GW1-2021-06853_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internat Use ONLY:
This form can be used for single or multiple walls
1.Well Contractor Information:
Mitchell Dean Cook ;:=s:;u �.nr>I✓ .. .:_22
FROM TO I DESCRIPTION
Well Contractor Name volt90' ft q I Ifa
2043 A A o2f6
Q 65•ft. ft.
NC Well Contractor Certification Number `O r1021 .9S P2 .tit(';S7tY foYrmlil' �Jc "a 0114'1N1 1 1 'R" 0 T r_y:'#'.�1;5,
t FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc,&YR 28 unit o• ft.
t 7.2 rt. �" !i° SOR- 1 PVC
Company Name I : ,.I R CA$
3t� ser'(%Qn FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: O 6 �Ct�wR ft. ft, to
List all applicable well permits(l.e.County,State, Variance,Injection,etc.)
ft. ft. in:
3.Well Use(check well use):
Water Supply Well: � FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultiral 19I&icipal/Public ft, fr in. ;
OGeothennal(Heating/Cooling Coolin Supply) ❑Residential Water Supply u. fa i°' l
( P/ g PP Y) pp y(single) �
Olttdustrial/Canmercial OResidential Water Supply(shared) FROM TO y MATERIALI f 3•.,1 EMPLACEMENT METHOD&AMOUNT
❑Irri ation . ft. ft
Non-Water Supply Well:
OMonitoring ❑Recovery, .3' ft' aO ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation "t9: ":n/, 'V.E ?k Ir? f•a` dbab e', .,._:...,:....
FROM TO MATERIAL, EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinity Barrier ft. ft,
OAquifer Test ❑Stormwater Drainage tt M
QExperimental Technology OSubsidence Control
9:=DIt>[lL .fit#I(1G'afa L+iilitdlSaalYd7ieet:tt1n :eJ""` 9„>;t:w-; .` .:
OGeothermal(Closed Loop) OTracer FROM I TO DE•SCREMON color,Garda Dolt rock type,amin An,etc.
gGeothermal Heatin Coolin Return ❑Other ex lain under#21 Remarks) ft. ft.
ft.
4.Date Well(s)Completed:123-IZ- Well ID# /U: ft. ft
5a.Well Location:NAeoOV CbueN�c�' ft, fL
,B r-(&h '" ar e?hsGryss 6 6 f fie 2Q ft. ft-
Facility/owner Name Facility ID#(if applicable) fA ft
3 6 w JL:�� o A 1 - ft. ft.
Physical Address,City,and Zip
m4GGY! _!.2reA7Lg
County Parcel Identification No.(PIN)
Sb,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one let/long is sufficient)
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�'�?~�'• a.3�' t, W //��c; s���+►+ L ' d.3- 7-•'�4a-/
__�� Signature of Certified Well Contractor Date
6.Is(are)the well(s): 1pFi'ermanent or OTemporat-f
By signing this form,I hereby cerlo that the wells)i4m(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or EW6' 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 ihisform. 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: 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 oneform. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: 305 , (ft.) 24a. For AU Wgill: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
t .
10,Static water level below top of casing: /.S (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. tor In' c'on 3yells 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 m �t Air lift 24c.For Water Supply&Injection Wells:
(gp )_aa[.Q Method of test:
Also submit one Dopy 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013
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4'Otec�
�� •m Macon C o u n t y NEW WELL CONSTRUCTION
o�JL�,°� Public Health -w CONSTRUCnON AUTHORIZATION
als PRIVATE DRINKING WATER WELL
Brian Bateman C • 060820-P • 061620-S
' ' Non-Residential • 6526271654 O.gs
• • 36 White Oak Lane r ,
' • Wa ah Road to Nantahala right on White Oak Lane building frst On left
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well should be drilled as far from tanks as possible while staying on property. Variance to allow for less than 100'to tank if needed.
Ensure well is 25'from creeks
See Variance issued by John Brooks on 8/11/2020 for extra requirements.
Diagram (Not to Scale)
25'
as
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100, Septic and
Pump tanks Creek
25'
Parking
Area
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J
36 White
a Oak Lane
a CrP
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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: 8/11/2020 Kyle Jennings, REHS 2142 �� Authorized State Agent