GW1--04643_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD R m- -------- --
This form can be ued for single or multiple wells • For Imamhl rise.ONLY
'.I.Well Contractor Information:
Mitchell Dean Cook 14.WATER,ZONES _ .,-_.__�.__
. ! �
FROM TO DE3CRIP'rTUN -•- '•� .._
Will Conn-actor Name - , ft.
2043 A ft. ft •—
NC Well Contractor Certification Number 15.DUTER'CASING. tor:multi-cased wells`AALINE its-Ileable T - . _-
FROM TO S DIAMETER ) THICKNESS . MAT RE tIi•'�'•-'
Dennis Holland Well Drilling, Inc, ft, _•rt. /,Company Name _ -- - d � .._ in. .SGh(' .I/ i Pe G
•16.INNER.CASING OR-TUBIIVC:•(gcuthernr_al.closed-loop) .
2.Well Construction Permit N: FROM TO , DIAMETER THICKNESS MATERIAL
Gist all applicable well permits(i.e.County St�Varia� Injection.etc) ft. -- ft �- -- in.
3.Well Use(cheek well use): _ . ___
_.
_ 17 SCREEN .-__ -..__._-._. ._.•� -.--_-__-_......._.-____.
Wafer Supply Well: '•' - .FRUM TIT--'• ,_DIAMETER SLOT SIZE THICKNESS MATERIAL.
°Agricultural 1]Municipal/Public ft• ft. in. "-
°JGeothennal(limiting/Cooling Supply) pitKidential Water Supply(single.) ft. II, in.
Ulndustrial/(onunercial t_]Residential Witter Supply(shared !g.GRUUT -—R -"'- '
°Lai atiell ) !R�>M��fO _ MA'fERIA4_ EMPLACEMENT ME771f)D&AMOUNT
Non-Water Supply Well: _ 'ft.
,/' Is. ��L�!_
.--_ .. 'Z1 ._:,'a 412%.S /gv-rya/°
°Monitoring °Recovery • ft , ft.Lyzll: --______`- _" '-- ft. ft. I '
CJAquifer Recharge C]Groundwate.r R.emediation i9.SAND/GRAVEL PACK(if gipticable) . ...._.,.
I]Aquifef Storage and Recover TO MATERIAL EMPLACEMENT METHOD"
ry liSalinity Barrier R. ft
°Aquifer Test OStorntwater Drainage —__ -_ -
17Experimental Tcchnolo ft. fr.
i5Y USubsirJencc Control 720:
tjCieothen»al(Closed Loop) DRII,LINA LOGSanachadditional sheets if necesi l•
°Tracer _FROM TO DESCRIPTION_Volpe,hardoees,soil/rock izpearain size,etE:1
iJ(!eothermal(Heating/Cooling Retunti. DOther(explain under#21 Remarks) ft. _ ft.
tt. _ ft- _ _
4, Date Well(s)Completed:C17-. 3 fLWeliMN /V � . -.______- y���mm� �_,
ft. �_ft t
Sa.Well Location: — -_ .�_y. !ii4''`� "*---
ft. ft. c/ I
t i-.0,E.-...,Z..- -e 4-.?1, 4,-. w._ rt. ft. V 5 2024
Facility/Owner Name Facility ION(if applicable) - -._...._..._ ..._.... _.___._..._- _......_
rt. ft:•
�2�'3 --• ft. IX;•ra•. .:?=L=•sires: ,; t._—-
_ tip►r-S
Physical Address,City,and Zip -_ _ Y^-..-
21,_REMARKS
County Pmrol Identification No.(PIN) ----- -- - - --_____�_..
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: _T____ T -. ___.T_____.___...�_
22.Certification:Certification:(if well field,ante tat/long is sufficient)
3 5° 165,',? ,I " , :g-i"" w t .f..i2_.e,/1__. ‘r _._ !'. a?--..il-.2e7.2-X
Signature of Certified Well Contractor •. Date
6. Is(are)the well(s): 14.1 e[f'manent or OTemporary
Ily signing this join.I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to so existing well: OYes or IDNo�- copy of this record has been provided to the well owner.
if tiros is a repuu',full out known well construction information and explain the naturr of the
repair under al 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
S.Number of wells constructed: I •_ ___ construction details. You may also attach additional pages if necessary.
For multiple injection or non•wtmer supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL,INS•I•(1CTiONS
9.Total well de th below land surface: _
P �7�'Q� (ft,) 24a. ERC..tjj Wells: Submit this form within 30 days of completion of well
Fun multiple wells list till depths if different('example•.l a 200'and 2@/oo') construction to the following:
Jae r _ ___ ____ _(ft.) Division of Water Resources,Information Processing Unit,Static water level below top of easing:.
if water level it above casing,use'' ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:• 6" (in.) 2 rb.For Inleetion Wells ONLY: In addition to sanding•the farm to the address in
Rotary 24a above, also submit a copy of this torn within 30 days of completion of well
12.Well construction method; consrction to the following:
(i.e.auger,misty,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
13a.Yield(gpnt) I� Air lift 24c.For Water Supply&Infection Wells:
__.._.._. Method of test:_ _
�`I M Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,__,,._.,•-• _- Amount:,�2 oz, well construction to the county health department of the county where
___ .... constructed.
Vann(iW-1 North Carolina Department of Environment and Nat Resources••Division of Water Kesnwces Revised Amos!2013

Q/otecr
r+ ° m Macon County 1830 Lakeside Dr
Franklin,NC 28734
•
Public Health (828)349—2490
°mod 0 l: [e-mail]
WELL CONSTRUCTION AUTHORIZATION
Owner Eileen L.Armstrong WEL 060624-1 SEP 071818-S
Location 283 Laurel Drive PID 6564554120 ACREAGE 1.25
Directions Wayah Rd.,to R onto Laurel Ridge, keep R and lot is on first curve on R.Across from#220.
Design Single-Family Well Permit T .e New Construction Ex.iration Valid for 60 Months
u Y
5' 11'
r i
12't '
0
28' 56 t
33'$
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FA-
15'7id
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ci
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23' -2- cIN
63
15, o:
7
c a
63 22 V
N7
,10 p\-
1P
Caere/Orive 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 14, 2024 ',
Issue Date Chaz Allen,REHS 3258