GW1--05188_Well Construction - GW1_20240903

•
WN;L,L CONSTRUCTION RECORD ._-T _ ____
This fonu can be used for single orw multiple olIn For Intentgl Use ONLY:
r
1.Well Contractor Information: _
Mitchell Dean Cook• la'ATERZON>,S'. . ..__ __.__
FROM__ TO� _ DESCRIPTION -....._.....-.--._.------Well Contractor Name ~'_ �5 r ft. y6, (t, -_...____._._-.
2043 A ,rt 3 26rr: '--
NC Well CoonracugCcrtificerimu Number 15.0UTER CASING. for:WUItI asetwellp`OR;LINE-If livable —
FROM TO S.._ - f PL .._......-.___.._
[.tennis Rolland Well Grilling, Inc. DIAMETER THICKNESS MATBRUL, -
Company Namr, —_—_ --- _ _ .�.. �: 'S `.2,1 i _ YC
• 1:6,INNER CASING C1R;TUB Gicnegthermal.cloretl-too
FROM TO DIAMETER MATERIAL 2.Well Construction Permit ll:_ -1.2 "A -fL ft. in.
Uri all applicable well pen nits i.e. ¢' v��" -_..._._._..__.-_....
l ( County,Slnle, Parlance,lnjrcriun,etc) _......_..-_..._ — _
ft. ft. _in. - ---
3.Well Use(check well use): „_„-,____,_-___ -1
WAteI'Supply Well: -- - •F^ROM To T- MAMKl'F:R SLOT SIZE TItICKNF.SS MATERIAL
OAgricultural tJMrmicipal/Public ft. ft. in.•-
f.IGeothennal(l Iratinp/Cooling Supply) 7 sidential Water Supply(single.) ft. ft. - in. -"
Oindustrial/(.:onmercial IS._C;ROUT--.-.-w.__.__-____-_'-'�'_'-liResidential Water Supply(slurred)
poet_��To -l-onit;RIAt. Ea1PLACEM EMI M Entoo h AMOUKr
Non-Water Supply Well: — -. 0 _ _ r
.It. rt.
°Monitorin .�^ ft, ,.ft.
Injection Well: — " -' .___-._ ft. ft.
UAquifer Recharge CJOroundwater Remediation .19.SAND/GRAVE!,PACK(N. phi is e) .. --,-,.
()Aquifer Storage and Recovery (:]Salinity Barrier FROh1 _ TO M1IATERIAh MEMPLACEMENTD
ft. ft.
°Aquifer'lest UJSlonnwatcr Drainage --- - - --- - _ — -- __,..
rt. ft.
IlF.xperimental Technology DSubsidcnce Control
20;DRIIII.ING LOG(a114vh'additional sheets If neceesa l_ —
(3Cie0lllerllal(Closed Loop) al-racer PROM TO DESCRIPTION color,herdors so_rook i min size,arc.
...I...� Wit.—_.....-2Pa,t L^
['Geothermal(FieatinVCooling Return) DOther(explain under N21 Remarks) ft. ft.
4, Date Well(s)Completed: t jy3 .F
-2- - ell IDN f V A�_ ' -• - -- - -• --- ---- - -
rt. ft. S P n ,,
Sa.Well Location: - - -- ---� �- t----
L - ft, ft.
ti ... -9CG6r2�,9f4G?5 -__ ��.. _ ft — ft.
Facility/Owner Name �._._-......._..__._..._._._ ._...__....-. __.__-_..._...yam.;,,._ _....___
y // ' Facility IDN(iCapplirablc) ft ft
•
7..5$ s ,,LoJ f--��9� ___2a4
.._ -ft._ _ ft. _ _- - _..__.-._..-._
Physical Address,City,and Zip 21,REMARKS -T__ -� _.�, _.. -- .__.,_.__
-__._._._._T.-___.-.-.-- �. —.— .. _
County Pnrral Identification No.(PIN) - --- _— _
--------------------
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,sire Iat/long is sufficient)
3 ty, J c'a. d .."3, . . 3 3 33 w ...M i -4:-.A. Ll__._ r.�2..- CT,?1?if.___- -??.2 - 2
Signature of Certified Well Contractor .. Date
6.Is(arc)the wcll(s): 1perriianent or /_!Temporary
By signing this Joan,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or ISA NCAC 02C.0200!Yell Construction Standards and that a
7. Is this a repair to an existing well: (']Yes nr glNir
copy of this record has been provided to dmo well owner.
If this is a repair,fill our known well construction it loramlion and explain the nanue of the
repair under fill remarks section or on the hack 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
S.Number of wells constructed:_1 ____ _ construction details. You may also attach additional pages if necessary.
For nndiiple injection or non-water supply wells ONLY with the sane construction,you can
submit one form. SUBMITTAL,INS'I'UCTIONS
_,9,Total well depth below land surface: L}'lfs _ .(ft.) 24a. C,q UI Wells: Submit this form within 30 (lays of completion of well
For multiple wells list all depths if different(example-t(a 200'and 2 aQ/00') constiuction to the following:
10.Static water level below top of casing:-__-5O 1 •__`_,__^__ _(ft.) Division of Water Resources,Information Processing Unit,
II water keel i.n abuse cr15/lug,use. "4" 1617 Mail Service Center,Raleigh,NC 2'1699-1617
I1.Borehole diameter:6" (in.) 246. For Injection Wells ONLY: In addition to sending the form to the address in
,--Rot 2'Ia above, also submit a copy of this form within 30 days of completion of well
12.Well cuustruction method:�_._�ry _� - construction to the titllowinl;:
(i.e.auger,rotary,cable,direct push,etc.) _ _
__ _ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: T 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(guild__ oZ� •• Air lift 24c.For Water Supply&lnjection_Wells:
_.-___•.-_., Mcthnd of test__•_•._-___._,__- Also submit ono copy of this form within 30 days of completion of
13b.Disinfection type: .Amount.-- _----
Rosined constructed.
Feted fiW-I North Carolina Department of Environmcm'and Natural Resources•-Division of Water Resources Rosined August 201 J

:11
� `" Macon County NEW WELL CONSTRUL I ION
�° Public Health Q't,uvia..'vo CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Dag- 3�0<- e3r� 7
APPIiCANTIOWNER Gumaro Cardenas LOG# 120923-P OSWWA N/A
INTENDED USE Shared Well, Residential PID # 7505527441 ACREAGE 7.5
LOCATION 1538 Bethel Church Rd
DIRECTIONS 1538 Bethel Church Rd
millions: -----
Animal Lot must be removed before well can be installed.
Well shall be constructed in compliance wifF all NCAC u s.
Maintain minimum setbacks as applicable.
Diagram Not to Scale)
iitilk
W - -N
.• .
'Sf .
i
4
/ss.:,,,,7 6).
P
f/ S�A�C' `/>/�h
,gy ' Ai d y4a�
Q,� y° O�\,e
7-' .. G4
- 1,
0 0
'50 Oil
100'Min 9,..��°G 't°O
c
N)1. % PA°4?
\\fie
ot�Ge
Animal Lot
This permit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change in any fact or
circumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. Flow volume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
�'
Issue Date: 1/3/2024 Trevor Justice, REHSI 3294 4*--- Authorized State Agent