta.
()Geothermal(Heating/Cooling Retool) DOther(explain under 0121Retnarks) ft. ft.
4, Date Well(s)Completed: !(yspd-f cW ell tD iT /V, ��� ft. ft.
�. -^--•__ __ _.�•-- - -���-�
� i._ .;
Sa.Well Location: ,- �_ i. �
ft _ ft.
r. /
4,414..—"',.....," ft, ft. JUN 1-8 2024
Facility/Owner Name Facility 1DM(if applicable) — �._........_ ........__.__—_._—_-•----._--
/ ft. fr. it'krwa ierl a' r
W/ �� y� - _^•_-,., �_ - _-__-- ,� �'�AwG?:c hp�
//I
Physical Address,City,and Zip ..____ _._— —,..—,—_
21.REMARKS _
-- 41 — ?..51.3_9? i12. . - _ ��i� ' ._ _ __ ____
County Parcel Identification No.(PIN) Y T�"
Sb.Latitude and longitude in degrees/to or decimal degrees: -� '._._._- __
22.Certification:
(if well field,one laVlong is sufficient)
,?S a i.5 S' 07" ..d3..`. . 4",,Z`,S'( '' w —M t 'i~' ...g_ lL_. 'r1EL.. 4-ede_-- a /,.i'- - --Y
Signature ofConified Well Contractor Date
6.Is(are)the well(s): 149e:fmanrnt or CITcmpnrary
i fly signing this Arm,/hereby i.et tyi iiw:the well(s)was(were)constructed in accordance
with l5A NCAC 01C.0/00 or l5A NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ()Yes or ERNS copy of ibis record has been provided to the well owner.
If this is a repair,fill out known well construction it foraaion and explain the nature of the
repair under Il21 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
R.Number of wells constructed: 1 __ _ ___ cunsuuetion details. You may also mach additional pages if necessary.
For multiple injection or nun.water supply wells ONLY with the sane coautrucdnn.you can
submit one form. SUBM1TTAl.,INS'1'UCTIUNS
9,Total well depth below land surface: q..1r,5_.i _ ,_,(ft.) 24a. j^o \l1,Well.: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example• T a 200'and 2 a@100') construction to the following:
7.��_ M.) livision of Water Resources,Information Processing Unit,
10.Static water level below top of easing:
If water level i.raboveeasing,use"--" �" 1617 Mail Service Center,Raleigh,NC 27699-1617
(in,)6" 7.41r. For Injection sending
11.Borehole diameter: tlon Wells ONLY: In addition to the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:_Rotary _ ____- __ 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.Fur Water Supply&Injection Wells:
13a.Yield
(gpm)___/AO _.____.._. Method of test:-_---,-____._•____.._..._
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H,&,.M._- Amount: 12 oz, well consttuction to the county health department of the county where
- -----
Revised.. constructed.
Form C\V-I North Carolina Department of Environment and Natural Resources••Division of Water Resources August 2al.t

Qotect •
�� 11 m M d C O n C O U n t y 1830 Lakeside Dr
p Franklin,NC 28734
d Public Health (Office)
[phone]
'y a-) [phone](Fax)
WELL CONSTRUCTION AUTHORIZATION
Owner Vance Loen WEL 041624-2 SEP 010724-1
Location TBD Wildflower Drive PID 7513991191 ACREAGE 3.04
Directions Take Highlands Rd to L onto Corundum Hill Rd onto Mountain Laurel Drive to L onto Wildflower Drive.
Design Eninal23111.11.11 Permit Type New Construction Expiration Valid for 60 Months
N
SP
(11%
,,,, .........._ ,
yll o „,e 1450)
propen"'
q
s
0
O5eal,
5ea oomi a
prop
'Garage ,Min 10 15Y
0 1 — m5� M�-n►
fro tom\ \-11
r.
LtdPermitted Or`�001 depar .,5) r - 5'
Well Spot >100'to all septic components t `g0 25� ) ~
50' r
' SP
2.5'1
iP
Property Line(450')
._/ Wildflower Drive
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.
April 30, 2024 Cam( /
Issue Date Chaz Allen,REHSi 3258