GW1--04547_Well Construction - GW1_20240731

W E1.41.CONSTRUCTION RECORD. - •---. -
'this form can be used for single or multiple wells For Intenigl,Use ONLY: --� -�
r
a I.Well Contractor Information:
Mitchell Dean Cook 14,WATER•.'foNBS _ ---Well Contractor Name FROM T0 -DESCRI T1ON �.� "-'� .
2043 A / .rt. _r ,; _ _._.
_---�... rt. rt. - -
NC Well Comractul(,onificatinn NnR mint
15^ OUTER CAVING.jfor_multi-eased 'O wells R LINE'k ap IcableL _-.-_-
Dennis Holland Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Inc,
Company Namr. '— F/R -2/, i jovc_
• 16:INNER CASING CfR:TIJBn. ' C:(Rcgthermal.closed-too
2.Well C onstr uclioo Permit II: ,or 5 4 FRDM Ti) DIAME'rF;R MATERIAL
(,i.,r all applicable well permits(i.e. �'�- "-"F` on ^-'•• „- ft rt. in, ""-' -
1 Cowley,State, Varimnee,In.
etr..J ,_
3.Well Use(check well use): rt ft---'___io.-
Water•Supply Weal]'.- __ 17.SI RKFN _. __..w.- _ _ _ - ._.__,
FROM 'ro—_DIAMF:I'F:R SLOT SIZE TIICKNRSS MATI:Fa,-M
DAuncultural l7Mimicipal/Public. ft• ft. in. -
°Geothennal(1•Icatinp/Cooling Supply) 7 .sidcntial Water Supply(single) ____ ft'' ___ rt.________
t-^,._ _._ in.
^-
Ulndustrial/Conunercial L7Residenlial Water Supply le^GROUT'^-��'�""'
I I y(sharer!) paoe� 'rn°Irritation _ NIATERIAI.T- EMPLACEM ENT Mentor)h AMOUNT
Non-Water Supply Well: ---•----•-----• fr fL i
pot-&4V .4.1 ,.5 .4 n/.4-1
C1Monilrn'ing ()Recovery sft. rr. L `_ /
I---_-_____----
njection Well: _. _ _ -:.___ m�+-____ '6.,„,,, ~ ll]E1 .,._•+�, 5 t
ft, ft.
()Aquifer Recharge fJCiroundwnter R.emediation .19.SAND/GRAVEL:PACK(jf:�ptieable). - -`—
°Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD-'-',
UAquifer'I'esl It. rt.
L'3Storntwatcr Drainage - __.
QExperimental'fclhno)o,!(y ft. ft.
LJsubsidcncc Control
UC)eothennal(Closed Loop) .24.DRII„•�1 IN(:LOC(at4ch'oilditional shoots if uecesttnt • -
OTr'aceb FROM TO DF4CRIPTIONAsolor,hu f ru,sx1krotk tart:rain sin,etc a.
IJGeothermul(Heatin(/ ooling Roblin!. 00ther Sexplain under N21'Remarks) ft. ft•
ft. ftT
4. Date Well(s)Completed: e��.IQ�J Well 1I)H /V � - �—
Sa.Well Location; -
Na
Q.h �re . 2`s. q.S4 /c,.}44H,t rR .[.I-t-/�... _ ft. ft.
-.. •., • _.
ft, ft.Farility/Uwnch' nte . �.'4..v
Facility IDN(if applicable)
-....__......._.. .._..._._ _._....._.... .._...��i.�--
ft. 1104
ft.
Physical Address,City,and Zip ___ _ _._- - -_
21,REMARKS
-,. :' -.._-"._-
.
"�1.4,a. 4 .44.2/3 9?LS' . f' ,- a _.__�....- --,-Coumy Pm-col Identification No.(PIN)
SI).L,atitude and Longitude in degrees/minutes/seconds or decimal degrees: _ ���^ -'�'�-�' !+
22.Certification:
Orwell field,one tat/long is sufficient)
o
° .2 9 8,37 .e3. ,i4e•s'qr w t 't eEILA L1__. a_.._Ceett_. . 0.7;/?-2.0-2,04
Signanue of Certified Well Contractor Date
6. Is(are)the well(s): piefmanent or f_' fcmpnrary
By signing this Joint,/hereby certify that the well(s)eras(were)con.rtr•ucted is accordance
with ISA NCAC NC.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7. Is ibis a r epe r:t as existing well: U Yes or lDfV6^ copy of this record has been proeidud to the well owner.
l/this is a repair,fill out known well construction infOrnmtion and rapiuin the nature of the
repair under 1111 remark.,section or on the back of this form. 23.Site diagram or additional well details:
You may use the back at'this page to provide additional well site details or well
A.Number of wells constructed;
_�____ ___ construction dentils. You may ids°attach additional pages if necessary.
Fur multiple infection or non.water supply wells ONLY with the snare construction,you can
submit one form. SUIiM1TTAJ.,INSTUCTIONS
9.Total well depth•below land surface:• SQS r _ ,T(ft.) 24a. J QL r111 Weil;: submit this form within 30 days of completion of well
Fur multiple wells list all depths if different(example•.t6200'and 2@100') COnSIIUctiorl to the following:
IO.Static water level below top of easing:____ /_5 (ft.) Division of Water Resources,Information Processing Unit,
I/water level irabinecasing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"T (in.) 20. Fyn Injct(J.Qn Wr.113 ONLY: In addition to sending the form to the address in
RQtafy 24a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: _,..._.._______ conshuction to the tbllowing:
(1 e.auger,minty,cable,direct push,etc.)
Division of Water Resources,Underground IoJecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gum) Method•
___,._.• Method of test:Air lift - 24c.['or Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b, Disinfection type:,M,_&,_H Amount:.12 oZ. well construction to the, county health department of the county where
_..._.. __._..._. constructed.
For (iW-I Notth Carolina Department of Environment and Natural Resources••Division of MawResntuces Rcvisr.A August 2013

•Qsotecr ,
A m Macon County i.iq..- 5*-Lf31830 Lakeside Dr
Franklin,NC 28734
Public Health (828)349—2490
E� ' ',>a
a [e-mail]
WELL CONSTRUCTION AUTHORIZATION
Owner Andre&Kathleen Van Teeckelenburgh WEL 051624-1 SEP 025508
Location 186 Breezewood Dr—Franklin, NC PID 6569139785 ACREAGE 2.02
Directions 28 N to R on Breezewood Dr; lot is on left
Design Single-Family Well : Permit Type New Construction Expiration Valid for 60 Months
•
% 1 l 26, i,�Well Area
Drain field I
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cb
G 7'
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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.
June 6, 2024
Issue Date Jere Pless, REHS 3157