GW1--04267_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD For Intemtyl Ilse ONLY:
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'nlris form ran be rued for siugle or multiple wells
1.Well Contractor Information:
Mitchell Dean Gook 14.WATER Z.ON'S
• - FROM TO DKSCRIMON
Well Contractor Name �Q'ft. "•"_" ,, ft.
2043 A ft. ft.
NC Well ComractotCenification Numbcr 15.OUTER CASING.,(for multi-cased wells R.LINER if ap IlcableL_T M
FROM TO DIAMETER TAICKNKSS MATERIAL.
Dennis Holland Well Drilling, Inc, rt. rt,
Company Narue.. _ T R 16;INNER CASING OR:TUlbim( cothermal closed-loon)
FRAM TO D�IAMF__' 'THICKNESS MATERIAL
2.Well Construction Permit 11: � �.1. ft. T"s ft. in, --
Lis,all applicable well pencils(i.e.Cotully,Stale, Variance,Injection,etc.)
s ft.
3.Well Use(check well use): `
17.SCREEN_ _ _
Water Supply Well: '" FRUM 'ro DIANIF: ER_ SLOTSIZK THICKNESS AtATF:RAL
Uricultural
LJMunicipal/Public I -
OA ft. _ _ ft, in. —�
_ _
flGeothennal(lleating/Cooling Supply) 7 sidrntial Water Supply(single) ft. ft. in.+ -
Olndustriul/Conunercial UResidential Water Supply(shared)
_PROM TO M_TEii EMPLACRM ENT M KT11OD&AM 0UNT
Cllni anion___ ft, , ft.
Non-Water, upply Well;
�
Divlonitoring URecovery ft. fr..__y__^
Injection Well: — '—' ft. ft.
OAquifer Recharge CJ Ground water Remctliation .19,SAND/GRAVEL,PAPACiC'(itffp lip cable) .
(]Aquifer Storage and Recovery f.JSHllnity BarrierFROM TO MATERIAL EMPLA'EMKNTMFTHOD T—
ft, ft,
OAquiferTest LJStonnwatcrDrainage - - -• -
(JExperimental'rechnology IDSubsidence Control
UCieOthetlnal(Closed Loop) 20.DRILLING LOG attach additional sheets if necwb �
P) OTracef FROM TO _ DESCRDTION�soror h rdoras soiUroek inn
�rainsize Lt�.L
UG cot[ernial(Hrating/Cooling Retum) UOther explain under 421 Remarks) rt. ft.
ft. _�n
4. Date Well(s)Completed: ! 07- ell IDH u_���-. �- ft. •�-ft. _ �� � _�������
Sa.Well Location: ft. ft. s `—
_ ft. ft,
Facility/Owner Name facility IC)H(ifapplirablc) ft. •- _ fl."_
T ,J i rf'v'�AT. --'—
Physical
l�Address,City,anti Zip Z1,REMARKS
County Parcel Identification No.(PIN) /f
Sb.Latitude and Longitude in degrees/minutes/secon(is or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Silptature of Certified Well Contractor Date
6.Is(are)the well(s): lucent or crfemporary
(7y signing this jairr,/hereby certify that the well(s)arcs(were)consnucled in nccordancr
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: UYes or Lam— copy of this record has been provided to the well owner.
I/this is a repoir•,fill out known well constnrction itYbonation and eapluin the nalurc of the
repair under 1121 remorks section or on the hark of this fornn. 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 ntlach additional pages if necessary.
Pot nudliple injection or non-tvater•supply wells ONLY with the.same construction,you ran
ntbmit one.form. SUBMITTAL INSI•UCTIONS
9.Total well depth below land surface: __ _(ft.) 24a. Eqr�All Wells: Submit this form within 30 days of completion of well
Po,nulliple wells list all depths ijelijjerent(example-3 rt 200'anr17• 100') eonstmclion to the follo%011g:
10.Static water level below top of casing:_�3d (ft.) Division of Water Resources,Information Processing Unit,
ff water level ir above casing,use"," 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6° (in.) 241). For Injection Wells ONLY: to addition to sending the form to the address in
Rot 24a above, also submit a copy rf this funn within 30 days of completion of well
12.Well cuusiruetion method:__ ry _ construction to the fi)Ilowing:
(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
l'3a•Yield m Air lift 24c.For Water_Suppl &ly njection Wells:
(gP ) �r Method of test:--- - ----._..........
Also submit one copy of this form within 30 days of completion of
13b.Disinfection •type:•H & H well construction to the, county health department of the county where
constructed.
porn GW-I North Carolina Department of Environmcru and Natural Resuurres••Division Of Water Reanm'ee5 Revised August 2013

Q<°tec.t
• 1830 Lakeside Dr
Macon County Franklin,NC 28734
O r ' Public Health (828)349—2490
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o � [e-mail]
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WELL CONSTRUCTION AUTHORIZATION
• James Martin 041124-1 032924-1
• TBD Georgia Rd—Otto,NC 6580785983 0.84
- Beside 7570 Georgia Rd(Putt-Putt)
• Single-Family Well New Construction r Valid for 60 Months
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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 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.
April 25, 2024
Issue Date Jere less, REHS 3157