GW1--04019_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD -------.-
".___ " ^---��-- For Intemgl the ONLY:
This form Cam he used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 14.WAT.ER;ZONE .
-- - _ __FROM TO— DItSCRiPT70N _ "-
Well Contractor Name
2043 A •d-73-• t. 27F.: L� __ft. ft.
—
NC Well Contractor Certification Number _15.OUTER CASING. fS_or multi-eased wells GR.LINB if a tlwb)e- Pam___IA -----
_
FROM TO DIAMETER THICKNESS MATERIAL.
Dennis Holland Well Drilling, Inc, rt. ft. - -
Company Namr, --- -- — _ .. �b -f �Ylr
16:INNER CASING OR.:TUBMG'(geothermal closed-Ioo
FROM TO -- ..-._.—
, DIAMF:'PkR 'rHIC'KNESS MATERIAL 2.Well Construction Permit 0`�^$�=-I -1 _,__.____r___
Litt all applicable well permits(i.e.County,State, Variance,Injection,...;;.)"--- _.:_T._____ - _
ft. ft. to. —
3.Well Use(check well use): 17.SCREE I- -
_...—._.
— _..—..-.__
Water Supply Well: '�' .FROM 'f0��'-'__•— __DIAMETER SLOT SIZE Tt1ICKNF.SS MATERIAL
OAgricultural L7Mtu)icipal/Public ft. ft. in.
t:lGeothermal(Heating/Cooling Supply) V4idential Water Supply(single) ft. h. in.
Oluidtlstrlal/COtnrnercial I.lResidential Water Supply(shared) RO
Ig..GUT--- —""-"T
fllitl,attotl FROM __TO _ MA! JAL Ea1PLACFM ENT METHOD h AMOUNT
Non-Water Supply Weil: -- --•— fr• ., fr. v
OMonitorin ft. s ft. z,1; 1 :- P-/
°Recovery _ _ s
Injection Well: -- `-'--'-" _ "-" ft. fr.
OAquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(Ltppltcable) -.-- '
(]Aquifer Storage and Recovery (°Salinity Barrier tl g TO DIATERRIA1I. EMPLACEMENT METHOD ..........
ft. ft.
°Aquifer Test f]StorinwatcrDrainage - _
(°Experimental Technologyfr. ft.
I:JSubsidencc Control
UGe..otherls)aI(Closed Loop) -20;DRILLIN(:LOG(iraeitadditional sheets if maces•&L
Carnet _FROM TO DESCRIPTIOncolor,hardness,soil/rock type,grain size,eta--_
(]Geothermal(Heating/CooliltRRetuntQ °Other(explain under N21 Remntks) ft. ft.
4. Date Well(s)Completed:46-2O-G., Well IDII /V - --- _ -- —....,._...- -—��—
..-.
Aft. ft,
Sa.Well Location: - — -__.
ft. ft.
Q --
Facility/Owner Name Facility IDII(if applicable)
fL h.
..,.JaZZ. G�*ph.�4i _ 2(t. ..__....__�,._ __ ft.— ._-----J��LQ S �n __••
—
Physical Address,City,and Zip --_���_.-_ 24
21.REMARKS
___ ram_.- _ 4 504. /.2.P..ea_. __i_c0=__ _ :;t4:gv M-__--
Comity Parcel Identification No.(PIN) rirr. -
___
Sb.Latitude and Longitude io degrees/minutes/seconds or decimal degrees: 22.Certification:
� __
(it welt field,one let/long is sufficient)
Signature of Certified Well Contractor • Date
6.is(are)the well(s): I4Pefmancnt or °Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 01C.0/00 or ISA NCAC 02C.0200 IVell Construction Standards and that a
7. Is this a repair to an existing well: °Yes or Llt'90 copy of dris.recnrd has been provided to the well owner.
If this is a repau-,Jill out known well construction it formation and explain the nolure of the
repair under fill 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 of well
S.Number of wells constructed: __ _ construction details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply wells ONLY with the soar.construction,you can
submit one form. SUBMITTAL,INS'I'UCTIONS
9.Total well depth below land surface:•_02 c9Q s _ _(ft.) 24a. j g ll Wells: Submit this form within 30 days of completion of well
For multiple teens list a0 depths if different(example-I tt 100'and 2 a@/00') constniclinn to the following:
10.Static water level below top of casing:. _TO ' .__.._._____ _(ft.) Division of Water Resources,Information Processing(lair,
//water level is above casing.use•• " 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole.diameter:6„ c
(in.) 24b. Fq.E_Ik ljQn Wells ONLY: In addition to sending the form to the address in
241a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: Rotary ��___ an)suuction to the following:(i.e.auger,rotary,cable,direct push,etc.) �-
_�
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS S ONLY: _ T 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6� 4... Method of test:Air lift, ' _ 24c.Fur Water Supply&Injection Wells:
_ Also submit one copy of this form within 30 days of completion of
l'I & H well construction to the county health department of the county where
13b.Disinfection type:.__..._....-----•..._..__.._.. Amount:.1?(az•.._.-....-__T-_ constructed.
Revised August 7.a1l
Form OW-I Not di Carolina Department of Environment and Natural Resources.-Division of Water Resources

cote
`� t•m Macon County
1830 Lakeside Dr
p z Franklin,NC 28734
r a Public Health (828)349—2490
of ym [e-mail]
WELL CONSTRUCTION AUTHORIZATION
Owner Duane Chamberlin WEL 060524-1 SEP N/A
Location 137 Cszonka Road PID 6596512880 ACREAGE 3.1
Directions N Hwy 28, R Riverbend Rd, R Lakeshore Drive, R Cszonka Rd, property on R
Design Single-Family Well . Permit Type New Construction Expiration Valid for 60 Months
Fence -52,
- •
�'
S�` P.Pole
Cszonka Road �e\\
1./
QoP '0
86' a
Meter Box MI p
\ �`v u
\ N.' a
\\ .9 I
\ _c tea,
m p`
�\
\d
3. \
6 \
Ex.House Garage
SePtic Area
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 place well into service.
Any person abandoning a well must submit to MCPH Form GW-30 upon completion.
June 17, 2024 ` / , L ..--/441‘. N -
Issue Date Select an Agent...