GW1--03862_Well Construction - GW1_20240628

WILL CONSTRUCTION I ECORD _ ._. _�- -_ -
'This form can he rued for single or multiple wells for Intemg!Ilse ONLY:
I.Well Contractor Information:
Mitchell Dean Cook R.ZONE^ - ---
14.WATER%ONKS _
FROM T0�"�- DESCRIPTION
"''
Well Contractor Name _ sfL� ^?�/,fl.
2043 A = of - __ _
NC Well Comuacit Cenificetimn Numin r 15.OUTER(:ASWG. for multi-cased wells OR:LINE if a^II ble T' •
FROM S-_-DennisPL.__-
Holland Well Drilling, TO DIAMETER THICKNESS MATERIAL.
, Inc. 0.. ft, ft. ,, in. •
Company Nnror, ^- �'�' 16:INNER CiASING OR,TUB GSgcathermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL '"-
2.Well Construction Permit _• ;H: J�s.��'�,"•'�,)•'- _ ft• ft. in.
er qq —-- —•_
List all applicable well permits(i.e.Coumry,State,dVarriia,,r.Injection,etc.)_....._._..___._-...
- tt. __ _ _ft.. _ to. �_.---
3.Well Use(cheek well use): _,_,. _
Vi.ifYilliii
Water Supply Well: — •PROM L. ___ DIAMETER SLOT SIZE THICKNESS NIATERIAI,
()Agricultural 0Munie.ipal/Public ft. ft. in. "'
ClGeothermal(Heating/Cooling Supply) ) sidential Water Supply(single) __ ft. �^rt. --� in. �-
Ulndustrial/C:ommercial tg.GRUU1'_._.�__._ ____._.�._ --"-�"""
(.)Residential Water Supply(shared)
(.111TI.Hl1011 �ott -_o •_ TTet ATERIAI. EMPLACEM ENT ETIIOD&AM DUNT
Non-Water Supply Well: _____------- ,o i fu,�,_g d _lit'j ••fft. ..20 ,ft. ��r
ei-
L7Monitoring IJRecnvery _
Injecting Well: -- - --„ _.�. �_ h. �� ft. tir�9 4u,fi�y/
OAquifer Recharge (')Groundwater Rentediation 19.SAND/GRAVEL PACK if a linable
l3Aquifer Storage and Recovery I:JSallnity Barrier ' PROM TO MATERIAL T� EMPLACEMENT METHOD 7.._._.
ft. ft.
DAquifet Test C)Stormwater Drainage -•
°Experimental Technolo R. ft.
g)' I:JSubsidencc Control _
DCieotltefmal(Closed Loop) 20:DRIITMLING LOG.(attach additional sheets if accesl l_.•
P) ()Tracer
FROM TO DFSCRIPTIONJeololor,hardness,soil/Jock we,grain size,eta__
f°Geothermal(Heating/Cooling Return) 1.30ther(explain under H21 Remnrks) ft. n.
4, Date Well(s)Completed: (4014114... i�.Well 11)il �r C/J� __ __. ft. -- -.ft.
Sa.Well Location:Location: — -/•_t G� 1/(.,
ft. ft. : `� L,_
JUN
Facility/C wncr Name Facility Mg(if applicable)
-._,__..,,.,_„__. ..._._-._._•..........._....,.-_.__ ,j._Q...�f 4-�_..-...._......._
rt. ft,
iniori1MRi4 sr7v
. /per ';S. e4 � . _- „_......____ft. ___-_._.fL_...._._._ "�iAO.^•p. _.._
Physical Address,City,and Zip ___----._..-- _
211 REMARKS
County Parcel Identification Na.(PIN) ---- --___._.- _ _-- _ _ _,.
SI).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: _ _ -
�_____--�'----
(it'well field,one 1st/long in sufficient) 22.Certification:
.,SC /�?s?� 3!T -2e". :1 /Y�., w 1 Co '' ,/- 2
Y� ..� .� � �'�:_ _�:Ll__.���.._ .per—. .�,�•�--�`�
Signature of Certified Well Contractor - Date
(i.is(are)the well(s): 1(•]Ee:fmaoent or LITcmporary
fly signing this form,l hereby certify that the we/l(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 IPell Construction Standards and that a
7.Is this a repair to an existing well: ()Yes or L9W1- copy of this record has been provided to the well owner.
If this is a repair,fill out known well constriction information and explain the nnmrre of the
repair under/12/remarkr.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
8.Number of wells constructed: 1 ___ construction details. You may also attach additional pages if necessary.
Far multiple tniection or nun-wrier supply wills ONLY with the.same construction,you can
submit are form. SUIIM1TTAl..INSTtlCT1ONS
9.Total well depth-below land surface: .30 S ' _ ,-_•(ft.) 24a. &LAD Wells: Submit this fora) within 30 clays of completion of well
All multiple wells list all depths if different(example•.1 et 100'and 2®/00') construction to the following.
.S�Q ' — ___ _(ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:_
If water level is above casing,use. "-' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For InietljQ4 Wills ONLY: In addition to sending the farm to the address in
Rotary 2'1a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method:_ ry• -_�T_ antstuuction to the tollowing:
(i.c.auger,musty,cable,direct push,etc.)
_ __ Division of Water Resources,Underground IDjecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: _ _ T� 1636 Mail Service Center,Raleigh,NC 27699-1636
•13a,Yield(gP m) ._ _.._ Air lift 24c.For Water Supply&Injection Wells:
- _ __ .. Method of test:__._......__.._.__..-. _.. _
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,H•_&•_M Amount:. 2..oz• well construction to the county health deportment of the county where
_.—�--� constructe .
Form GW-I Noth Carolina Department of Environment and Natural Resources••Division of Water Resources Kennet Au(usl 2013

ootect
�m Macon County 1830 Lakeside Dr
o (828)' Public Health Franklin,NC28734
349—2490(Office)
o, � (828)349—4136(Fax)
y � a
+�/ WELL CONSTRUCTION AUTHORIZATION
- g /7- � � - ILf �i �
Owner Danny L. Stanton WEL 060324-2 SEP
Location 149 Peeks Creek Rd PID 7512996156 ACREAGE 5.2
Directions 149 Peeks Creek Rd
Desi.n Single-Family Well. =MO=New Construction Ex.iration Valid for 60 Months
PL851, 01%
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Concrete pad
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1$, Well Areao
Well Area (LO'x 10'
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PA.819, ti351 10') 10, 10'
3 /P'``-39 x_Gravel pr'
32 rve
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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 1SA 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 place well into service.
Any person abandoning a well must submit to MCPH Form GW-30 upon completion.
June 13, 2024 _-
Issue Date Trevor Justic REHSi 3294