GW1-2021-02488_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For inteniql Use ONLY:
I.Well Contractor information:
Mitchell Dean Cook S Go
7
FROM TO DESCRIPTION
Wel I Contractor Name 1 r ft ft.
W
2043 A In ':
DV4R
NC Well Contractor Certification Nuinber
!-7
Dennis Holland Well Drilling, Inc. FROM
TO DIAMETER THICKNESS MATERIAL
ft.
0 ft, �in' -
Company Name
1M."AN K
FROM TO DIAMETER THICKNESs MATERIAL
2-Well Construction Permit#: ft. ft.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft, I in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER{SLOTTHICKNESS MATERIAL
OAgricultural DMunicipaUPublic ft. fr.
in,
OGeothermal(Fleating/Cooling Supply) 96'sidential Water Supply(single) ft.
0111dUStriRl/Conitnercial OResidential Water Supply(shared)
01rr1Rat10n
FROM TO MATERIAL EMPLACEMENTMETIIDD,&AMOUNT
Nun-Water Supply Well:
Obilonitoring ft,
ORecovery GJ fr.
Injection—Well: ft.
OAquifer Recharge 00roundwater Remediation lgitam ..... .....
OAquifer Storage and Recovery 08alinity Barrier FROM TO I MATERLAU EMPLACEMENT METHOD
OAquifer'rest ft.
08tormwater Drainage
DExperimentalTechnolotL fa
gy OSubsidence Control
OGeothernial(Closed Loop) OTracer
—M(—)M TO I DESCRIPTION(color,hardne&%3ollfrock type,grain size,etc.)
00cothermal(Heating/Co r#21 Remarks) ft. ft.
ft.
4.Date Well(s)Completed:4!!Jzt4Q3_-.,ZL Well 1D# /V, ft. ft.
So,Well Location:
ft, ft
ft
Facility/OwnerNanic
Facility ID#(if applicable)
ft. ft.
ft. ft.
p
Physical Address,City,and Zip
4/1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient)
22.Certification:
N LEJ�116 -W
Signature of Certified Wall Contractor Date
6.Is(are)the well(s): OP-efirnauent or OTemporary By signing this form,I hereby ceri(fy that the well(s)was(were)constructed/it 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: OYes or M?fo-- copy of this record has been provided to the well owner.
If this is a repair,Jill Out known well construction information and explain the nature of the i
repair tinder#21 remarksection or on the back of thIsform. 23.Site diagram or additional well details:
1 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: 7-4 Q1.5. (ft.) 24a. For AU We Is: Submit this form within 30 days of completion of well
For multiple wells list all depths ifaYfferent(example-3@200'and 2@100') constniction to the following:
10.Static water level below top or easing: (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" 24b. For Injection Wells ONLY: In laddition 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,Un'derground Injection Control Program,
FOR WATER SUPPLY WELL,$ONLY: 1636 Mail Service Center,�Raleigh,NC 27699-1636
1 1
13a.Yield(gpm)—5— Method of test, Air lift 24c.For Water Supply de Inlecuon wells:
Also submit one copy of this form NWI'iin 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-I North Carolina Department of Environment and Natural Resources-.Division of Water Resources Revised August 2013

`� •m Macon C o u n t y i NEW WELL CONSTRUCTION
a �' Public Health CONSTRUCTION AUTHORIZATION
'v a' PRIVATE DRINKING WATER WELL
lGarden
n Cliffhangers LLC/Gary Owens • 11I1120 P • 112320-5
' ' le-Family WeII Residential ' 6564176135 2.34
_Y r_� — ...----..._....._ — ... ---.._.._..
• • Branch Lot 36
Road to Garden Branch, driveway on left after Garden Flats Road lot is at en• d of road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. "
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Click to enter text
Click to enter text
Diagram (Not to Scale)
-------------------
Iron Pin
,
,
Proposed
Permitted Septic Area Three
(Initial and Repair Areas) ; Bedroom
Log#112320-S House
,
130, 2S'min.
1 p0./)ir)
,
Iron Pin
25, -
o
04
L
ro
N
10'x 10'
Well Area
This permit is valid for a period of five years except that it may be revoked at any time if it Is determined thatlthere 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. QUESTI N f?1(828)349-2490
Autho�izedStateAgent
Issue Date: 4/27/2021 Kyle Jennings, REHS 2142
I