GW1-2021-06846_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland FROM TER ZONES
FROM TO I DESCRIPTION
Well Contractor Name )}yt �)% ft. i
c p`
2178 -A � 2 U K
cess�'�g n ft. ft.
NC Well Contractor Certification Number �p`0 15 OUTER CASING for:mdlh-cased'wells QRhNER if_a lic&Iile
torm3t OR Selc� FROM T DIAMETER . THICKNESS MATE L
Dennis Holland Well Drilling,�nc. D ® ft. ft. c�
Company Name I INNER C ING OR TUBINE 'eothermal closed,loop)FROM
�J 1 I�U — FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 97-SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(HeatinglCooling Supply) J6 sidcntia1 Water SuPPIY(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. 3 fa ©r Ll a m
Non-Water Supply Well:
❑Monitoring ORecovery ft � ft.
Injection Well: fr• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL FACK0401plicablO
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20;:DRIL:LING LOG attach jidditionafsheet£iifiaeces9
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardoess soil/rock type.zrain sim etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. &
-13 2 ft, ft.
4.Date Well(s)Completed: Well ID# ft &
5a.Well Location: ft. ft.
CVreGl024 6• AAMD► 5 ft. ft.
Facility/ ner Name Facility ID#(if applicable)
I �i� ft. f
I t.
d to I�cJ ft. ft.
Physical Address,City,and Zip) 21.REMARKS�591�1 z52D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(Swell field,one lat/long is sufficient)
35'lq ' qJ N �3°21'S3,1BL W �_� -_ J
Signature of Certified Well Clronlractor - Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that;the well(s)was jwere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC b2C.0200 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No 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#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 some cons&ucdon.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: z-� (ft.) 24a. For All Wells: Submit this torn within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(a 100')a t construction to the following:
10.Static water level below top of casing: ` D (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 601 (in.) 24b.For Infection Wells ONLY: In addition to sending the 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(gpm)_ Method of test: Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form)vnthin 30 days of completion of
13b.Disinfection type: H $t H _ Amount:_12 oz. well construction to the county heal Ith department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resourccs—Division of Water Resources Revised August 2013
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Qtote�t
���m M a c o n C o u n t y NEW WELL CONSTRUCTION
01 o�Ja Public Health CONSTRUCTION AUTHORIZATION
mod` PRIVATE DRINKING WATER WELL
r Gregory A. Morris ` r;, • 111520-P • 113520-5
Single-Family Well Residential ' 6597712520 3
• • Lot B-2 Lyle Knob Estates
' To SandersTown Road, turn right on Lyle Knob Road to R onto Lonesome Dove,turn right thru gate.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Dia ram Not to Scale
o�
50 mir
sa
^\N95 Pro e rty Line �Q
�i Repair t Steeper
.�r Area ,; Uneven
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2
15, 6ti 15'min Iron Pipe
15'
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SP rp
\ O Cp
We
\ PQQ� \ 355'
sed�t \`�yea \
-6 h
Property Line
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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: 12/22/2020 Charles Womack, REHS 1300 Authorized State.Agent