GW1--05958_Well Construction - GW1_20241009

WELL CONSTRUCTION RECQRD - ---
ll,is'tonu can lie used far stogie or multiple well. T^Ot�^^^ l�•_---__-�-Y~--- -T__^ '
fur Intnrgtl Use QNLY T
r
T.I.Well Contractor Information:
Mitchell peen Cook 1 T' __:.._..
-- 14WATER•ZONES. I• .,.
Well Contractor Nance _ :. ._.._ ^-^- �k Tt) - -- D�SctirrnON-7
ft. ft. ; -
NC Well Comias•.lut Cenification Number 5,;OUTERI:ASING. for:multir. sed•wells`QR LINE ..tf:applicable - ._
FROM^ S..__ Z.. �..,.�.--..,_
[�(�nnis Holland Well Carillinc�, Inc, ff6:51'0 1DIAMETERT THICKNESS i MAATTERiAI.(:__-_Na ur. _. _____-_ ___�...__....-_--__..- .•.1:6;1 '.11' f;AS1N'''ri.BI„„4 I'' _ .
FROM MS. (Koothermal-.Cosed-loo ), •-
2.Well Construction Permit/l: _ .,_w DIAMF,Tc:R THICKNESS P ,
SS MATERIAL
us/all applicable well panics(i.e.Come ...a � .� /_..._.___.__,.__•... in.
ty,Smle., Variance,injection,Prc,J ^•-_3,Well Use(cheek well use): ft.-- ft,--' iu.�T'~'""� '
Water Supply We11 ___ ___ _' -- -- _— ^ ROM 11,SCRFSCREEN�._...._^ _.__..y.�It __
F _ TO-"' ^DIAAt ETER'_. SLOT SIZE THICKNESS MATEIAI.R
°Agricultural (7Mwticipal/Public fr ft, in,i -
I.
f.IGeothermal(I•icating/Cooling Supply) (IX.] idential Water Supply(single) ft. rt. in:
Ulndustnal/(nnnnercial I Residi 0IraI Water Supply 18,f RUUT�'_.____ —`- -`" -•--
•
(shnrctl) Fei�hi_ 'ro____
°IRlgation_ _ hIATFR1Al• FEat P1.A(:FM EMr M t771OD h nMrtunrr
an-lYa ter,Supply Well: ._..-...._ .�__._..._.___ �Q 'fr, ... �"...-ft, 1—
°Monitoring °Recovery .? ' N.A,;)(�' R.
Injection Wall: - __��._ _ - -, T� ,2uPrxi_f " 5 �.... - �i ' _.
DAquifer Recharge -CJGroundwnter R.enlediation • .1,9.SAND%GRAYEL PACED i1:a'!i'cQtih - ._-.-r_
IJAquifer Storage and Recovery �PP. )
(:)Salinity Barrier FRONT�_ TO h1ATER1Ai, EMPLACEM6TlTMFTHQU" _.•,
lJ Aquifer'I'esl ft. •ft.
C7Stormwatcr Drainage -- _ .-
lJF.xperimmual'fccisiu)lo,Y R. eft.
t °Subsidence Control°Geothermal(Closed Loop) TIae , . .2Q;DR11d,i E tec_i allllifioABl sheets If.neceSBu ^
FROM TO DFSCRPTION�er,hardness,sal UrockT i P,�r ein tze ir.l
liCieothennul Hratin Cooling Return) GUther(explain under H21 Remarks) ft. ft.
4, Date Well(s)Completed.: f 9;...Z,j,-2j�Well IDU /V � ft. �� ft.
So.Well Location: _ -ft.. ft.
