GW1--04020_Well Construction - GW1_20240708

WELL CONSTRUCTION REC(ORI) ----_----------
'Ibis form can he mid for siugle or multiple wells For'mental(Inc ONLY: —_
1.Well Contractor Information:
_Mitchell Dean Cook 14,WATERZONES _ - "-'
^- FROM TO'— ----D.iaLYEION"_.* �-'' -"
Well Contractor Name TR� r ft a ft. -'
2043 A -,. �6_
m. ft. --
NC Well Contactor Cenificatiotr Number 6� � __ --
I5.OUTER('ASINQ�(tor multi-cased wells OR,LIIVE if Ai Icable�_�—�_
'FROM ,_TO DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc.
Company Naror. -.- __ - ---_-.. a / h. .r R. /a im. tSO/Q.2/•._, _ 2vc
16:INNER CASING OR:TUBED geothermal.closed-boo
2.Well Construction Permit N: �./ FROM PTO - DIAMETER MATERIAL
.as I .2,.�_ ___.. _.._.___ - rt. rt. in.
List all applicable well',mints(i.e.County,,State, variance.,Injection,etc.) -.---,--7--
ft. ft.. to.
3.Well Use(check well use.): _ __�`_
^1Z.SCREEN' --,r-N — -
Water Supply Well: Iftftkid_TO DIAM ETKR _4LUT SI'LE _TIIICKNF.5s MAT F:RIAI.°Agricultural 0Mtinicipal/Public ft. in. 'f.lOeothermal(Heating/Cooling Supply) 7 sidcntial Water Supply(single) r ^rt. ,- tn. —'-,
n(ntluslrinl/Commercial 1g.GRUUT
C1Residential Water Supply(shard)
(.11nl:aliott met _To.•_, -EFIATER1AI. EMPLACFMErrr'METHOD hAMOUNT
Non-Water Supply Well: - -- ^ ft. s . ft.
_
❑Monitoring °Recove r ft. -20 t fr.
Injection Well: "_'_._,_--. --'-. ry _ —_ - ��`e�.tril^� Q�s�.-�/�
ft. ft.
(]Aquifer Recharge °)(Groundwater Remediation .1,9.SAND/GRAVEL PACK iA licable
CIAquifer Storage and RecoveryR. ft.FROM TO MATERIAL _ EMPLACEMENT METHOD��
(]Salinity Barrier "''
OAquifer'lest OStorntwater Drainage
(7Fxperintental'fechnolr ft. f►,
Technology I:JSubsidence Control _
0(ieolherltlal(Closedl oo -20;DRILLIN(:L(1GStattach-additional sheets if necaslital '-
p) t 1Tracer FROM �� TO DESCRIPTION• oloIor,hsrdoeas,4giL a k I1Pe,•join du,ei ,,_
°Geothermal(Healing/Coolit Retu i) ClUther(explain under#21 Remarks)._ ft. ft. —
4. Date Well(s)Completed:0 -•.`fM Well'nit /V Zi�� ^' ......_ _______.
ft. 'ft.
Sa.Well Location; - F . a. ;V
ED
Famlity/(.iwnerName Facility ID 4(if applicable) -_.__.......-..__. ___ __._................,
..._&T k'7 y04vH.:l_ O H ef -._. —ft._----ft-.- ~_ ` Ir LT ,OCl ?l.r•Y—
_
4A � tPhysical Address,City,and Zip
,21,REMARKS.^-_�—- �,
Courtly Parcel Identification No.(PIN) ---- T�'~ '—'_'-_....
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
—^� —
(if well field,one ladiong is sufficient)
3S° i ;'V „ ' 9./39-1 w t 't' 4, /l__ Le'-4e .: ‘vd'_- ,06.,2 44-..2a.2 s<
Signature of Certified Well Contractor ' Date
6. Is(are)the well(s): l .Pefmanent or °Temporary
By signing this font,I hereby certify that the well(s)was(were)constructed in accordance
with/SA NCAC 02C.0/00 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: :]Yes or u - copy of this record has been provided In:he well owner.
If this is a repair,fill out known well consuuction it jonnatiun and explain the nature of the
repair under li?l remarks section or on the hack of this forte. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed:
__
construction details. You may also attach additional pages if necessary.
Fur multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9.Total well depth below land surface: ___6',0_5 ' _ _,(It.) 24a. Eor_.ty1 We1b: Submit this form within 30 days of completion of well
Fur multiple wells list all depths if different(example•t«200'and 2®I00') construction to the following:
,�D r „_ (ft.) Division of Water Resources,Information Processing flail,
10.Static water level below top of casing:„
I/umterlevel Lr above musing,use"a" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6'__ _,�(in,) 24b. For Injection Well. ONLY: In addition to sending 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: ROt`Iry _ �____ consuuction to the following:
(i.e.auger,tritely,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYW�+ELLS ONLY: _ _ TT 1636 Mail Service.Center,Raleigh,NC 27699-1636
I3a.Yield(gpnt) J J 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 department of the county where
.._...
�, , "-T constructed.
Form(i W-I Noah Caroline Department of Environment and Natural Resources--Division of Water Resources Revised August 7.01

Qs°tec.e
0 � m Macon C o u n t y 1830 Lakeside Dr
c Franklin,NC 28734
r Public Health [phone]
kt
al� [e-mail]
WELL CONSTRUCTION AUTHORIZATION 4al J° 09'
•
Owner Jim Byrd WEL 051824-1 SEP 052524-1
Location TBD Patton Downs Rd-Franklin, NC PID 6583076407 ACREAGE 3.0
Directions Patton Rd to Patton Hill, L on Patton Downs, go past 264 on left, R on gravel uphill drive
Design Single-Family Well.. Permit Type New Construction Expiration Valid for 60 Months
- 0
' /' 32'
,,L '2, • ,i \ )
•
/ J
10' •
•' a\x°
/' °„2 ,' 41'
30 \
V
yea
ti`'
1
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 6, 2024 ,,,, .—,
Issue Date Jer Pless, REHS 3157