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Home My WebLink AboutGW1-2021-00399_Well Construction - GW1_20211230 n WELL CONSTRUCTION RECORD For Intemgl Use ONLY: ' This form can be used for single or multiple wells ` I.Weil Contractor Information: Mitchell Dean Cook { ;v,<.Skzj� :>,1>1,�_:a'•:F s'3 l l '4 ,d"Yx`'' ;l Z531. FROM TO DESCRUMON Well Contractor Name � 7 'ft. / 7/ •ft. 204 s a ft. ft, NC Well Contractor Certification Nwnber 1 r'0 L$tGi' :¢ii!>i'i mamma FROM TO DIAMETER I THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. o , fi. 40= fV 6 „ +n R-,21 Sezr vk Company Name ';i';It, CA �- 1. �aEPfs rr° :� FROM TO DIAMETER i THICKNESS MATERIAL 2.Well Construction Permit#:_ /oLD 8e2/ -� fa ft, in. List all applicable well permits(i.e.County,State, Variance,Injection,etc.) 3.Well Use(check well use): ft ft. in. Water Supply Well: I�':.f < EE.�,':;_'�'<a��_=a�;�n'•a��J';.;t:i�aa,..i.3ai`•�3�a�:_� :•�s�w�^�t.'. j�-�.r,�?��;:��1'•z.t'-�t FROM TO I DIAMETERf~ SLOTSIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft. fa In. i ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑industrial/Commercial g1�idential Water Supply(shared) ;, .d `u ' " '"l'' '" ` "`' r �.N.,:L�:;>__.::.4.7d1.w%i<`<•'•'.�.?s.Y�2'3`f;.:.5'}i�'-t ';:s jai`*r Y`•rl s f ❑Irri alien FROM TO MATERIAL I EMPI.ACEMENTMETHOD&AMOUNT D, fr. Non-Water Supply Well: fr. 3 S /y�r ❑Monitoring ❑Recovery & :Zo � ft. e - 3-6 Infection Well: ft ft. ❑Aquifer Recharge ❑Groundwater Remediation i S R/, ?�V " lr; 'i c ,;�R`>�. ,>ttW":"aW;i d;• ,? ft•l ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEIIIENTMETHOD ❑Aquifer Test ❑Stormwater Drainage tt ft. ❑Experimental Technology ❑Subsidence Control ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRDMON color,hawHo soll/rock type,grain size etc. ❑Geothermal eating/Cooling Return ❑Other ex lain wider#21 Remarks fr. rt. ft. ft. 4.Date Well(s)Completed:/,ZZ./�Well ID# ii/ �i l ft. ft. Sa,Well Location: tr. h DZDWP,76Fr ft r,ZA,j i A4 A/ /R'iG 7r19 E L Qa.2zi Z ft. ft. Facility/Ownor Namo Facility ID#(if applicable) ft. ft. DEC i ft. ft, Physical Address,City,and Zip 44 Cowry Parcel Identification No.(PIN) Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (ifwell field,one lattloag is sufficient) Signature ofCortified Well Contractor Date 6.Is(are)the well(s): OPtfmauent or ❑Tcmporary By signing this form,!hereby certify that the well(s)was(ware)constructed in accordance with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a 7.is this a repair to an existing well: ❑Yes or `01 0 copy of this record has been provided to the well owner. Jf this Is'a repair,f ll out known well construction Information and explain the nature of the repair under#21 remarks.section or on the back of thisform. 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: construction details. You may also attach additional pages if necessary. For multiple injection or non•waler supply wells ONLY with the same construction,you can submit one form. SUBMITTAL INSTUCTIONS 9,Total well depth below land surface: S'4� (ft.) 24a, E2r All 3yell : Submit this form.within 30 days of completion of well For multiple wells list all depths#'different(example-3@200'and 2@100') construction to the following: I %�D r (ft Division of Water Resources,Information Processing Unit, 10.Static water level below top of casing: Ifwarer level is above casing,use"+" ) 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6n (in.) 24b.For Injection Wells ONLY: In addition to sending the fotw to the address in Rota 24aabove, also submit a copy of thislform-within 30 days of completion of well 12.Well construction method: ry 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)_ .30 Method of test: Airlift 24c.For Water SuRply&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 Euvironment and Natural Resources-'Division of Water Resources Revised August 2013 Qiote�r ', 2 I. Macon County %I NEW WELL CONSTRUCTION o �m Public Health CONSTRUCTION AUTHORIZATION PRIVATE DRINIQNG WATER WELL r in Partners,LLC 120821-P • 022017-S esidential 3144182 8,02 ills Road ndustrial Park Rd.,to R on Patton Rd., L on Potts Branch Rd.,to Hidden Hills Rd.,to site on L. Well is in ad. Permit Conditions Well shall be constructed in compliance with all NCAC 2C Rules. Maintain minimum setbacks as applicable. Any questions call MCPH. Diagram (Not to Scale) Ref r � ---- y; e nce Log#022017-5 ® Ex ?L dden hips R for Initial and Repair Areas ST add IN Old Bathhouse Debra Drive It Ex.OSWW------------------------ Reference Lot#5 Hidden ^ o Chuck Holland Hills; I Creek Y� ------------------- --1 >100, I 28' #1337 Hidden I a Hills Road a I Ora Proposed Driveway % Well Area 2'x 2' Soil Drive 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 dreumstance 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. TIONS?(828)349-2490 Issue Date: 12/13/2021 Tanner Stamey, REHS 712 uthorized State Agent