GW1--04948_Well Construction - GW1_20240816

WELL L CONSTRUCTION RECORD) --- - ---
•fltis forte c toed for single or m ent
multiple wells For letill Use ONLY: ��
an be
11.Well Contractor Information:
Mitchell Dean Cook -...____ .._ . -_--_ __�_-
14.WATER:%ONES
FROM TO DESCRIPTION -...—well Contractor Name _ __ rV90 ft�� _�� ___ ._,_.__..._
2043 A — 1.59, n •�
—----_ . . ft. ft, _—
NC Well Cowectot Certification Number IS UTER C;ASll'sgiiorrmulti-eaied wells Ball E-,if BP leable ^" •�
FROM E,ro DIAMETER p� Z"IAC-• -—
(r�t?f1fllS Holland Well (�i'IIIIfICj, Inc, 4:3 • • t. THICKNESS MATBRUL
Company Name "' - - i ter,
•'IJi:INNER'CASING OR:TUB .f:-(geOthertnal.closed-too --
2,Well Construction Permit It; _ FROM TO DIAMETER iHICKNESS MATERIAL T-
f fist all applicable well',emits(I.e.CountyS$� Nance.
n e%jecllonn,.etc.) ..._.'-"_.___.._._-._. ft, — ft. _—_v_ ia.
3,Well Use(check well use): ft. _ ^^fL m.'
If iiiii571—
Wafer Supply Well: — FROM To�"�-' DIAMKTF:R SLOT.SIZE T2ICKNESS MATERIAI._Y
(]Agricultural t7Mtuticipal/Public ft. fr. _ in.
f.IGrothermnl(hleatinf/Cooling Supply) . sidcntial Witter Supply(single) -~ ft. ^^�ft. in. —
Ulndustnel/(.:onnnercial 1S,QRUUI'_. --�__.__.._..-t"f_7Residcntiel Witter Supply(shared) ..
El Int titian FROM 'YO . h1A'r iiiAt. ,_.,.( Ea1PLACEMENT METHOD d AMOUNT
Non-Water Supply Well: — ,, • ft.. . 3 . ft. ,p !/
OMonitoring ,^ fL • i fr. 1..f..ea�id��.-'.���_ �`��17/e,_
L)Recovery h•4.'42 :, .-z,._ r7s, - /
Injcctiuo Wr.IL '—'-' "` '—" ""'-- ------
ft._ ft.
UAquifer Recharge CJOroundwater R.enlcdiation .19, AND%GRAYEL PACK(Ifoplicali e)..
IJAgatfer Storage and Recovery • FROM TO MATERAAI, EMPLACEMENTMETH—W
IDSalinity Barrier ft. 'ft.
°Aquifer'I'est t7Stornlwatcr Drainage -- --
UF.xperimcntal Technologyft. ft.
l:J:iubsidencc Control _
OGeolhennal(Closed Loop) .20;DRIlliNG L044iattaeliadditional sheets it neces l •
p) OTracet ' FROM_ TO DFsClalrrloN•ironer,tintless,soil/reek IYpryirate size,ao.L�
fiCieothermal(Heating/Cooling Retunt) DOther(explain under N21 i eemarks) ft.• ft.
4. Date Well(s)Completed: r.de�z�d' ,4WeII ID# /V T�_
So.Well Location: -�--- l a /
ft. ft. `,.,� '�. tt✓ ;w
/41d.---.,.., ,V(0- ` u_„ ......-Z14.144.. rt. ft AUG
U ,
_...u...l.-. ._2024._...._.
Facility/QwncrNnm¢ Fncilit,Ylr)N(if applir,ablc) ------•__.. ....__.._......._._ �......_. _ _
ft. n.
'y G
�P `ske ii. l!�',Gfti Tr i. _..._.ft._w__ ft. %)�"3
Physical
Address,City,and Zip 11.REMARKS ..._..__—_—_._._._— ,.-_. ' _.._..�._.__
County Porno'ldentilicntirnt No.(PIN) _____`-_,__ ,�._ ____....
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification; _ �_�__ ��
Orwell field,cite Iat/linig it sufficient)
As° a45 -�R ,) • S3v '71-'20 5 W _d6, .t-4=::i..e /L_. rel...__i! .e_i_'_. 6r6.-v5-an-154
Signature of Certified Well Contractor •. Date
6. Is(are)the well(s): Ia.Pi1 aocnt or fa'fcmpnrary
fly signing this feet, I hereby ceriihr that the weil(s)was(were)constructed in accordance
with ISA NCAC 01C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and than a
7.is this a repair to Ro existing well: DYes or Lt:}t,fg.. copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it formation and explain the nmarc of the
repair under ll2/remarks.section nr on the back 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
A. Number of wells constructed;_� __ ___ construction details. You may also attach additional pages if necessary.
Fur multiple injection or iron•water supply wells ONGY with the sane construction.you cot
ntbmit role form. SUILMITTAl.,INSTUCTiONS
9.Total well depth-below land surface: 6'4:5 • _ _Aft.) 24a. Er,Ajj Wells: Submit this form within 30 days of completion of well
Fat multiple wells list all depths if different(example-3(u 200'and 1 a@l00') construction to the following:
water level below top of casing:• _ Division of Water Resources,Information Processing Unit,
10.Static
it way level it above casing,use. "+" 'T-�^ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter:��_ (in.) 24b. For Injct;lj„q•n Wells ONL,Y: In addition to sending the form to the address in
Rotary 2..4a above, also submit a copy of this font within 30 days of completion of well
12.Well constriction method; _ _ ctalsuuction to the tbllowing:
(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
•
13a,Yield Air lift 24c.For Water Supplx t Injection Wells:
(gpnt)„�_-�,S •• . Method of test:__._..___._._.----..._....._
Also submit one copy of this form within 30 days of completion of
I-I & H Amount: 1.2..0Z., well construction to the county health department of the county where
13b.Disinfection type:
.__..._...._.._.......__.._. . _I_ constructed.
Form OW-1 Notth Carolina Department of Environment and Natural Resources•-Division of Water Kesnwtt Revised Altruist 2013

Q<otect
• ori •
m Macon County 1830 Lakeside Dr
Franklin,NC 28734
° s Public Health
; (8(828)3492440136(Flax) •
,d gam ( )
WELL CONSTRUCTION AUTHORIZATION
Sal - 567
Owner Paul Byrtus WEL 060522-PR SEP 061622-S
Location Lot 18 Sunset Trace Trl PID 6568714341 ACREAGE 2.1
Directions Lower Burningtown Rd to R on Sunset Trace Trail to Lot 18(on R near end)
Design Single-Family Well Permit Type New Construction Expiration Valid for 60 Months
IP
°11111
E A
a• rope
S �
P41
/201
rdl.
e • 11hIP Well Area(5'z5')
L
Proposed
House
-ova.
Sunset Trace
Diagram not to scale
Permit Conditions
1) Well shall be constructed in compliance with all i5A 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.
July 9, 2024
Issue Date Trevor Justic REHSi 3294