GW1-2021-02253_Well Construction - GW1_20210722

t t,'W
" WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intem�l Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook g, + >;�. � ,_ .,*,x ,.;�:,.f_. k.v .tr . :. ...
FROM I TO I DESCRDMON
Well Contractor Name �) ft.
2043 A f ft.
NC Well Contractor Certification Nwnber 15 A :,ERit~`;S'. )foX'iiu7 'Q#t 1iIN1E
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. r�1 rt :ft. ,r z
Company Name ...
`1ft:v . ,.E4R�_G''`ASIIYfxil2 s••.B .(if'a4ili mil r`cl d1�X �;�` t��:t �=;,,�� :rr
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit>e: r,` Y ) - 1 ft. ft.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft in.
3.Well Use(check well use):
a17t5.C31tElaNU
Water Supply Well: FROM I TO I DIAMETER ! SLOT SIZE THICKNESS MATERIAL
❑A ricultural it. ft. in.
g OMunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ORes dential Water Supply(single) ft. fa
❑Industrial/Commercial gResidential Water Supply(shared) g<d 11 1iUT h •_-•_`'- r. . r,;;:?�;l".,f..sr�s r, .; „.� ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. fr.
Non-Water Supply Well: rc -'
❑Monitoring ORecove tt. 1/ ft.
Injection Well: ft ft.
OA uifer Recharge ❑Groundwater Remediation
q It,'.R`A 1t`f 6" fe e'i:�* .=a':5iss�sTt?sue''-.s•<ai��.rt- -csy -t;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ir. tr.
& ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) OTracer "�9�1)ItIU1 (iL(lR'aNa?litiftl fioasl?ti.bets", "~ sa"�, t ,�; 4;'>>
FROM TO DESCRIPTION color,hardons,solUrock typ,grain size etc.
❑Geothermal (Heating/Cooling Return 00ther(explain under#21 Remarks) I ft.
4.Date Well(s)Completed:r"s 3:L _d Well ED r , fr. ft.
ft. ft
5a.Well Location:
fr. raLd
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1 ft.
f ` f Al+ •. V' 'i 1/�G�✓% t1 /t� /t t'' fL ft. 1'S►
Physical Address,City,and Zip' I —� �s►tti9
Cowry Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
i Signature of Certified Well Contractor Date
6.Is(are)the well(s):ePermanent or ❑Temporary
By signing this form,!hereby certo that the well(s)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 19IN6 copy of this record has been provided to the well owner.
lfthis Is a repair,fill out known well construction information and explain the nature of the
repair under k21 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 wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injecrlon or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9.Total well depth below land surface: ';..SSG' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdlfferent(example-3@200'and 2 tt 100') 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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Infection Wells ONLY: Inf addition;to sending the form to the address in
12.Well construction method:
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
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&Iniection 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 Environment and Nahval Resources-Division of Water Resources Revised August 2013

�m Macon County NEW WELL CONSTRUCTION
o '
o ( �d Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Michael Harrell • 042021-p • existing
Single- amily We11, Residential • 6578828882 n/a
• • 8441 Bryson City Road
• 28N> before Joshua Lane> # 8441 on right hand side of road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well area marked with pink flags on left hand side of front yard between house and other driveway.
Click to enter text
Click to enter text
Diagram (Not to Scale)
Joshua Lane
xr=3.5* 16' 14.5"N
83*25'40.56" W
Planter
'Private Driveway
30 •.: 25, �
Bryson City Road - -. F._.
L'—: —:"
R1
1
21. J...
C f tw R.q ci :::: :._.....:.::...:...� : : diversion ditch
:...............:.......:..........:......:...:.. ...
M M! T y 100' N
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 fad 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?[phone]
I
Issue Date: 6/15/2021 Harold Faircloth, REHS 2189 C u sz Gam—; Authorized State Agent
i
r