GW1-2021-06845_Well Construction - GW1_20210429

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.WATER ZONES
FROM TO DESC ON
Well Contractor Name
2178 -A ft. ft j
NC Well Contractor CertificationTON Number (► 9 ON 15.OUTER CASING for multi eased%wel1s'UR LINER'ita bk
�K {I UP� FROM TO DIAMETER TBICIaVESS MATERIAL
Dennis Holland Well Drilling, Inch sS014 h• ft. �, in. , a
�t'�
Company Name 3VONN uMANNER ASING OR TUBING eothermal closed-loo5W�
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L.J}d ft. 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
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmici al/Public
❑Geothermal(Heating/Cooling Supply), identia]Water Supply(single) ft. ft to
❑Industriat/Commereial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation_ G ft. 3 ft, r�Idyl
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL a-0 fL ,2h bon;
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g, ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additional sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock type,zrain size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft fL
r� ft. ft.
4.Date Well(s)Completed: % Well ID#
ft. it
5a..^Well Location: �^ _/ ft it
�AJt L'�s�C� a-�Ir01V`, ft. fL
Facility/Owner Name Facility ID#(if applicable)
1 ft. ft
P—Cl C\ l S �/\(A ft ft.
Physical Address,City,and Zip 21.REMARKS
11'ick CC')r, �t� 69a
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica'on:
(if well field,one lat/long is sufficient)
3\50
1*7 'ysa I N 05 r 9, 23-49 w
Signature ofCertified Well Contractor ( Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby cerr fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 330 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3©200'and 2Q100') construction to the following:
10.Static water level below top of casing: �U. (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
sn 24b.For Iniection Wells ONLY:I In addition to sending the form to the address in
(io.)
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: Also lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim;within 30 days of completion of
136.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

Q�pLe�r
E�.� Macon C o u n t y NEW WELL CONSTRUCTION
m Public Health CERTIFICATE OF COMPLETION
PRIVATE DRINKING WATER WELL
lfred&Windy Hargrove • 061620-p • 063220-s
jW28N>
an Falls Trail 6569026993 2 2 2
le-Famil Well Residential
Left @ Dean Falls> straight on site on ri ht
83°29' 23.626" W 35017' 45.976" N
As-Built Diagram (Not to Scale)
Bryson City Road
PL
10��
, ea% N
day, Road Neer V/ell
15'
• • 23'
25'
Proposed
In
Proposed Drive 3 BR K �
or 100'
/
71' /,•
15' f /•
O� 47' 50'm n
7
50'
Al
50'
50' /
• Neat Cement Depth: 20 ft Method: Pump Cap:Cement 0-3 ft Date 4/19/2021
0.188 Steel w/Drive Shoe Depth: 33 ft Diameter: 6 in B : H Fairclot ,Z
Height: in Vent: Y❑ NO.. I Seal: Y❑ NO Threadless Sample Tap: Y❑ N❑ Hose Bib:
.0107 J(2) ❑ Date: De the ft Yield: m Static H 0 Level: ft Permit# ❑
.01073(3) 0 Date: Depth: ft HP: Cert. #
Mark Holland Cert. # 2178A Partial Date: By:
• Final Date: By:
The well owner shall not place potential sources of groundwater contamination closer to the well than the separation distances specified In 15A NCAC 02C. This well was
constructed In the designated area and according to the well construction permit and the Private Drinking Water Well Rules. QUESTIONS? [phone]
Issue Date: 7/9/2014 Choose an Agent... Authorized State Agent