GW1--06334_Well Construction - GW1_20241022

W.ELI,CONSTRUCTION RCORI) • °' ,
'Bus tuna can b a iu�d for single or mutiil>I ;ells.' T' --___
Forinient4lIlseONLY T -I ��
r, : 1.Well Contractor Information:
Mitchell Dean Cook �_ --
II,WATER•%ONES _ • �I .i _ ...
Well Contractor Name
, _ w_-.. .__FR'QM TR 'D65(:RIP'T'ION ......._.._._._..._.-_...�.�.._..�_.__..,_..__.._
2043 A
cur r.
t C ntfication Number fI fr
NC Well Coana
IS,OUT (;ASING tfor multi casedrvells OR;LIiVE if:ap pcablc�r
Dennis Flollanei ' - FROM Tf).. DIAMETER • THICKNESS MATERLII•�- •,.�... _ WPif(�i ILlinc� 1nG, . .. . . ._ � ,
• '
l'.6:iNNF R(AS1r OR:T hI c.'(Rcothermol•closed loop)
('onstt uetion.Pernut ll - r! '"' FROM -- T(T(>.._ i)IAME'rER 'I'RICKNFSS MATERIAL' �
list all opplicnble well penmtr(i.e.Coriii •-•---_ -, r 1- 'i ft. �r •'EL-
"`"
• 2,Well
ry,State; Vnrianre,/njeNlon,rrr..J � � _a�/ � �, C �,��. .:4
), -���
3,Well[Ise(cheek well use): n-J fr,, r,
Water'Supply�"Well: • r__ F�RUM 'ff> DIAMF:1'KR,• SL(1T.S1'LC TIIICKNF.5S ' h1AYF:R1A1.°Agricultural l7Mtulicipal/Public rt. rt., in, , -
CICreotltfri>laI(I'leatinp/roollllg Supply) 7 sidcntinl Water Supply(single) fl' ft ~-^-_- in.'_�
D li diistrial/(..onnnercial L1 Rr idenliTl Water Supply 18-(,RUBY"--.-•_._ - __ I.
I I y(shared) .�_.�. _. ti,
rllrulaniet ' • _FROh1 r0_.__ htnilltAI, '-'— EMPLACEM ENT MRT>IODhAMOUi`rr
Non-Water Supply Well: -ft. •3 e fL /or"'!`J A
OMonilm'ing °Recovery r 3 "ft, ,43 /rl, •
Injell; ^---^-_._._-_._.._.._ _ T'—,._—.� - i?�hyi a r i ection W
()Aquifer Recharge ,OOroundwater Rentetliation ..1.9,SAND/GRAVEL PA(K`ifa IieabJe T
I.-Aquifer Storage and Recovery �_ PP. )
I.JSRIInIIy Barrier �' FROM- TO hiATER1Ah -EMPLACEMEnTMETHOI!-•'
°Aquifer'lest ft. ft. .
C]Storn>water Drainage _, _ -_..^, •
1-E.xperilnental'fechnolo _ ft. It. _ _
Technology lJ;iubsidcncc Control
�.
UCieolhennal((lased Loop) 720:DRIId.IN(�LOC•('attach'aitilitionalsheets ifaeces5 1_ • "-'
P) Li Tracer FROM TO DESCRIPTION color,hardaw eoiVroc
, - FJCieothent>al Hratinf/Cooling Return) f_lOthrt explain under/12i Remarks) ' I •" •" S '.- ---kt z�`'er°tri�,r1�
4, DateWell(s) leted: r �� W`,- F s ,1
1Y ((imp _ , Well II)H �V-11 _ _ _, _._•
�� __; i.- x_�_
Sa.Well i ocation: ft. f! ;; �l
Tv.,,.,.,.:.C,e& v- 1C. ,-i/c�. fi,- . ft. . is (. f b LQ�� _._
e'-'-.Peer`'-- •..s`0-. .�... �ti �_ fL �mm f! ,. P. r, _ .U t�
Facility/OwnerNanie __....__:_. .:._..�.._.._..._:_. ._.._....i . '-.• „ d+ '
FncJity i[>N(tf applir.ablc) ��__.__ .: __ ._ _...._..._
fl. fl; YGI. ' -� r5g
i
' Physical Address,City,and Zip vim— 7_' ^ T_ _ _ __...__
y���� ,.21,-REMARKS _-:__ ._j_.,. _ •• -
Cuunly Pmnel Identilictilion No.(PIN) �'--— "`—
tt
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees •
_�- "_____'- ____-___.__•_ -
fil'well field,one tat/long is sufficient)
22.certification, 1. __
Signature of Certified Well Contractor:i I Date
•6. is(are)the well(s): 1�Ref'maoent or f.:ITemporary f
, • fly signing this form, l hereby terrify drat the well(s)was(were)constructed in accordance
with 15A NCAC'02C.0100 or ISA NCriC 02C.0200 Well Construction Standards and than is
7.Is this a repair to an existing well: la Yes or VINO , • copy of this-record has been Nrovidcd to the Well-owner.
