GW1--06636_Well Construction - GW1_20241108

W E I da CONSTRU CTION It If C OR I) ---•-----'----•—T--•-•--•-----•--
nlis form redo be used for single or multiple wells' -��-j �"�
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For Incrnhtl Utc ONLY:
- 1.Well Contractor Information: —
Mitchell Dean Cook .11.WATER ZONES __ • I ; . . -_-
FROM ___ TO . _T DESr:N1PTi0N_ . T..•.__.,.
Well Contracts'Name � ft, ft. {
2043 A rt. f�' f. _� '
m ---- _
NC Well Contiactot Certification Number 15 OUTER CASING Sfor-muln ciised wells OR:LINER tf a liable ,— ,_
C ---.'FROM TO` DIAMETER TRICKNESS MATERL1l.
[? nnls fdtallani'Well f�rllllng Inc
ft rt. in,
Company Nato,: __ — _.. O �/�-2/'f G- �.
^~^n /�/-- ., 1.6:INNER(ASIN(�OR TUB .G•(geothermal:closed-too i. _ —
2,Well U 1•`l 1 f FROM. ��_To ___ DIAMETER 'r)IICKNESSMATERIAL ' •!
CenSII'UCI100 PfrlTill u: ,J.2 �/ li __ (L (t, in.
List a/1 applicable uell pr/rune(i.e.County,!Stare, Vorinnre,InlPction,err.:) '-__-_.____..,_. —TT��— ^�
ft. ft. in,
- --_
3.Well Use(check well use):
17.SSCREEN ..__.-r.-"it
: ._..._..,-._-._._�..__._.__
Water Supply Well: _ - _ _______ — �V
Pp y ,FROM _ TT DIAMETER . SLOT SIZE THICKNESS MATERIAL
DAgricultural (7Mttuicipal/Public R. ft. in, I ""
I
f:IGeolhermal(Floating/Cooling Supply) 7 sidential Water Supply(single) fr, fI ��_T— in;, i �� —" -"
Dln(lustrial/I ommercial IJResidential Water Supply(shared) I8..c1ROU1'_"_-"�T'_-.'7.4.__` ' -_ ,-. -
lllrrl IIIIOII FROM -TO...� _M A•__rER1A lT T-� EAPI•ACF.M ENTMETIIOD&AMOUiNT
4.
g tion_._._ -- ft y t: fr�
Non-Wa,erSupply Well: . ----..-.-•,-..._ .__.— ,Cw/- -
°monitorinll eft. f.L. '
Jecovery ..__:.__—r — h_4r�Zi'/z',' ti= . :
Injrctin Well: _ _ __"— fL fr.
OAquifer Recharge (:]Groundwater Rents diatiun •.19,,SAND/ORAYEl,AACx']fie liable _
_t__AP L
DAquifer Storage and Recovery OSalinity Barrie( FROM , TO MATERIAI� EMPLACEMITTMETHQU
ft. T ft.
❑Aquifer Test L'],Stonnwatcr Drainage .T _ -�,
Q Experimental'lerllllolo, fL ft. —
gY l:�Subsirlence Control _
DOrolhernlal(Closed Loop) 20;DRILIANO LO_GArrich additional shiers if oecess ), _--_ _
p) OTI'acel' �FROa1 _�f0 - _DFSCRIPT'ION-(color,hardness,�oiVrork 17Pc,Rrainsize,r.n.Z,-
fJGeothermal(Floating/Cooling Return) C)other.(explain under H21'Reinarks) _ �I• a_ 11.
4, Date‘Yell(s)Completed: %.. vi _
_ r, >� 1
'Ss.Well I,oc)itinn: — _ ; a/
;ft ft. !�
�L7G7r//�CL"�' I-4 1�,��..�Af Lll, 4. • ft. ft N U,•V; 'tY O2.112474-.-•- ..
Facility/Owner Nance , facility It//(rf applicable) - _. ._-_ ,.....,.__-.._ ._�._.._._...--...: .. •. .
ft. ft.
... 12[07. . s l lq ' burn i —it( __r.._ - - -- ;- - -W _ .
rt_�� rt L :.
Physical Address,City,and Zip 7— L' �,^-.-- .,_--:__-.-- - 1 _.�..._ --._._...__
21.REMARKS.
County Parcel Identification No.(PIN)
Sb,Latitude and Longitude in degrees/minutes/ser.onds or decimal degrees: _ T �'......---....-_ -_�._._.—_.
