GW1-2022-01936_Well Construction - GW1_20220224

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WELL CONSTRUCTION RECORD For Intemgl Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Mitchell Dean Cook
FROM TO DES ON
Well Contractor Name .2 f W 51" 2495-6 'fy . I
2043 A ft. ft.
f
NC Well Contractor Certification Niunber =.15 OJffER i``.$ " r :w
foX miilti-vk3 t; cUa,Qft 'Ipl i b e,
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o - ft. 6:? 'ft, 6 •- in. klwd
.21 ,wc
Company Name 511 EMU :f; t)I3 (i. '_t'e trait; 1 u '':i"';,. ,. ti
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: /D// —� fn ft, in.
List all applicable well permits(I.e.County,State,variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): z i7,!Yt1t13F E �, c ,
Water Supply Well: FROM I TO I DIAMETER I!SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) t31lCe-s—idential Water Supply(single) tr. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) ''S�C�R:UT. ;;,.,,`.- •`•-•„t;, ..>�» a
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Otrri ation !
Non-Water Supply Well: O ' ft. fr. tle^ G S
OMonitori 18 ORecovery tL -W fa h! ist
Injection Well: ft. ft.
OAquiferRecharge OGroundwaterRemediation -.^19;. ';D/Gt :+:. <p ° Kt a Ifc" e',. > Y +,$.; ,; „ { .tz.: •`;'
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL! I EMPLACEMENT METHOD
fr. ft.
OAquifer Test OStomtwater Drainage
fa ft.
OExperimental Technology OSubsidence Control
O bIt z tIN (C)G:T OWN 'li"�§a •i;`tf: <;;;':�`1�r.;
OGeothermal(Closed Loop) 01'racer FROM TO DESCRIPTION color,baNaM soil/rock type,gritin size etc.
❑Geothermal (Heating/Cooling Return GOther(explain tinder#21Remarks) ft. ft.
4,Date Well(s)Completed:aA:Jg -2�2 Well ID#_ ft. ft.
Sa.Well Location: ft. ft.
ft. ft. 22U2�
Facility/ wner Name Facility ID#(if applicable) ft ft.
Lc f- /D a u r�l 1/� S act ft. ft. r, 4
a
Physical Address,City,and Zip <l1 1tEMA•. ;= ...`:_' ;iin fr;,-_;., a . 6 � ;: ,.:i
L
Ai a card G S8 5 c>g,l z
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Teel
(ifwell field,one lat/long is sufficient)
;� a2 a/. 7 7-7- N '.302 X. ., w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): f>i'Permanent or OTemporary
By signing this form,1 hereby cerr(fy that the wells)was(were)constructed/n accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7,Is this a repair to an existing well: -OYes or o copy of this record has been provided to the well owner.
If tltls Is a repair,f ll out(mown 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft,) 24a. For All Wells: Submit this for within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 1,56 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.for Iniec)Eon Wells ONLY: In addition to sending the fonn 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: 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 27699-1636
13a.Yield(gpm) 3 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 jto the county health department of the county where
constructed. "
Form GW-1 North Carolina Department of Enviroument and Natural Resources—Division of Water Resoidus Revised August 2013
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Qtnte�� 5 �t�)1 - 4 5, h24,
�;� d a c o n .C o ti'm y NEW WELL CONSTRUCTION
; ;7 Public Health CONSTRUCTION AUTHORIZATION
PRIVATE bRINIGNG WATER WELL
f Roger A. Goss _ • M 161121-P • 102121-S
Single-Family Well Residential • 6585091770 3.0 ,"
• Lot 10 Laurel Vista
• 28N to L on Airport Rd. L on Lloyd Tallent Rd. stay L on Trimont Lake Rd. L on Laurel Vista Trl. site on Rafter#211.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
If 25'is not maintained to detached garage then a variance will be required before final Certificate of Completion can be-issued.
Any questions call MCPH.
Diagram (Not to Scale)
30' LDP10
Repair
Area
o
64__
eeosed 95,
BedrooM
IS�Mi� 110' �
115'
' Triple
Forked
--- --- ---- Oak
Proposed -,.____ ----'
Detached Proposed Driveway -�--- ------Fill
Garage 33'
25 Ar
i1
Min 20'1 20 115' �a�relvista�ra
i
Proposed 320
Well
Area
This permit is valid for a period of-flve"yearS except that it maybe revoked at any time If it Is determined than there has been a materlal 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. Now volume(well yleld)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. QU ONS?(8 )349-2490
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Issue Date: 12/29/2021 Tanner Stamey, REHS 712 Authorized State Agent
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