GW1-2021-00827_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD For mten,al Use ON].
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook C'W TERTONES —
m/om TO DESCRL ON _
Well Contractor Name Ole ft 'fL
2043 A f, rL
NC Wel I Contractor Cortif,luo.Notater 5F'OUTLRC STN(r' for mWti-eaipl weW ORrIi1NE t G )1'.'bs 77777
FROM TO DIAMETER TRICKNESsi MATERIAL,
Dennis Holland Well Drilling, Ina
Company None 7(1NNFR C AR .O' R'TURING' cot arms;YlbleU to
MOM TO _ DIAMETER TIIIfKN ESS I MATERIAL
2.Well Construction Permit li: C SA%/a�'i
LIST oll npphrable well peralrs(I.e.raoro,5'In a, Vnrlance,Injec,ian, .Ie) -
fs ft. m•
3.Well Ilse(check well use): ,'17MCREEN_ !
Water Supply Well: mom I To DIAMETER SLOTSIZE TNCKNPSS MATERIAL.
I
n.
C1Agriadhnel DMwticipaVPublic (t.
❑Geothermal(HuatinglCoohng Supply) ISKes�idential Water Supply(single) tr. fe iD.
ClindUSOHII/Commercial L-IRasidential Water Supply(shared) lq:'CAOU7 ' • -.<-.
MomTO MATERIAL. F.MPI ACEMENr MFTIIOD&AMOUNT
Obligation f, rft. 0. e
Non-Water.Supply Well: fL - r(L .r
DMo -nitoring rJReeovcry 7 z1.;ZZliftY- ' J ae4-
Injection Well: T R. ft.
DAyuifer Recharge ❑Groundwater Remediation 19 4 ND/O ' VRLTAOICAVi plika6 e
D Alin ifar Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL EMPLACEMENTMETROD
ft. h.
DAyuifer Test DStormwater Drainage R fit. —
❑ExperimentalTechnology ❑Subsidence Control
20.DRILWfgG( E(7G aba!';adtlilibnal ebeele ifiu esfe i`.
C1Geothermal(Closed Loop) D'I'mcer mom I To Inescalrf7oN�aotor Errdn.,e,,my,o<Rnn aria a;..,aim__
11(icolhermal kleatin Coolin Rehm [-]Other(explain under 421 Remarks) ft. ft,
4,DRte Wells)Completed: @+L-Cps'21 Well IDN N,, /AL-__,_ R. -"T fc —'_— ---�---
Sa.Well Location: fe ---D, --- ^--
Facility/Owner Name Facility ID#(ifepplicable) —�� --ft. i---_- - _'---
Tf' -2 / .!y JJ L c7 4 c),l cr> R.
ft. --
Physical Address,City,.,it Zip '21::REMAR"
Comity Parcel Identification No,(PIN)
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/lang is sutLcienQ
N am.c' _3 _..� .v ��p' ._ �_..1,.v✓�' ClX_,r C.�..T C)J..'-. L%.Z.
- Signanac nfCcrti6cd Well Contractor Date
6.Is(are)the well(s): 01.maneut or DTempors p By staining this form,I hereby certify thin the well(s)was(were)constructed in accordance
,� r, LOT with ISA NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Seandords and Thal a
7.Is this a repair to an existing well: ❑Yes or ffJPfn l- copy.of/{pis recardhas been provided m the well owner.
/f this a a repair,fill oul known well commvcian information and e+pla�n the,ramm of the .
repair under k21 re,narks sec000 or on the back of this fona 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You cony also attach additional pages if necessary.
hbr muhiple injeaton or nan.wnrer supply weNx ONLY with+he none eanrtr.edou,Ym+con
,.bail one form. SUIiMITTAL_INS'f ll(Tf IONS
r 24a. For All Wells: Submit this form within 30 days of completion of well
9."Guist well depth below land surface: C-.y/I (D•)
Form.lriple.wells list ill depths ifdtfferenr(ernmple-3@200'and 2rLa100') construction to the following:
10.Static water level below top of casing: _�Cl (ft.) Division of Water Resources,Information Processing Unit,
Ifwate,level is above cnonf .se"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter;
6" _(in.) 24b. For I ie tioarWWls ONLY: III addition to sending the Finn it)the address in
Rotary 24a above, also submit a copy
py of this form within 30 days of completion of well
12.Well construction method: !_ construction to the following
(i u.anger,ra.,y,rabic,direct push,ate.)
DIVIalOn Of Water R[FDUPCe.4,Underground Injection CODIrDI Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Supply&IniecfiOD Wells:
13a.Yield(gpm)._-_ Method of teat:__ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H $ H Amount: 12oz. well construction to the county health department of the county where
constructed.
Form GW�I North Carolina Department ofP.,,a wrant and Nanaal Resources-Divio-o,of Water Resmaces Revised August 2013

M a c 0 n C o if n t y NEW WELL CONSTRUCTION
E e' Public Health CONSTRl1CTIONAUTHORIZATION
PRIVATE DRINKING WATER WFLL
WoRo'bert Mitchell • 050118 p • exisbnge Fan> 11
Well On> setbacks� Residenl9dl • 6591670006 .09to# 21 Old Laurel Lane
s Chapel Rd> Fukhel Rd> McCoy Rd>_R rr Old Laurel Rr> Lnd house on right Lust past# 71 on tTInP tree
Permit Conditt0ns
Well shall be constructed in compliance with all NCAC 2C Rules.
Malntaln minimum setbacks as applicable.
Minimum 35'casing due to reduced setback from septic lines. Maintain new well construction on Flagged location requested site plan.
Click to enter teed
Click to enter text
Diagram(Not to Scale)
Repair Indigo
e Initial OS W W Nitro Line
67' 51'
Proposed
F Well Site
y � 1
w
25'
xy= 35`` Pill kb , -..-.._
83*21'42.378" FY >,..
Old Laurel Lane
�I�fr
nit v,«4 ^4
This permit is Valid for a period of five years except that It may be revoked at any lino'r it Is determined that mere has tl a matedal change le any fact ur
circumstance upon which this permit Is Issued. Well location, Installation,and proteclfon must meet state regulatlons.The well shall oe Inspected and spiel by Macon county
Public Neallh before It Is put Into use. The location of du!well Indicated by Mcr-i Is to provide raccoon,from posslde sourres of contamination. Flow volume(well yield)is NOT
guaranteed at any site by mcPN.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED Q$THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS) [phone]
Issue Date: 5/9/2018 Harold Faircic[h, REES 21ft�_: l -_ Authorized State Agent
D�F 61(- (E� bt