GW1-2021-00234_Well Construction - GW1_20211213

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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.WATERZONES
FROM TO I DESCRIPTION
Well Contractor Name ft. f0 I
2178-A ft. rt
NC Well Contractor Certification Number IS.OUTER CASING for miilo cased:ivells UR LINER if a ble
FROM TO DIAMETER ' THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a ff• ft, ; in. , PUS
Company Name 16..INNER'CASING OR T BINGIetoffiermal dosed400
O�w I3 12 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (,� ((y,�O tr. fL in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17..SCREEN I
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
ft. fL in.
❑Agricultural OMunicipal/Public
OGeothernlal Heatin Coolin Su 1 ❑Residential Water Su I ft, ft. in.
( i;/ g PP Y) � PP Y(single)
Olndustrial/Commercial FdResidential Water S y(shared) FROM
GROUT
RROM TO MATERIAL EMPLACEMENT METHOD k AMOUNT
01rri ation - - ff. - fL. Z_
Non-Water Supply Well: t ft. ft �.
OMonitoring ORecovery
Injection Well: fL ft
r
❑Aquifer Recharge ❑GroundwaterRemediation 19.S ND/GRAYELPACK iCa ble
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ff. ft.
❑Aquifer Test ❑Stormwater Drainage to ft.
OExperimental Technology ❑Subsidence Control
20.i?RILLiNG LOG'attach additionstl:eheeta if
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solUrock sin etw
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tL to
r1 (� ft. ft.
4.Date Well(s)Completed: j/•-.2ls4 2/ Well ID#� ).yG { ft. ft,
P
5a.Well Location: ft. ft
Orn P_ N,/A, ft. ft.
Facility/Owner Nam — Facility IDff(if applicable)
Y
Physical Address,City,and Ziy 21'.REMARKS
ALL ZA
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
3.�.'•13�5 I6 N r�� y �- f W
//'' Signahue o Certified Well Contractor Date
®6.Is(are)the well(s): fiermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A 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 kiQo copy of this record has been provided to she well owner.
1f 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 49�5 D S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdterent(example-3 a 00'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+' 1617 Mail Service Ce 1 ter,Raleigh,NC 27699-1617
611 246.For Injection Wells ONLY: 1n addition to sending the form to the address in
11.Borehole diameter: (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 27699-16M
Air lift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) ' Method of test: Also submit ohe copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 OZ• well construction to the county heath department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

Qtoce�r ' '
•m Macon County NEW WELL CONSTRUCTION
o r �Q", Public Health CONSTRUCTION AUTHORIZATION
," • a' PRIVATE DRINKING WATER WELL
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DIRECTIONS
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Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as ap licable. d Fi,f �oes �- ►ne4• loot S�c,k from Sep*ic
-proposed well area as �roppase4 6y 'De�� � yor +o m,el• sel- back.
prta Q-F 7o(e Tohn -TeAtgme-AD. /mil US1 mov 5
Diagram (Not to Scale)
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1 Pati r Area A
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ppgps CH•��:
This permit is valid for a period Of five years except that it(nay 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. 'rhe 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: f p/7 �� _._ _ Authorized State Agent
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