(irwell field,one IaVlong is sufficient) 22.C�et'Ci(iCAtiOn:
Signature, if Certified Well Contractor •. . Date
6. Is(are)the well(s): IjlktImanent or :ITcmporary
.11 By signing dn's;Jortn, /hereby Certify lhar7he-+eel!(s)was(were)constructed in accordance
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with I-5A NCAC 02C.0100 or:/SA NCAC-02C`.0200 Well Construction Standards raid that a
7. Is this a repair to au existing well: t7Yes dr YRVo copy of/Iris record has been provided to the well owner.
If this is a repair,fill our known well construction it fbrrrmrion and explain the nature of the '
r•epoir under 1(2.1 remarks section or on the back of this form,' 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Numbe.r of wells constructed:_1____ '•_____ ' construction(lentils. You may also(Mach additional pages if necessary.
Cr,,multiple injection or non-water supply wells ONLY with the snnte construction,your can
submit one form. SUIIMITTAL.INSTUCTIONS ; ,
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9,Total well depth-below laud surface: CS.tS 'T ;T(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-.?@200'and 7.@I00') construction to the following:
�' __T��_ (ft.)., Division of Water Resources,Information Processing!blur,10.Static water level below top of casing:,_
l/worerlevel is above casing,use. "+" 1617,Mail Service Center,Raleigh,NC 27699 1617
11. liorehcile diameter: ^_ (in.) 24b, For Injactjon Wells ONLY: run addition to srndiitq the form to the address iti . :
�� Rotary 2Ia above also suhnut S. cop) nt this fOrm within'30 days of completion of well ,
12.Well construction method:. ___a__ �_ _ s__ ctmxuu ion to the li>Ilpwtni;: s'
(rc etig i rotary,cablo'dtrect Nish,tree.)
_ _ __ Division of Water Re'sources,iUnderground Injection Control Program, . ,
• FOR 1!'A'fFRSIJPPI;Y 11'EI LS ONL;Y:'�' ' . 1636 Maif,Service Center,Raleigh,NC 27699-1636' , .
RI
•13a,Yield(glint) -"�� •^ 'Method of test: Air lift 24c.Fur Water SuP ly&Injection!Wells:
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` Also submit ono copy of this form within 30 days of completion of
_Id & M _ well construction to the county healt1.1 department of the county where
13b. Disinfection type:,�-,,,_ Amount:.�2 oz.
...._.._....-__...._-. constructed.
Form OW-I North Carolina Department of Environment and Natural Resources•-Division of Water Rrsom'aes Ravised Aul;ust 2013

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Yancey County Environmental Health 0 202 Medical Campus Drive Burnsville NC 28714
WELL CONSTRUCTION OR REPAIRPERMIT
Property ID# O $ 300 Lib 3tg L1 q-000 Acres ?7. D Permit# 1N551
Property Owner: CluAs-c.k - S Vifaa t ciree_k. 130...p,L;5
fr d
Property Address: /A7- I 05. /ik/ 1-1 E a s5v,f�� , WC 2g--/1.e
Subdivision: NM Lot# /Y/4
Well Construction:®New ❑Repair ❑Abandonment
Well Type: ClSingle Family Residential El Multi-Family Residential f36 mmerciai I:Agriculture/Irrigation
This permit is issued subject to all of the provisions of applicable state and local laws,rules and ordinances pertaining to private
drinking water wells in North Carolina.This permit is VOID if any permit conditions are not complied with or if any changes are made to
the permit or permit conditions unless changes are approved in writing by an authorized Environmental Health Specialist.This permit is
valid for five years,provided site conditions do not change.The completed well must be inspected and approved by an authorized
Environmental Health Specialist from the Yancey County Health Department and a Certificate of Completion issued before any portion
of the well is put Into use.The issuance of this permit in no way guarantees any volume of water at'any site. -
Environmental Health Specialist: -Date Issued: 1�/likoz4
Ap ved Denied El
SI OF WELL STRUCTION LAYOUT W�� .•
Minimum Setback Requirements: CET'C N
Septic tanks,drainfields and repair areas,existing •-
or proposed-100 ft
Building perimeters,including any attached - ...4
structures-25 ft S
Property lines,easements-1 ft o
Streams,rivers,creeks-25 ft /1
Animal barns,feedlots-100 ft.
All others as per 15A NCAC 2C. •
If well Is constructed doser than WO'to any part of
a septic system or repair area,a minimum of 35 ft
of casing Is required. ,
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1.0000, 1 ot /