GW1-2021-06848_Well Construction - GW1_20210429

I
WELL CONSTRUCTION RECORD ®. For Internal use ONLY:
form ¢
This fo can be used for single or multiple wells ®q
1.Well Contractor Information: "
�YAI'FR=Zt .' .
Mark E. Holland 9 1�11 14 WES"
FROM TO I DESCRIPTION
Well Contractor Name � 9 Sg�n ft ft.
2178 -A ,�{o` �`�NP�J°� fL ft.
s t
NC Well Contractor Certification Number 0 15.OUTER CASING.f6r multi-cased Wells)::::UR-I IN.ER if a d61e
FROM TO DIAMETER . THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. ft. Iin. vc
Company Name ;16;INNER CASING OR TU11WG eoflermakelosed=loo`'r
_ IAMETER
2.Well Construction Permit#: FROM TO- I � _ R ft. D in THICKNESS MATERIAL
List all applicable well permits(i.e.County,State, variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply), \pOesidential Water Supply(single) R ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irri anon_ ft. ? ft.
RIt(J
Non-Water Supply Well: �p
ft ft.
❑Monitoring ❑Recovery
3 a `TV
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '
20:DRILLING LOG attacti sddmttonafsheets;if rteeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sonfrock type,grain size eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft, ft.
04 n—/ r/ I ft. ft.
4,Date Well(s)Completed: V l ( Well ID# ft. ft.
5a. ell Location: ft, ft.
En Sm i�-l� ft. ft.
F.Zty/ m net N sp��� Facility ID#(if applicable) '
/�J11 /VI Slt t—L11 d f t.f
fL ft.
Physical Rs,City,anZip / /I 21.REMARKS
County (`/1 (�W� Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if 1l field.nnn.larAn�a:��..M�; ) 21�
� o W s-a
3` N-- 3 22 m �4 �—
Signa a of ertifi d Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify thai!the well(s)was(were)constructed in accordance
with 1 SA 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 ONO 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 same construction,you can
submit one form. h I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: V (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@)200 and 2@100'r)n t construction to the following:
10,Static water level below top of casing: lY O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For lniection Wells ONLY: It addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a:Yield(gpm) l 4 Method of test: Air IIf1 24c.For Water SuRp!y&Injection Wells:
Also submit one copy of this form 1within 30 days of completion of
13b.Disinfection type: H & H Amount: Off• 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 Res�ouices Revised August 2013
I

1-Y1�1 VT IT IT.VV 1'IMM VI IVY V111 11 V 11♦1.11 VL5/./T 7T IJV r LJ L
t
Qtae. �
o m M a con County NEW WELL CONSTRUCTION
° } Public Health CERTIFICATE OF COMPLETION
PRIVATE DRINKING WATER WELL
M416
An Smith • 021021-p • existing
82 Old Barks Cha I Road 6$92494978 n a
Si l FaM1I Weil Residential
441S> Prentiss Brd .>L onto Clarks Chapel rd> R @ Old Clarks Chapel>#82 on left
83.22' 3.412" W 35°7' 39.138" N
As-Built Diagram(Not to Scale)
' NewWell
k.
2 S' ..
. .... .•.. . . ••;$Z�•Qld•Qarks•Ckiapel .:� . ..
._.:.: ; .:...;.,t..�.;'!.; • _;i...;-,;.:�_:,•; 'fit .
.:.i:Roatli.J
r
.._.....-.
. , ....-
100'+
V.
..................
'•_�1:XISCIi1
................ ---
Old Clarks Chapel
■ Bentonite Slu Depth: 20 ft Method:>'um Caw.Cement 0-3 ft Date 4/6/2021
SDR21 PVC w/5 ncmr the 127 R Diameter: 6 in H Falrt:l
Height: In Sample Tap: YCl N(7 Hose Bib:
.0107 3 2 0 Date: h: ft Yield: QPM Sty H O Level: ft Permit#fl
.0107320 Date: Depth; ft HP: Cert#
• Mark Holland Cert.#2187A Partial Date;
Final t7ate-
The well owner shall not place potential sources of groundwater Contamination Closer to the well than the separation 08tanoes X MdW in 15A NCAC 02C. TMs well was
amstnuted In the designated area and accanding to the well construction permit and the Private onnking water well Rules. QUEMoNP {828)349.2400
bwe Date: 7/9/2014 Choose an Agent,., Autlr *editteAgent