GW1--06307_Well Construction - GW1_20241022

WbaL,L,CONSTRUCTLON IlleN)Rb ' — • - . ' ---- ' ' .
flits form ran;be iscd Fnr siuglr.or multiple wells
For'lotenigl Use ONLY
I.
I.Well Contractor'Information: _
Mitchell Dean Cook - [a.�►'ATR:%Oiv>S _ I _ ____.
_ _""'T"^ --. FROM TO :DESC —emir'.... _`__-,_-_'_
.Well Connactm'Name•i' /�Q i ---_-.-_-___-._
D. / rt. • h'L.'
2043'q'. :..:....... ...: ri. - •'r�. ) I , '
NC Well Contractor(rrtification Number -,. . .. .... _ .(for•multi-cased lwells)OR;LA IWilf up llcabie _ _
SING
---,. T 0 DIAMETER -THICKNES& MATERIAL,. "
Dennis h�olland
/ry-� . UTER(p
,Well Drlllln 'Inc' �,.. o.
I Company Namr. �'� ,•1'.6:INNER CASING OR TU13 tirf la cotherroal•closetl-too
FROM To DIAMETER_ rHICKNE.SS. MATERIAL
2.WUll,Constrticlion Permit II; . (}9/0 �,y4 /J ,rt /�y p '-
' n.ecl,o.t./..•....--•----1---,-.. `'"- - .' 'ft. i in: 1 I7Q�- ' Ve. _
'l,i,si all nj�plicnhle well permits(i.k.Coiorry,,Shalt, Vnrinnce,Injection,ric.J _, .J � �,,,�tw_
/'ft. �. ! d'Sh
;).Well[.Ise(cheek well use): yj,` �r_,- �! r N _L� _``_
Wafer Supply Well' "'"- .FROM _TIT' -,_DIAMETER _SLOT.SIZE THICKNESS MATERIAL-~
°Agricultural Dfviw)icipal/Public ft• ft, in, - - "'
fiGeothermil(Heating/Cooling Supply) 7 sidential Water Supply(single:) ft. ft. in.
—
P :
Ulndust I it/C:oiiunercvil f-1Residential Water Supply(sheared) le.GRUU1� "-- I'IT'''"' - T"
_Fa 'TO h1A•CgilAL, Ertl CEM EP(r ME711OD&AMOUMr C1Urigalion �_ ft..•. - R, T o-___
Non-Water Supply Well: __ Ry_ _2,,,,, , ^ c5_ 6, . /,
.0Monilorin �v . ft.� r ft. _
g 1 Recovery emu!' .4 4 /2
Inj,eetinr.Well: ,._ _ • , - �,.-._ ___- it.- - ' ft: i v
0Agtiifer Recharge: CJOroundwater R,emediatiun •.19.SAND/GRAVEL PACK'if:a' hirable .. -
--'--(]Aquifer Storage and Recovery 1:3Salinity Barrier ' FRONT TO MATERIAL EMPLACEM}'NTMETHOD M
ft. ft.
❑Aquifer lest • C'7Stormwatrr Drainage --- - �„_-,_-.
O. ft.
OExperimental Technology DSubsidence Control —
°Geothermal(Closed Loop) .20:DRIId.tNl:LOGA-anaeti•aiiititio'nel sheets if aaces
-
p) L�Traeet' FROM TO DES(RIPTIUN(Color,hardness,soiltroek Inc,grain size,me Z__
C]Geothermal(Heating/Cooling Return) 'CDOther(explain,undcr f121 Remarks) ft,: 'ft. _.__ 1• • ___ __� _
4, Date Well(s)Completed:4 -03 44/Well IDNr'Vl.. r. .:_ . . n. ft.7.-:I;. I?'�,- . `-.7: ,.:77- r. t:,aj
Sa Well I ocainn: - •
- . .. ._ - __
�� ei� i,,/�� �,, ll , � � 0rT �024
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T rr +
Facility/Owner Name , ___._.._._:---,..._..'-. 1. a,- e. `:,:::,._Facility Mil(if ft. V ft.M I ... .' "" ' '�r1:2 '
1 G .;� �<�
G7 v—
Physical Address,City,an lip -'- " •21.REMARKS —7,T"'"-,. .
ram 3 __ 6�:5 5!vSe� �.- __.._ __ __ .
is . -1 CO r-dfe_ceL ._-___._-....