if this is ore/:Pi/',fill on;Atictrirwai;-ccu>:trciicr•,it JbeiniviOn,.rnd-r:xpta•in the'Hamra of171!'-"`_"•'' '-"I'''''''
repair underXII remarks section or on the hrick of thi.sforrn. 23.Site diagram or additional well details;
You may use Ihc,back ol'this page to provide additional well site details or well
R.Number of wells constructed: 1 ' construction details. You may also attach additional pages if necessary.
For multiple infection or nun-water supply we/ls ONLY with the sante construction.you can ,
.urbmli mie form. SUBMITTALINS'I'11C7;tONS
9.Total well depth-below laud surface: C2( 5 51 __(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths;f different(oxaniple-.l a 200'and 2(6100') construction lit the following:
P ,
10.Static water level below topof Basin '^� [; ft, Division of Water Resoui•crs,Information Processing Unit, ,
I(wnrer level is above easing,usr. " " '^__ �._:___,__ __( )
1617 Alail S¢rvicc.(t ... .,Raleigh,NC 27699;1617
1 L Borehole.diameter:m6�_ (in.) -. 2db.:For lnict.{on�WclLs ONLY; ln.eddition Ii)srndinq.the'fonn toahc nddtess,u>
2Aa above, also submit a copy of Mts limn within 30 days of completion of well
12. Well construction method;_Rotary co•nstruction to the,•R)Ilowing . • -' .,. ,.,c: ;: ''.
(i.e.auger,relay,cable,direct push,etc.)
"
Division of Water Resources,Underground Infection Control Program,
FOR N'A'fBR SUPPLY WELLS ONLY:- ( 1636 Mail Service-I:enter,Raleigh,NC 27699-1636
13n.YieldAlf lift • 24c,For Water Supply Bi injection';Weils:.
(gpm)_.._. 1Q_._-- "--'- Method of test:
Also submit one t:opy of this foH within 30 days of completion of
13b, Disinfection type: �-1 & M Ammo. �? Oz, well coast uctir > to the county l e.alth depainnent of the county where
m_..._................._...,..
_ ---_._____. construe ten.
I
Font MY-I Notlh Carolina Department of Environment and Natural Rasuurres•-Division of Water!Resotu•ces Revised AaCuti 7.n1 1
is ,

-.-% �A 0 0 9 '(v -).''
(11-otecr Ugc ) 'r
a " iNm Macon Courity
1830 Lakeside Dr
Dn 1,r 1 es—EbYLej P Franklin,NC 28734
E m Public Health � VIIJ�( I (828)349—2490
°, . of J t [e-mail]
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37/-17`20 - .
. .WELL CONSTRUCTION AUTHORIZATION
1 '-h2nt.S.-IooKes;l:di- 9-,i--)LI
Owner Tommy,Lee&Rella'Jane Reece WEL 091224-1 SEP N/A
,,.Location 3605 Patton Rd PID .6573197925 ACREAGE 1.05
;Directions 3605 Patton Rd ' .
. ° Desi•n , Single-Family Well 111=1=111 New Construction Ex,iration Valid for 60 Months
" v
Permitted
Well Area
••
i 5'
20' 1
3
Ex. c=• 54'
` _ Well 50'
-- Min Existing
House •
•
E r`,`Xlstin %,�Sy
\ Shownb Area
\I\ OWey�
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.
4) Properly Abandon Ex. Well according to 15A NCAC 02C.0113 (c)conditions 1-7 and submit a GW-30 to the health department.
The issuance of this permit by MCRH 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 Weil 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.
' • September 13, 2024. - (114— ,� r _ . .
Issue Date Chaz en,REHS 325'8