GW1-2021-05615_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intomgl Use ONLY:
1,Well Contractor Information: �.
Mitchell Dean Cook
,NE ti
Well Contractor Name FROM TO DESCRIPTION
2043 A .. .fr =rc
NC Well Contractor Certification Number sl3i01-i Lt1(i;'"
�TN.$,'foirlmiih'.•' 5..: �::Q•� IN. Ii.{.,,.�.a,�t,,:;•r.,;.,�d)x`=3''?
FROM TO DIAMETER THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. fr. ft, :; In.
Company Name „ ✓e-
01A.. Ni }:Ci►SllyCx'Olt?T[f .(�. of'er a ref' 0 3,t' p yyl '= a;at w .. c%i C`,�.,.{L Yila'Y.'3r:!f°•,k p�h{ :�
FROM i0 DIAMETER THICKNESS MATERIAL
2,Well Construction PerDtit#:- 0 d_ �, % -/� fr ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
fA ft. in.
3.Well Use(check well use): •
7t/' E N. i'.. ;`.; 7 S S/1A�e:A;;:;s i,j'f•11'G'h�r:t`L'FA'd'1!"'iYA ti Z"`q 4.;..ii.\',:�t WeterSupplyWell: RROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
QAgriculhural OMunicipal/Public ft. fa in.
OGeothermal(Heating/Cooling Supply) 121Gsidential Water Supply(single) ft. fa in.
❑hidustrial/Commercial
❑Residential Water Supply shared( ) RO. ;nai;5:: :.e.: ti; >r,,. ''s'<Y'i' k4iv?':3ti!li<a,i •:(�r�� .: ;,. "'Yi;
• .
❑lei at, FROM To MATERIAL EMPI ACEMENT METIfOD.&AMOUNT
Non-Water Supply Well: ft. fr.
OlYionitoring ORecove - fa ,• ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation P�-X .Id VFjl;iiyA. 1z'f+e' tit a"ui"i'ts"_s hc;?;•iu7:=% 1.:, :h<';<':^ect'K',;,i;
OAquifer Storage and Recovery OSalhtity Barrier FROM To MATERIAL EMPLACEMENT METHOD
fr,OAquifer'fest OStormwater Drainage ft.
OExperimental Technologyfa ft.
QSubsidence Control
QGeotherntal(Closed Loop) OTracer O L .fiSoGbC>
FROM TO DE—SCR—M...color 6erdne solFrock tylle,grub size etc.
OGeothermal Hcatin Conling Return OOther ex lain under#21 Remarks tr. ft.
/ ft. ft.
4.Date Well(s)Completed: 1' [Jj:.7.i Well]D# !J/,t6
Sa,Well Location:
ft
l/c� Idlt t� n:Y: Al. /A fr. ft. r�r yY
Facility/Owner Name Fncility IDk(if applicable) 1 tl T t
/,� ft. ft.
ft. ft. an,
Physical Address,City,and Zip °t ! ra �� iin,1
Ci
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/)ninutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N y'r* 3 J if "� W ... _�.t �''
Signature of Certified Well Contractor Date
6,Is(are)the well(s): RKerim anent or OTemporary
By signing this juror,I hereby cerify that the well(s)was(were)constructed In accordance
with I SA NCAC 01C.0100 or I.SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or EIAto'^ copy of this record has been provided to the well owner.
If flits Is a repair,Jill out known well construction Information and explain the nature of the
repair tinder#21 remarks.section or on the back of thlsform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
F Number nj wells r constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or Hot-water supply wells ONLY with the same consducNon,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: J (ft.) 24a, For All a ls: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: .5 63 (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" (iD.) 24b. For In'e tion Wells 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: ry
construction to the fallowing:
(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: Air lift 24c.For Water Supply&Injection Wells:
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 liavironment and Natural Resources—Division of Water Resources Revised August 2011

a • •�
Q tote ct
•m Macon County NEW WELL CONSTRUCTION
oPublic Health CONSTRUCTION AUTHORIZATION
EMAILEDI RRIVATE DRINKING WATER WELL
Della Wilson • 091521-P • EX.
Sigle Family Well Only tba Csecks), Residential ' 6593845070 1.06
........................._..... - -- _..
159 Allen Ta for
Road
iff—clarksn
Chapel Road to Frazier Road to Allen Taylor Road to #159 on Right —
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 56'minimum from septic system.
Call MCHD for questions.
Ensure Old Dug Well is completely sealed for safety or properly abandoned (GW-#30).
Diagram (Not to Scale)
I
I
I
o
e
d
�µ°a Permitted
qa`1\0 Well Area
(091521-P) i
(15'X 15'X 15')
L
Gravel Drive
,0 v�OC °aa -0x.Septic Tank
Pia
N
W • o • E
(P '
S i
i
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: 9/30/2021 Jonathan FOLIts, REHS 1979 �} Authorized State Agent
` 1