County : • Pmre6ktentilication No.(PIN)
'SI).Latitude and Longitude is degrees/minutes/seconds or decimal degrees: 22 Certification �-� ^�'T T-
(if well field,one Iattlong is sufficient) - - !
3 a o A J a.2 '' R y O 4/ ' B G' W -.Al t 1 / / f I, e /d _,,, ,LA.
Silntalurr,of Certified Well Contractor... i Date
6.Is(are.)the well(s): l anent or, CITemporaty
By signing thus focal.I hereby rert 'd,at the well(s)was(were)constructed in accordance
with I SA NCAC 02C•.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that is
7.Is this a repair to an existing well: (7Yes or lrJNti_ - copy of this record has been provided to the welt owner.
If this is a repel,;fill out known well construction-igformation and i:iproin the media ohlte; "- { s '
repcir raider 112I remarks section nr on the hack of this foam, 23.Site diagram or additional well details:
You may use the bark of this page to provide additional well site details or well
S.Number of wells conch ucte.d: � construction details. You many also attach additional pages if necessary.
Pm-multiple injection or non-wear supply wells ONLY with the same construction,you ran -
SUBMITTAL INSlUCTIONS ,bit me/ora.
9,Total well depth below land surface:, ' CQ:S / ,-(ft.) 24a. her All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths if different(example-?0P,200'and 2(0/00') constniclion to the following:
•
I0.Static water level below topU / (ft,) Division of Water Resources,Information Processing[)nit, '
of easing: _ .�__.__,__�_ 1617 Mail Service Center Raleigh,NC 27699-1617
l(ernter lever is above cirsbrg,use. "+" , g '-
a„ .
Il;aloreh�lediameter=: (in.) 24b. For Inketion Wells ONLY: _Pi addition trsending the Form to-lhe address in
_-' _ -, .. ..- . _ ._ , 2tla above- also submit ai co aflm within 30 days of completion of well
- _ - i copy this lia
12-.Well construehon'methad;:Rotas • ,construction to the ti)llowing. - ' . -_ `-• - -----` " - - -•
(rc sage, rniaiy,cable,direct push,etc.) ! - , .
e _
- Divisuro of Water.liesources,Underground Injection Control Program,
f-OR�1'A'FFlt S[1PPI,Y W'F1.,LS ONLY: - ' 1636 Mail:Servicr-Center,-Raleigh,NC.27699-1636. .- ..
i
Air lift 24c,For Water Supply&-lnjecnoh-Wells: -- , - -
13a;Yield(gpmi ,.,,D Method of test:__,_„_____,_,__-.-••.___,._
-'-' Also submit one t:op of this foI'm within 30 days of,complction of
13h.Disinfection type:•I�i„ ,� Amount:, 2•,��z• well construction to the county health department of the county where
__A .-. . • ___�__::_. constructed, ;
Form OW-1 Notth Carolina Department of Environment and Neutral Resources•-Division of Waicr Rcsmu•ccs Revised August 2013
I

Qtotec,
o TIN Macon County •
1830 Lakeside Dr
•
o Is Franklin,NC 28734
Public Health [phone](Office)
o 40 .0 I 'i - [phone](Fax)
• ' WELL CONSTRUCTION AUTHORIZATION
•
' Owner Pamela Underhill WEL . .091024 1 - SEP __ Ex:
` Location 160 Shady Top Rd PID 6589080496 ACREAGE 1.91
Direct ons 441 S;R to Coweeta Lab Rd, L to Buddy Ga. Rd, L to Stewart Rd stay left to Howard Branch Rd L to Shady top Rd.
. Design Single-Family Well . Permit Type, Revision of Valid Permit Expiration . Valid for 60 Months
• N
✓ Y
Revision of Log# 080823-P
0 Il .•
Well Area #2
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1‘11141r4411,0 . \c:Sr.1-1
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5
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-\`: 51♦ a. •
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Permitted •
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• Well Area - •♦ :-1 • �'
(15'x 15') in ?.
,<T1.1 r?.9- t
*Id Garag-
Fell down, ,
Property Line (200') •
-- • • - - ' _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 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 wellhead 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. ..
September 16, 2024 C 7
Issue Date : Trevor Justice EHSI 3294
350 0Z + -2.-2 „
(}3 o ,.4/ ' 114 (3 f'