GW1--05956_Well Construction - GW1_20241009

WIt,C,,Ia CONSTRUCTION Itb;C(.)RI) __.. .� Ii
This forts ran lie used for single or multiple%volts For •
Intenittl DSc ONLY: �L~�
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1,Well Contractor Information:
Mitchell Dean Cook Ia.1VpTER;%()NtiS�_ I --- _�...
Well Co Witte FROM. _.T0� --7 .DF:S(:RIPTION .--..-.......�.---
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NC Well Coaiiarttit( aiinn Number 1.._.._
15,OUTEWC:ASING. or;multi-eased wells''nA LINE if:app leablc — --
Dennis Holland Well D I 1 .•.-.._._-.._
Drilling 'Inc._ - I, �j MF
_.�..__. 111 C It,L 43 •'.- /, R�in.c
TO (^
fA E'' :TH C ESS MATERIA-
(:ompxny Narur, :._..__�__.�...:._.....�.�... -_ p ,,, r
•1.6;INNER'(ASINC�RiTUBIqC�ootheriiiehclosedaoop)...
2,Well construction Permit lf;_; •• / FROM TO , DIAMETER 'THICKNESS.. _MATERIAL
all applicable well permits(i.e.Caen CY "'! -.. R ft. I in.
ty,.Stare, Var attee,Injection,etc.J ....----' _
• 3:Well Me(cheek well use); ft.- fr.^ 'ib.- ---
- Well c _ 17.;SCR1 FN __ ._.__
Watei•Supply 1/271 ' -- '"- FROM _ f(t DIAMWFR I, ;SLOT SIZE TIIICKNF.SS MA'fl: 7AL-
°Allricultural (7Mttnie.ipal/Public ft. ft. in'
f.ICieolhrnnal(lIenitn(JCooling Supply) 7 sidrnlial Water-Supply(single.) • ft. fl- ' in.;, '--
0Inchtsteml/(.;onunercinl IJResidcntinl Water Supply(shared) 18 C_RUUT m-—'�" "�'"
f)ifTigiistoo Fli Dot ...'rt�•.. _ 61A'rFRIAL F.MPLACRh1Errr METHODN AM(lurrt
Nnu-Water Supply Well: . .__.,..�._._.._ ' . rt. ft.
-- "-- -
gatg
��.7MDniloring URcarvery ft. • r ft.r j/< urfnjrctioD Wcll: '�'�" —"�-'""• '---- rt. ft. ^ / �
OAquifer Recharge DOroundwater R.entediation •.19.CAND/GRAYEI PAG! r g licatiteT -' • _ " _
OAqulfer Storage and Recovery I.]SRlinity Barrier• FROM TO _ MATERIAL.. EMPLACEMENT METHOD ."_..
OAquifer I'esl . ft. ft.
torntwater Drainage _ . . . .L'3S ;.--__ ...
13F.xperimental fechnoio, ft. ft. r . -'^ "�
liy 0Subsidence Control
(7Cieolhcnnal((nosed Loop) .20:DTII I.IN(:LUC,(ett8eb'afttlltioRal iheeta ifueceaaaL: _ -
p) LiTi'aeeP FROM TO DESCRIETION•,,1color,hrrdars,.soil/jock Izrs,grain aixe l,c.)_.-
thermal(Fiealing/Cooling Return) oOther(explain under a2)`Rt:tnnrks). ft.- _ ft.
4. Date Well(s)Completed: r rScl�/] V _ ft; .-" -ft.�^ 1, '�—''—' ' '-
WVell IDN Ale !!! .._.._...-..__._.---. .__._
. ft. fl.
5a.Well Location: -- - _ :
ft. ft. e k+e,, '1:';:::'
t <j;C
^�' & ft . �
—. r 1 n ail.. •r
Facility/Owner Name FecilityION(ifepplicablc) __.......__..,.. ..._._.,._._......::...........�_.__ o� .._ _ (j� ._...._._
f /1 p fl. (I. I; �tl[4..
