GW1-2021-05613_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD For Intarngl Use ONLY: '
This form can be used for single or multiple wells `
1.Well Contractor Information:
Mitchell Dean Cook ;^�:�,_ :• ;d'ei"4 Yf;.;.'�: :ts
FROM TO DESCRIPTION
Well Contractor Name /3d•ft. 3� •ft.
2043 A 3 V/,ft
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NC Well Contactor CertificationNwube!
FROM TO DIAMETER TRICKNES,4 MATERIAL
Dennis Holland Well Drilling, Inc. it,
Company Name .- F
P Y t"' Rh 4 goo
FROM TO I DIAMETER THICK14M MATERIAL
2.Well Construction Permit#: e5 g/ 4(/ 7 • ft. ft. in.
List all applicable well permits(i.e.Coun%State,Variance,Injection,etc)
ft. ft, in.
3.Well Use(check well use): t,.f r,u
?T7; ,.' ";:':eJ;Qc;,F:>•.x: `'%`fF1`:3jt+;:
Water Supply Well: FROM TO DIAMETER I SLOTSIZE ISTHICFOMS MATERIAL
OAgriculhtral 17MunicipaUPublic R. ft.
i
OGeothertnal(Heating/Cooling Supply) [Ures—identiel Water Supply(single)
ft, ft. in.
❑Industrial/Commercial OResidential Water Supply(shared)
FROM TO MATERIAL EMFI.ACEMENTMETHOD&AMOUNT•
OIrri ation ft. ft.
Non-Water Supply Well:
Oldonitoring ❑Recovery ft ft
Injection Well: ft. ft.
OAquiferRecharge OGroundwaterRemediation >fl•r:'t: ./ ' In+PA c g ;:Y•.tt:!r _. ;:cy ta4.2s�:_nos
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEniENTMETHOD
tr.OAquifer Test OStonnwater Drainage fr.
erimental Technology fa ft.
OEx
p gY OSubsidence Control
Yr o,iii f FI '` ,�a if9n .a ee't si :• , ,i.J j:",OGeothermal(Closed Loop) DTracer FRoM To DESCRIPTION color hardy aoivreck Y rain size etc.
DGeothermal Heatin Coolinj Return DOther ex lain wider#21 Remarks) ft. ft. I
4,Date Well(s)Completed: Well 11D# rt. ft.
ft. ft. h.
So.Well Location:
l ft. ft.
[f bs^ic� � /1/. /l�, fr, ft. 0
Facility/GivnarNama
Facility 1DN(ifeppGcable)
ft.
ft. ft. SOC1 01.1
Physical Address,City,and Zip R`"
AA
Cowity Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient) �A
��-- Signature of Certified Well Contractor Date
6.Is(are)the well(s): 8fiermaDent or ❑Temporary
By signing this form,I hereby cerlO that the we (s)was(were)constructed/it accordance
with l 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 (fw copy oflhls 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 Ike back ofthisform. 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 infection or non•waler supply walls ONLY wllh the same eottsbueNon,you can
submit one form. SUBMITTAI,INSTUCTIONS.
9,Total well depth below land surface: (ft.) 24a. For t111 Wells: Submit this form within 30 days of completion of well
For multiple wells Bst all depths ifdifferent(example-3@260'and 2@100') construction to the following:
10.Static water level below top of casing: :4 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Ralelgb,NC 27699-1617
11,Borehole diameter: 6" (in.) 24b.For Iniecfion Wells ONLY: In addition to sending the form to the address in
Rota 24aabove, 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,otc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm)_ /.-;L Method of test: Air lift 24c.For Water Supply&In'ection Wehls:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: �2 oz. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Nattaal Resources-'Division of Water Rosourices Revised August 2013

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« �m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
i Gary Abrignani and Joyce Corvino • 031417-P • 031417-S
Single-Family Well Residential 6581691364 8.48 Ac.
• • Near End of Pitts Farm Road on Left in field
• Georgia Road to Right on Coweeta Church Road to Right on Addington Bridge Road to Left on Pitts Rd.to Pitts Farm Road to end of
Rd.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from all septic system components and 25'from building perimeters.
Diagram (Not to Scale)
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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: 3/17/2017 Jonathan Fouts, REHS 1979 Authorized State Agent