GW1-2022-01867_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD For Intemr>1 Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Mitchell Dean Cooky " ". s �en 1r` tirtEsV
FROM TO DESCRIPTION
Welt Contractor Name Z 5--o*- 5j• ft
2043 A. . FEB 16 V .ft. ft.
t{+".i + �� 1 , FROM TO , DIAMETER
NC Well Contractor Certification Number _ P t i
� :�, "%:s'.,.JIFtJ(,Iti IS Q5J111:R:Gt,1�1'. fot$iiiltitg
R THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc�'��-ice '
ff. 6o ft. I in.
Company Name 1'6r, .ER?c�ASIND'`.tti. 13711 `ed e'urel I"iglslo
FROM TO DIAMETER I THICKNESS ' MATERIAL
2.Well Construction Permit#: O/d j6a?=I rdf ft, ft, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc..)
ft. ft in
3.Well Use(check well use):
21, tS.QAt FN. `� ..'!:?� ,.:(J.�..,.. ,-.,+• ? =}x.u`Ssr C .at,.,. e f
Water Supply Well: FROM I TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL"
DAgricultural OMunicipaVPublic It. ft. In.
OGeothermal(Heating/Cooling Supply) GK-e�sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial CIResidential Water Supply(shared) r,;r ::'
FROM TO s MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrl 8t10I1
Non-Water Supply Well: O • ft. 3 . fe. >`/�h ! _ 1:2
OMonitoring ORecovery fA .2a' It' AA4 *.;,6-
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation RA
r t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft.. TO ft. I I
MATERIAL. EMPLACEAfENTMETHOD
OAquifer Test ❑Stormwater Drainage
tt. ft.
OExperimental Technology (]Subsidence Controls�R 'Lv(iti3hCs a"c iu''ditto a1.d
OGeothermal(Closed Loop) OTracer ietA'•1f`ti' "5 atr r:`s<„=. 3 :•k}r::~ s?
FROM TO DESCRIPTION color,batdn soil/rock type,grain size etc.
OGeothermal Heatin Coolin Return OOther(explain tinder#21 Remarks) ft. ft
� fr. fL
4.Date Well(s)Completed: a -o ell ID# Jl/./r9. tL ft.
Sa.Well Location: tr. ft
�sfh�A- LL/a y/'eh -/V./, ft. ft.
Facility/Owner Narne Facility ID#(if applicable) ft ft.
o Y- 7 PA a ve R e�d Af �. � a ft. fL
Physical Address,City,and Zip
211.11HEMA,
M,24gA 6,S'88 �S/ao 6 ..JE
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is srd5cicnt)
350 a2 -Y , J57 N ��� �/6 :�./� W o2-ag-. ..:2.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Vyerm aneut or OTcmporary
By signing this form,!hereby cert fy that the well(s)was(were)constructed to 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 91bW- copy of this record has been provided to the well owner.
!f Ihts is a repair fill ll out known well construction information and explain the nature of the
repair tinder#11 remarks section or on the back ojrhisform. 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _ f%s r (ft,) 24a. For AU Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ! O , (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" (in.) 24b.Eor Iniection 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 following:
(i.e.auger,rotary,cable,direct push,etc.) i.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
6
13a.Yield(gpm) 15 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
M constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i

Qtot@�.r
A to Macon County E57lwlz- P TO CUSTO/yIEls NEW WELL CONSTRUCTION
° r Public Health CONSTRUCTION AUTHORIZATION
5fepht4nPRIVATE DRINIQNG WATER WELL
nd Heather Warren • 010421-P • 011321-S
I, C28N
e- amil Well Residential 6588451006 3.06
Phase I Red Oak Rid e
to R on Cowee Crk. Rd.,L Snow Hill Rd., L on first Rickman Crk. Rd., L Jim Donald Rd/Red Oak Rd.,R Crepe
le Ln.to site on R past#111.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well shall not succumb to vehicular traffic.
Any questions call MCPH.
Diagram(Not to Scale)
Proposed
Well Area
IP PL
10'j----- _i4'
_ IP
60'— 25'Min
50, Proposed 3 BR
Min
PL
1�
72'
t--------------------------------------t
t t 10'
130' LDP 10"Repair Area Min
t t
t t
-------------------------------------�
80'
75' 10,
70' 10'
15' 23'
,, '-----------------Cut Bank----------------------
P
Crepe Myrtle Lane
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?(82 49-2490
Issue Date: 8/31/2021 Tanner Stamey,REHS 2 2 uthodzed State Agent
f
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