GW1--04584_Well Construction - GW1_20240731

WEL,I., CONSTRUCTION RECORD PorintamalUscONLY: _T��- ^!^ —
This form can be used for single or multiple wells
1.Well Contractor Information: —
Mitchell Dean Cook 14.WATER ZONES ___ _ .•
• PROM TO DESCRIPTION
Well Contractor Name �— �/uJ'ft. � ��r ft. —.___. ____.__
2043 A ice,rt. ft.
NC Well ContractorCertificatimt Number 15,OUTER CASING. for,multi-cased wells OR'.LINE if air_
T-- _ �TY_'_' �'.R DOM ft. TO s•ft, DIAMETER in. THICKNESSRIAL.
Dennis Holland Well Drilling, Inc. ""
-- -1.46 6 (s,�P�..z/ i r°Lrc
Company Name • la:INNER CASING OR'TUB 7(.'(Reothermatelosed-loop).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: 4„,./Q-.' tf-/ ft. ft. in. V'—`
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) V --. .----------.--., . _--
ft. ft. to.
3,Well Use(check well use.): 17.SCRRi:N_.,_...__--.1_..._.__..µ.._ _ --
Water Supply Well: — _FROM TO_ DIAMETER SLOT SIZE THICKNESS MATERIAL.•_—,
DAgriculhlral [7Mlmicipal/Public fr. rt. i6•
_.- _-- -4 _.__
f:ICjeothennal 1-leatin Coolie . 7 Supply) sidential Water Supply(sin,le ft. ft. in.
Ulndustrial/Commercial (_°Residential Water Supply(shared) 18.GROUT __
mom 'f0 TMA_rERJAL EMPI.ACF.MENT METHOD&AMOUNT
°Irritation R. ft.
Non-Water Supply Well: _� '- 0- - �Qr��?0' ✓ 2 fq��S _pS, ,-
3 / ft. ft.
❑hl0nitol'ing ,,T _ (,Recovery _.. _- n lfrveiyr. —_� i
Injection Well: --- -•�.-"_ "-' . It. ft.
0AgIIifer Recharge []Groundwater Remediation .1.9.SAND/GRAVEL.PACK(if applicable) . - _
' FROM TO MATERIAL EMPLACEMENT METHOD— _
(]Aquifer Storage and Recovery (:)Salinity Barrier It. ft. _
°Aquifer'l'est C]Stormwater Drainage - -- -- -
ft. ft.
Ol.xperimental Technology 17Subsirlence Control -20:DRILLING LOG(attach additional sheets if necesa t_.
°Geothefttlal(Closed Loop) (_7Tr'acer FROM TO DFSCRIPTIONJcolor,hardness,IoiVry ps jr ck liain size,eta._
°)Geothermal(Heating/Cooling Return) °Other(explain under N21 Remarks) _- ft.T _ ft. `-_
`^ � __ _-��
ft. ft
4. Date Well(s)Completed:ul?7/.2 ! Well Wit /V ft. ft
Sa.Well Location: ` r 1..; i=i _
ft, ft. r - J j
Facility/Owner Name Facility link(if applicable) -_---•ftft.
_.�____.........._._._.__.__-.._. .,` 24_ ._..._...__._
L.0 jt-- S /� /2_ . ��44": he i//S ft._ _� ft. ___- `^ , r'3 a t�r9,_..^
Physical Address,City,and Zip 21,REMARKS -_ , _Al!,::`••,.1— a C :'i' v,_—___
_ ram ' _ rv�BG.L S�,�i/!7�_ _�__ �_ _._._.__.._ __T__
County Parcel Identification No.(PIN)
T -T—
Sb.Latitude and Longitude in degrees/minutes/seconds ordecimal degrees: 22,C.ertification:
(if wall field,one lat/long is sufficient)
,3 5 , /D /. ..2.2 w __Al i 't' :1..e././_. "m_.._ .--,vd'_. �_/? - .i o-; V
Sibmature of Certified Well Contractor • Date
6.Is(arc)the well(s): I].Pefrnaecnt or CDTemporary fly signing this form,I hereby cerib,that the well(s)was(were)constructed in accordance
with ISA NCAC'02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or !$tVo- copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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 or well
8.Number of wells constructed: __ __ _ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INS'1'UCTIONS
9.Total well depth below land surface: rpOS- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-.t a 200'and 2Q100') constntction to the following:
10.Static water level below top of casing:_� ,.RO __.--(ft.)
Division of Water Resources,la formation Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6„ 24b. For injc.e.tion Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: (in.)
Ma above, also submit a copy of'this firm within 30 days of completion of well
12.Well construction method: Rotary _ _ eonst action to the following::
(i:c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WAFER SUPPLY WELLS ONLY: T __ 1636 Mail Service Center,Raleigh,NC 27699-1636
)_ Air lift 24c.For Water Supply&Injection Wells:
(gpm 13a,Yield �'� Method of test:_____,___.____._..._.._.._ Also submit one copy of this form within 30 days of completion of
H & H well construction to the county health department of the county where
13b.Disinfection type:,__...__...___.......__.._, Amount: � ��•
-,__._--_._--._... constructed. '
Revised August 201 i
Form(I\V-1 Not th Carolina Department of Environtncin and Natural Resources.-Division of Water Resources

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Qrotecr —�--�(� (r /( (il V �" va v /1 IL
1830 Lakeside Dr
o .`� 0 Macon County Q1- 05 yq Franklin,NC28734
o Public Health q� /� c U [phone]
��A CDC '
WELL CONSTRUCTION AUTHORIZATION
Owner Lucina L. Hernandez WEL 061024-1 SEP 061424-1
Location Lots 12-17 Cedar Hills PID 6582431117 ACREAGE 18
Directions GA Rd to R onto Addington Bridge Rd to R onto Skennah Rd property is the on Right
Design Shared Well Permit Type New Construction Expiration Valid for 60 Months
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15'
eC\%'e, ,' 4-4-1..Qo,_,. ,' Permitted
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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 20, 2024 cite ---
Issue Date Chaz Allen, REHS 3258