GW1-2021-03340_Well Construction - GW1_20210603

WELL.CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland 14.WA'1'ER:ZONES I
FROM TO ^ DESCRIPTION
Well Contractor Name ��fL I Ot ft I
I
2178-A 6o ft.
NC Well Contractor Certification Number IS.OUTER CASING(for muhikased..-Wells UR LINER:if a ble
FROM I TO DIAMETER THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. Q ft. ft rn .CDR C
Company Name MANNER CASING OR.TUBING- eothermal elcsed-too
1�2 l� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: [✓ J��7 f. ft. in•
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft, ft. in,
3.Well Use(check well use): 17..SCREEN
LOAgricultural
ply VI'ell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Municipal/Publical(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO TERIA'L EMPLACEMENT METHOD&AMOUNTft. ft
Non-Water Supply Well: (0 3
ft tt
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.5 ND/GRAVEL PACK(if-analkabW
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft, ft.
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additionil.sbeeta.if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,badne3s,soltfmcktype,grain size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ft.
ft. ft. I
4.Date Well(s)Completed, -a Well ID# ft. ft P
59.Well Location: ft. ft:
D,D n,ni e� lac r-r►1 on ft.
Facifity/Owner Na a Facility ID#(if applicable) iwA
// ft. ft s p fOCt; S
ft. ft IOVk ' '
Physical Address,City,and Zip
21:REMARKS
�ma i✓aY-t &5867 /0L7(c�t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient)
7a7�ffs�3 - 13�7/7 2(,277/6 W
Signature of Certified Well Con for Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If dins is a repair,fill out known well construction information and explain the nature of the
repair under#21 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.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,your can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6" (in.)
246.For Infection Wells ONLY: In addition to sendingthe form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gp m) dip Method of test:
Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount; 12 oz. well construction to the county heaith'department of the county where
constructed.
kf '
Fora GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

Q(ote�r -
`� in Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
t Donald Harmon • _030821-p • existing
-Famil Sin le Well Residential ' • 65867127i n a
• • 336 Parson's Wad_
' • 28N> L @ Parson's Way> # 336 on left
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. "
Pre-determined approved new well location marked with blue flag on left hand side of driveway near power pole.
Click to enter text
Click to enter text
Diagram (Not to Scale)
Turn
Around
Septic Tank per Applicant
,� 1:arson;
130'
Parson's Way
y Road
[p'N
.ry=35*12'49.59"N
R 83*23'-48.048" W _
1 S'
N
This permit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change in any fact or
circumstance upon which the permit Is issued. Well location,installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. Flow volume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS? [phone]
Issue Date: 3/19/202.1. Harold Faircloth, REHS 2189 ��`� —Authorized State Agent