GW1-2021-07639_Well Construction - GW1_20211201

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WELL CONSTRUCTION RECORD For intemrsl Use ONLY;
This form can be used for single or multiple wells `
1.Well Contractor Information:
Mitchell Dean Cook1
FROM TO DESCRIPTION'
Well Contractor Name ; �, u ft. �
2043 A a 5M 2-g"l.
NC Well Contractor Certification Number i' A1C`4 07 im Q I i!• d ?,��.`y)git,;;:
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o . ft, ft, l0. _ 1 v�
Company Name t
p Y x .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 6�Q 7� 1_ ft. ft. . In.
List all applicable well permits(i.e.County,Slate,Variance,injection,etc.)
I ft. ft. in.
3.Well Use(check well use):
Water Supply Well: k FROM "P TO DIAMETER t{rSL TSSIZEt= THICIavess I MATERIAL '
❑Agricultural OMunicipaliPublic it. M in.
OGeothermal(Heating/Cooling Supply) Z21RIesidential Water Supply(single) ft. ft In.
❑Industrial/Commercial ❑Residential Water Supply(shared) { m' '' '';`s:t;'. (s': :`,.I�j,M`t;"R "
h ." i` d. Y:`..31 i.�. .t .=U. 3`atti 34 a•.tL:::•K' eF'
FROM TO " MATERIAL EIV ICEMENTMETIIOD&AMOUNT
❑hri ation ft. ft'
Non-Water Supply Well: gaz
OMonitoring ORecove rY ft ft
Infection Well: ft. ft.
❑Aquifer Recharge 00roundwater Remediation I19 t "/ ?t';F113v 1i1 ra`' �';z7 ,',u'Sj t ,;Jh::;�'_ ,•a_ ' ;.rft;
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Ertl PLACEMENI'METHOD
tr. fr. -
❑Aquifer'fcst OStormwater Drainage
❑Ex erimontal Technology ft. fL
p gY ❑Subsidence Control
DGeothermal(Closed Loop) OTracer •L)(t a" 8' r'o"al.d 'et! ufr_,,.i • .,3 a:3� ;`
FROM TO DL,SCRUMON color,hardam sollfrocittypt,grain size etc.
OGeothermal Heatin Coolin Retum ❑other ex lain under#21 Remarks R, ft.
4,Date Well(s) it. ft. ��f%IM I' �ra
Completed://_/�i Well>D# IV, ,�,�� ,
Sa.Well Location: ft. ft.
ft. ft DEC 01 .7021
Facility 3nior Name Facility IDN(if applicable)
ft. ft.
��t/ CO!✓C/t^®: 1�' �.cy.G� �1�h ft. ft v vr7
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/ininutes/seconds or decimal degrees: 22.Certification:
(if wall field,one lat/leng is sufficient)
Signature ofCortified Well Contractor Date
6,Is(are)the well(s): anent or ❑Temporary
By signing this form,1 hereby certify that the wells)was(were)constructed/it accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repAir to an existing well: OYes or .@}i Pie— copy of this record has been provided to the well owner.
If this is a repair,fill out known well constmellon information and explain the nature of the
repair tinder#21 remarkssecilon or on the backofthisform. 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 consiruction,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: D (ff) 24a. For AM Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jd(ffereni(example-3@200'and 1 rt 100') eonstniction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
fwater level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in,) 24b.For Iniecnon 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: 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) 6Z1 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 heaitii department of the county where
constructed.
Form GW-1 North Carolina Department ofEuvironrnent and Natural Resources-Division of Wator Resources Revised August 2013

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�� .m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
I
Trang Duong and Sean McCann • 060721-P • 013720-S
Single-Family Well Residential 6567287413 5
• • 6ffKelly Cove Road and Selah Ln.
Lower Burnin town Rd. ly Cove to property on right at the intersection of Kelly Cove Rd and Selah Ln.
I
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minim[ um setbacks as applicable,including 100'from septic system components and 20'from power line R.O.W.
Diagram (Not to Scale)
80, PL
Iron Pin
� I
,
PL N
310'
I
Strgam
I Proposed
I (i House I Power
Pole .;p•
�<VA
J. QC I
1� N 70' y//
i 9' D' / /90•
18
Iron pin ound iIt 66' eno� ��C°�� �`� ��,' Permitted
;I 66' "e 4P ° Well Area
18, (060721-P)
ut
/. by
i 100'
c
70'
---
e rive Repay
Cut Is- �`� //30'
� yco`PRa
This permit is valio 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 kPH.
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: 9/1/2021 Jonathan Fouts, REHS 1979 Authorized State Agent
I.