; 4- AA4 `t L...�_!4,/ . GJy /f /(lG�_ .........._.fl. fl. _•_.__ .C.. Ki,c..:.;-:,<-�r"^_:-._..._.._.._
Physical.,ildress,City,andZip ..-.T____._._-._ t __.^ �tr` �Y,,• .o Jn}
21.REMARKS ''
County ['erne)Identification No.(PIN) " �� -^ 1__L_ _._ �_ ___ _..-� _ _ ..
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fib.Latitude and Longitude in degrees/min utes/seconds or decimal degrees; -T_____.� - -- ,7-,--___.,--.
'._...�____.._....__.__.._ ., _.__._.._._.---
(if well field,one tat/long is sufficient 22,Certification:
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�j,5a OJr/c�" .-5.o Z / •G) W ' /
.SiLmature ef.Ccr ifiectWelt Contractor •. Pate
6. Is(are.)the wcll(s): permanent or OTcmporary
fly signing this fink I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.010U or ISA NCAC 02C.0200 Well Construction Standards and that o
7. Is this a repair to tin existing well: (7Yes or WM. ._ ropy of this record hat been provided to the well owner.
1f this is a repair,fill own known well construction in/Or/nation and explain the naiure of the
repair under 1121 remarks section armi the hack oftlitsforrn. 23.Sit diagram oradd(tiOoalwelldetails:
You may use the back of this page to provide additional well site details or well
A.Number of wells constructed:
� construction dcttiils., You may also attach ndditional pages if necessary.
For multiple injection or non•wt{uer supply wells ONLY with the.sane coup cilctina,you rein k ;
sumonne form. SUIlM1TTAL.INST[ICTIUNS
9.Total well depth:belOw land surface: „5,0 ._ ,_,•(ft.) 24a. For AllWells: Submit th Is form within 30 days of completion of well
Fur multiple wells list all depths if different(irxmnple•.l@200'and 2t®100') ' construction to the following: t
10.Static water level below top of casing:.___,G4TM _ ^_____, (ft.) Division of Water Resotircrs,Information Processing::lilt,
ifwmrrlevetisabovecasing,use. "a 1617 Mail Service.Center, Raleigh,NC2')fi99-1617
(in. L_.0.i,.•,.•Q,n Wells ONLY:, In addition to sendingthe.form to the address in
II.Borehole..diameter: ) 1.4b. f?D I crti
?.'la above, also submit a copy of this limn within 30 days of completion of well
12.Well construction method: Rotary a>nsuuclion to the litllowinit: I
(i.e.auger,rotary,cable,direct push,etc.) — . . _--T-"_r_.._
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service.Center,Raleigh,NC 27699-1636
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13a.Yield(gent) _ , Air lift 24c.Fur Water Supply&Injection Wells:
- . _-_.. Method of test:___ - - -..�..._.. . r
I"i & HAlso submit one•copy of this form within 30 days of completion of
13b. Disinfection type:„ _•••_..•,, •. ^ _ Amount: 12 oz. . well constructioO to'this county Health department of the county where
.�__ _ constructed.
Forst OW-I Nor th Carolina Department of Enviroiniteut and Natural Resources•-Division of Watcr`Rissniu•ccs Revised August 2013
• 1 i .

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•Qootecr.
0 ��t -tn Macon County 1830 Lakeside Dr
pVz.
z i Franklin,NC 28734 - , '
P u b i i e H ea I t h (828)349—2490(Office)
od0 (828)349—4136(Fax)
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WELL CONSTRUCTION AUTHORIZATION
Owner James&Wanda Jones WEL 071624-1 SEP N/A
Location 65•Echo Hill Rd PID 6581366221 ACREAGE 4.5
Directions 65 Echo Hill Rd --
- Design Single-Family Well Permit Type ,New Construction Expiration Valid for 60 Months
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Well Area
25'x 10'
8s,
Driveway.
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' 711141
NIIIIINIPI1/4:
g %c60-
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• °`dii ��S�ne3' Shed
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co #65
' 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 Constructidn
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.
• August 2, 2024 L � _
Issue Date Trevor Justice EHSi 3294