GW1--04645_Well Construction - GW1_20240809

W.ELL CONSTRUCTION RFCORD -
Tins form can be used for siugle or multiple - Fur Imp enigl Ilse ONLY R—R ---- --
r
.1.Well Contractor Information:
Mitchell Dean Cook 14.WATER•%UNES-
Well
FROM -TO" —DESCRIPTION Well Contractor Name
2043 A a �t�/
1.4.,ft. ___
_--------_ ,ft. /rr. --- —
NC Well Cuatraeir C ificadon Number "-P'^-'•5i4/ _ _
MUTER CASING.jfo►multkissed•wells'Aare -.hap Iwble .....
Dennis Holland weiI Drilling, •
ROM ; PTO 1 DIAMETER THICKNESS " """__-
, Inc.IncMATERUL_�.-
O •r fl. eft, „ in. r�/
Company NAM,. "" "'"". -- --- _ _ _. _.� r � � iz._
IC INNER'CASING OR:TUBg•(geothermal•cl sl-f
2,Well Construction Permlttl; FROA PTO , DIAMETER ER MATERIAL
l.i.cr all applicable,roll permits(I.e.Cuwn .,...er.2_ _a'"".._.^^_..-._�... ft, ft. in,
y,.State, Variance,Injection,etc) _ -—
3.Well Use(check well use): ft. fs,^-__ _ ---ib.^ '-
Water Supply ' 17.SCRRiiN_.-....---_,_,.__.--..�,._ _,.-.--_--._.--
Well: FROM ii��--:DIAMETER . ,,SLOT SIZE THICKNESS MATERIAL°Agricultural (7Mtrnicipa1/Public ft. ft. in. -
f.IGP.othennal(Heating/Cooling Supply) 7 .sidential Water Supply(single) ft. �-ft- in.^�' R -
Uln(hlslriul/(:rnnmercial L7Residenlial Witter Su)it (;RUUT_-.-'__- -. - --
Simply y(shared) ,aw _To.� MATERIA I. EMPLACEMENT M Vigil)6 AM0UKr
•Nan-Water Supply Well: --- ft. fr.
°Monitoring ___ CJRecovery ..irt• �,� i rr.
Injecting Well; ---._-._.--.,__._-..- _.--._-_..-_,.....-___ _ t.oPS'! t �c�r. k?.^ •-�4� �uiz��-ft. ft.tt.
UAquifer Recharge l7Grountlwater Renlc(1iatiun 19.SAND/GRAVEL,PACK°-f:app,Itcablo).. "-
°Aquifer Storage and Recovery I.)Salinity Barrier FROM _ TO MATERIAL EMPLACEM6NTMF.TNQU"
°Aquifer'fest fr. h. __.._
l']Stormwatcr Drainage
°I'.lfpef1111riutal l'eeh IOfe ft• rt.11Y 0Subsidence Control
.
OGe..0theflllal(Closed Loo 20;DRI1 1.tN(:I.U4 tt>toh additional shoots If neessial_ • .____-•�
p) OTracet FROM n TO DESCRIPT•IOU color,hsrdars jolUrock 1 gi -
. °JGeothermal(Hcatini�/Coolina Reim!. DOther_(explain under 1121 Reinert)._ 1- ----Y�`'s+'I"ilu is�
4, Date Well(s)Completed: r d7-j4, Well IDH /V � ft.
ft.
Sa.Well Location; - r_ ,�1 +` i
Facility/Owner Name FncilityIDU(if applicable) ----.._._.__......._..__.-__ ._..__..................�_.__-_.__._ _�...-__.._...._...._._
.y�, ft. ft.
`r"f Irfvlr.:,, A-r.r`s ".e +
Physical Address,City,and Zip , - -� ��-
21.REMARKS •,-_,-__
County _.. Pascal Identification No.(PIN) -- ----�- -_ _, _.._ ___..
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ___..____.- - - ---� _-�""�------
(if well field,one IRVlong is sufficient) 22.Cet'tification:
-'3'p�s,Q o2S ' w __Alt '�' : ic,:/L_._,L .. C,P1'_. o.7- Z y_ -2oa 9-
Signature ofConilied Well Contractor • Date
(. Is(aro)the wells( ): Icrfmaocnt or f•'I'fcmpnraty y hereby (/ (were)
(1 signingthis grit, / certify that the wells was were cwrsavttrd in accordance
with ISA NCAC'O2C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7. Is this a repair to au existing well: 0Yes or IOmir
copy of this record has been pro,•ided to the well owner.
If this is a repair fill out known well construction it formation 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
S.Number of wells constructed: ___ construction details. You any also attach additional pages if necssnry.
For multiple injection or nun•wnrer•supply wells ONLY with the sante construction,you can
submit one form. SUBMRI,TTAL,INSTUCTIONS
9.Total well depth below land surface: a 0.5 _..(ft.) 24a. fql„IIII Wells: Submit this form within 30 days of completion of wel l
For mrdriple wells list all depths/fdifferent(example-.1 ft 100'and 2®100) constmction to the following:
10.Static water level below topof casing: 3 / ft, Division of Water Resources,Information Processing Unit,
theater fere,is above Casing,use. " '• -_�_.____�_( ) 1617MRilService('enter,Raleigh,N('276991617
11.Borehole diameter: 6„ (in.) 24b. For_lnjgf(!On Wells ONLY: In addition to sending the form to the address in
___ -Rotary
12. also submit a copy of this limn within 30 days of completion of well
12.Well construction method,` colisuuction to the following:(i.c.auger,intaiy,cable,direct push rte.) �� _ _ ___
__ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �^ 1636 Mail Service.Center,Raleigh,NC 27699-1636
1 Ta.Yield(gpnl)_.__ ...Lt1' • Air lift 24c.Fur Water Supply 8i Injection Wells:
_.-___..__. Method of test:-_,_•,_____._.__..,..._....._
Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type:,___&•.M•,.,_- _.. Amount:,1 g•P where
..._. .._..__ ._... well construction to the, county health depnrement of the county
_. ._., constructed.
Form(iW-I Noitlt Carolina Departmmn of Environment and Neutral Resources••Division of Water Rest-autoKevisrd August 2013

/ I 3 Se, -'dx�
} (ii—t—oeet• 1 I P l "V
o Macon County •
a Dr
a Franklin,NC 28734
kr Public Health (828)349—2490(Office)
40r/. aoJ (828)349—4136(Fax)
WELL CONSTRUCTION AUTHORIZATION
Owner David&Sandra Foust WEL 021724-2 SEP 024024-1
Location Lot 44 Buck Mountain Rd PID 6597833113 ACREAGE 2.6.
Directions 441 North,L on Sanderstown,R on Thompson Rd,L onto Buck Mountain Rd,Lot at the top.
Design Shared Well Permit Type New Construction Expiration Valid for 60 Months
,
2.'N'''''.'N'N..... '
I
---- =- 0/� o• Well Area •O-—d—B—d '— 6Y RoadCenser
10'
We raj ---__—
(10'x 10')
•'$ Pm f
a o
P
t
Gravel Rd '16
Q Pine Marked with Tri• - ••• White Ribbon ``,j
17'
I I '
I
I /
I I
I I ',
I Septic area Initial and repair I ' { ''
I I , .
L I ,:�
15'Min. 25'(15'Min.) 1
•
Cut bank_____ ______ 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, and home is ready for CO, 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.
July 18, 2024 L /#.—Issue Date 1,.. ...—/ANiv"b1-411".".
evor Justice,REHSi 3294