•
Facility/Owner Name p. rt.. ..._.__._.In. Qr.I_.a_J.1 r /�
FOCII ly If) applicable) _ 112"t
i N(ifappl Ic
E E ' { y F/ .44... �d"_ �.' J Ys t V)1/ !? ff. f I �.tli:v:: " -� - _
Physical Address,City,and Zip 7 _ _._.__
21,REMARKS
L� a'J
Couiny Prurstl Idenliticolion Nn.(PIN) 1
Sb,Latitude and Longitude In degrees/minutes/ser.onds or riacimal degrees: --T—T ' T-_�' _--7--------
22,(.ei'nfication:
(il'well field,one Wong is sufficient) �7 ,(� / /
._1 G/ . .1 j? _ ,`:5'. r�-2 r1 W _YJ i 't-4%Le,...[ Lk- L !"9'•,?. "-arr'...)-j<
_ Sibmatare ifC:enifietl Well Contractor •: Date
6. i.s(are)the well(s): 1,4.Lcf'mane.nt or f.:ITcmpnrary
tly signing this Jima,/hereby certify that the well(s)was(were)constructed in accordance
with iSA NCAC b/C.0i00 or iSA NCAC 02C.0200 Well Construction Standards and that a
7. Is this a repair to an existing well: DYes or WWI.-
.- .. copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it/brmuniva and explain the nature of the
rep0ir mndm'➢2/remarks.section or on the back of this font. 23,Site diagram or additional well details:
You may use the back ol'this page to provide additional well site details or well
8.Number of wells constructed:_� ________ construction details. You may also attach additional pages if necessary.
Fa non-water multiple in/ectiun or non- nter supply walls ONLY with the same construction,you can
submit one form. §IJ_!I TTAL.INS'1'CICTIUNS
9,Total well depth:below land surface:L c3''7....r_ __ _...(ft.) 24a. for All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths iI/diifferent(example•.1@200'and 2®100) construction to thin following: • ,
10.Static water level top of easiiug:._T_/D ___ _• •__� (fl.) Division of Water Resolircrs, InformHtion Processing Unit,
If water'ferei is above casing,use..," 1617 Mail Service(.'.enter, Raleigh,NC 27699-1617
I t.lloi eliole diameter: 6 (in.) 2dh- For-Injcgtion Wells ONLY: Ui addition to sending the Form to the addrl:ss in
Rotary ?An shove, also submit a copy of this limn within 30 days of completion of well12.Well couslrad ran method::_ eonsuuction to the ri)Ilowing:
(i.e.auger,t'nlaiy,cable,direct push,etc.) .� ... _ _f _ .
•
__ __ Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: !_ TT 1636 Mail.Service beimter;Raleigh,NC 27699-1636
I AI( lift 24c.Fur Water Sully&Injectiou Wells:
13a,Yield(gpnt)_.._./_.:1._.____..-_.. Method of test:_ ---- i
H & H Also submit one. copy of this form within 30 days of completion of
IX Disinfection type:__•,•_• Amount:,�2 oz. well construction to the county health depnrtment of the county where
._____.____.._:___�. constructed.
• i
Form Ci\Y-I Nor lb Carolina Deportment of Environment and Natural Resources•-Division of Wald Resotu•ces Revised August 2013

otec \IITA ( I
P • 1830 Lakeside Dr
r
:.,�m Macon County
7 Franklin,NC 28734
yy ' Public Health [phone](Office)
o � a [phone](Fax)
WELL CONSTRUCTION AUTHORIZATION
t'"Owner C -Peaceful•Meadows Tlny Village,LLC WEL• ; 081724-1 ... SEP �TBD�
,:igl canon" .527 Saunders Rd ' --�� PID :: 7504393663 ACREAGE 28:86 —
_rDirectlons"> Cat Creek Rd, R onto Saunders Rd, Property on L.
y 0:esign? Shared Well Permit Type. New Construction „,:Expiration:.!. Valid for 60 Months
*100'Min to all septic.* Pad Ex. House
• F_ ._
I Well Area Oak "' Ex.Well
;(5'x 25'x 25') ro
it � '0:
IP
Oak
•
• S C
•
•
•
•
•
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. 100'setback to all parts of septic systems,
3) When well and pump are completed, contact MCPH for inspection.
The issuance of this:permitby•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 incorporatedrby 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.
G �
_ September 9,2024
Issue Date Trevor Justic REHSi 3294