GW1--06754_Well Construction - GW1_20241112

AILUI 1F2._
'WELL CiDhs'TRUC�['IQN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1,Well Contractor information: 1 __
//���� .�C` �/ p (r� •
•
14,WATER ZONES 1 ' �•.
_..•.`-'-'-�-'-•_- Z e I I Dean ` D 0 t'�.../ FROM TO nrSCRIYrION
Well Contractor Name _� __ �i "ft.� /.ft I Y~ - ——•__.__._
NC Well Contractor Certification Number 15.OUTER CASING(for awlti-used wells)OR LIINERJif a alit
f1 I I 1i r %� j FROM TO DIAMETER TNICI(NP.SS MATERIAL_!
1d.Qtn►1, F}Q L1 LZ YiCJ 1�1C1 I V n II ft. ft, . in. y
Company Name 16.INNER CASING OR TUBING(geothermal clwud-loop)
_ FROM TO DIAMETER THICKNESS MATERIAL
.2,Well Construction Permit W: 09Q .fj .2 I• - .2-
Lin ;ft' 6''" ....ft. /.•-, in. .Sip-...) �'Y�6s all applicable well permits(i.e.County,State, Variance,Injection,etc) Q h
3.Well Use(check well use): 17.SCREEN 7� �r/ __/ AP Sfiers/
Waiter Supply Well: �. ��' -^ -'- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL_T
ClAgncultural °Muni ipal/Publie ft fL i itt
ft. ft. in._C:eothermal(Heating/Cooling Supply) d ial Water Supply(single) �- -'
Dlnduslriat/Commercial e 'lentiel Water Supply(shared) Ie,GROUT
1.1117 �1Un
_-- FROM TO MATERIALp EMPLACEMENT METHOD&AMOUNT
Wtm-Walter Supply Well:ir
... - __ __ 4 ' ft. ,P ' ft. 1 /���z1. g9 p�F i .
C:1Monitoring °Recovery 3 ° ft. ' ft.
-Injection wen: —•�.-.,____._.__._.____ rt. rt
_)Aquifer Recharge (Groundwater Remedintion 19.SAND/GRAVEL,PACK_(if a pplbcable) .....
(]Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ^
ft. ft
❑Aquifer Test ❑Stormwater Drainage • -•-
rt. rt.
(]Experimental'Technology ❑Subsidence Control
20.DRILLING LOG(attach edcUtiomal sheet)if ueucwary)
(]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(oWr,hardness,soil/rock type, rain sire,etc.)
_(.]Geothermal(Heating/Cooling Return) ❑other(ex lain under#21 Remarks) ft. ft. .
ft. rt . I, , ,
(I.'Oate Well(i)Completed:'Li..47. . 2 (Well 1DI(w.._.__,N4_/,14,, _— ft ft.--- ._
Fe,Well Location: —' -^ r', '�-•- - "-'
._ ... ft ft. ( 4 a.-.�,.,e, t f`' a . .
_.tell... rs .,f'o� ci ash iv,41 , M_ ft, ft - ��iQ4t� -- _�.
Facility/Owner Name Facility IDlI(if applicable) ft. ft.T
Physical Address,City,and Zip 21.REMARKS J.
._„Gl i_4e t ,6 �2a3.3 L 9 ., >41'5 14e�/ 1/Rvr: •-Y 7.---
County Parcel identification No.(PiN) rJ /rd
f�'c <- J
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one let/long is sufficient)
___e&.3'5`0a 6_�,i7a " N _...k.3°-?., ' 45 .5. ' rv .r.. //.11 ,2.
Signature of Certified Well Contractor Date
i
6, Is(are)the well(s):t-711Yerni3nent or DTer+poror
y By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with i SA NCAC 02C.0100 or i SA NCAC 02C.0200 Well Construction Standards and thor n
7, Is this a repair to an existing well: DYes or ' . o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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
II.Number of wells constructed: / _ T construction details. You may'also attach additional pages if necessary
Par multiple injection or non-water supply,wells ONLY with the same construction,you can
submit one form: SUBMITTAL 1NSTUCTIONS • •
9.Total well depth below land surface:,•.��a i„ ,_ _____ (ft.) 24a. For AlI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@/00') construction to the following: •
1,0.Static water level below top of casing: J�-� (ft.) Division of WaterjlBesources,Information Processing Unit,
(twiner level is above casing,use"+" _ 1617 Mail Service,Center,Raleigh,NC 27699-1617 . . .
1.Borehole diameter: G. (in.) 24b. For Injection Wells ONLY: in addition to sending the form to the address in
.24a above, also submit a_copy of this foal.within 30 days of completion of wet
12,Well construction method:_ , „R0 t . .1 construction to the following: ;
t re.anger,rotary,cable,diiecl puts(,,etc.) - . '' '' ' '-
_ Division of Water Resources,Underground Injection Control Program,
FOR WATER-SUPPLY A'f FR SUPPLY WELLS o NLY: ^ _�~^w 1636 Mail Service Center,Raleigh,NC 27699-1636
mI ( l 24c. For Water Supply&lniection Wells:
13a.Yield
(gpm)_ a Method of lest:_ Ai.L.L.1_1-I_..._.--
Also submit one copy of thi's form within 30 days of completion of
� � II--11 l well construction to the county!health department of the county where
13b.Disinfection type:14-= r l __ Amountt:_,)roz•_______
..._...-_-_._..._ ...__._._._._.—_.-.-.._-,..—..____...-_.v___._...._.........._____._� constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

o
66 ',C5 ri
/Q,.otect 30 ).r ' o5s/
/o .kS Macon County 1830 Lakeside Dr
o Franklin,NC 28734
0 e. Public Health (828)349—2490
• o4 �J •• [e-mail]
a . a
WELL CONSTRUCTION AUTHORIZATIONa _ 6717
Owner • Russell Pancoast . 4.2.VVEL ^`. 090324-2 . `, SEP" N/A ..
. " Location- TBD Hodgins Rd PID_ 6572338940 ACREAGE 20.71
Directions Take Addington Bridge Rd to R onto South Skennah Rd to R onto Hodgins Rd to L after Bridge. • •
, ,Design Single-Family Well PermitT .e New Construction x Ex.iration. Valid for 60 Months
Y
a?'"/&' c ' . 7777
Jonquil
Hodgins Rd Woods Rd
_ Pro
ert Line
61'
Witness Tree 2j1'.I®-....,
Large Poplar e p ....°^�
Pink Ribbon o ertnittecf •-®®, �y3p,
cp. i Well Area ®�®q.
®®o, 030,x40,I
... /4p,
•p.
s.
a130, ''''''''"I ,
R`
•
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 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 9, 2024 C J ._ 1 , "L_
Issue Date Chaz Allen,REHS 3258