GW1-2021-06849_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland FR;wATgRzol+llvS I ;
IN FROM TO DESCRIPTION
Well Contractor Name ft.
2178 -A 2411 ft. It,
U NC Well Contractor Certification Number ,t S.A11 CER CASING for multi cased wells OR IiW,R if:a licaiite
�+ ( 6`� OM T� DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. Qc , ft. ft. !in.
Company Name yy ( 'a Ib:1NNER CASINGOR TUBING."eothermal closed-loo _
�7 !� •' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t�� V ��� ft.
List all applicable welt permits(i.e.Coumy,State,Variance,Injection,etc..)
ft. ft in.
3.Well Use(check well use):
:17:SCREEN
Water Supply Well: - - FROM - TO DIAMETER +.SLOT SIZE THICKNESS MATERIAL
OAgricultural OMtmicipaVPublic ft. ft. in
E
OGeothermal(Heating/Cooling Coolin Supply) OR sidential Water Supply ft. ft. in.
{ � g PPY} PPY
OIndustriaVCommercial I OR
Water Supply(shared) 18.a".ROUT
FROM I TO MATERIAL i i EMPLACEMENT METHOD&AMOUNT
Olrrl atlan _ ,R 1 fr ft D._I t
Non-Water Supply Well: 0 i7
❑Monitoring ORecovery ?j ft0 fL +
Injection Well: ft ft
OAquifer Recharge OGroundwater Remediation 19.SANDIGRAYEL.PAC C.it:a ,licatiie.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0Salinity Barrier ft. ft.
OAquifer Test ❑Stormwater Drainage
ft ft.
OExperimental Technology OSubsidence Control
20.-DRILLING LOG,agar,adilitionsi sheets it'necess
OGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION color,hardness soilfrock rain size etc
OGeothertnal(HeatinglCooling Return) OOther(explain under#21 Remarks) ft. ft
ft ft. `
4.Date Well(s)Completed: Lf_ ,_c� Well ID# ft ft.
Sp.Well Loc `on- ft. fL
ft.
FacilkylOwlper��Name
�/�k ��Q � Facility lD9(ifapplicable) ft, ft.
�11 b rooK cD 1J ft. ft.
Physi 1 drres(s,,fCity,and Zip 21.REMARKS
G�V
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreestrninutestseconds or decimal degrees: 22.Certifica'
(if well field,one latlong is sufficient)
36�, 1706 9 d b N - ��557 q���? W �
Sig6otdre of diified Well Con6actol Date
6,Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02.0.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E+INo copy of this record has been provided to the well owner.
If this is a repair,fdl out known welt construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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 may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: d 0 1 (ft.) 24a. For All Il Wells: Submit this form within.30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 r@200'and 2 rQ+100) construction to the fallowing:
10.Static water level below top of casing: (ft.) Division of Water Resource's,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in.) ` _.! g
24b.For In ection Wells ONLY: Irt additson to sending the fariit to the address in
Rota 24a above, also submit a copy of this f1.orm within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-I636
m 13a.Yield
(gP ) Method of test: Air lift 24c.For Water Supply At Injection Well
_
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 health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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Macon County NEW WELL CONDUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Darrell McDaniels • 030421-P • 101908-S
Shared Well Residential `` • 6564866515 1.50
•' * Off Millbrook Cove
• Old Mur h Rd. R on Mill Creek Rd. to R on MillBrook Cv. 'o up hill and site is,on L to newly graveled drive.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Is a proposed shared well and all septic systems initial and repair areas must maintain at least 100'minimum.
Any questions call MCPH.
Diagram (Not to Scale)
P� 6^0.
INIZ„ Well �o
Area a0
L� Soil `
Road
arre��'S D
61�e � ✓� drre//s Fx�stig9 G
shed N p rdIle/
Roaa
90, Pat-,
1179
s
Septio dnk
IP pdrr,
pro e i
��S
y01'se ed Darre//
6, h S
p p s n g
, raiq f%
t: r
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. QUEST ONS?.(82 349-2490
Issue Date: 3/11/2021 Tanner Stamey, RE 2712 uthorized State Agent