GW1-2022-03657_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wolls For Intemgl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
' I+RAM TO DESCRD'770N
Well Contractor Name 3 •ft. ft.
2043 A ft. ft,
NC Well Contractor Certification Nmnber 15 00..PIt>'ty'' 2 for'imiil''` ►r`f'e ' q : TIC.
FROM TO I DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. r ft .ft, .� ;n
Company Name t �• SCR l Pl�e
_ .il'6:=i .�RrG''•A IIYfr _$ - `_F o "t�l' 1� ':i.��'�tz�..?;31;=;,.�1 T'�+'_.,:,•a
FROM I TO DIAMETER THICKNESS MATERUL
2.Well Construction Permit#: fL it. in.
List all applicable well permits(i.e.Coun%State,Variance,Injection,ere.)
3.Well Use(check well use): ft. ft m
1•I,5`(7,RFb` x. f• �`[ c ,.,-1:/�.s1t, .,a.•.}si�..:�).�,�' 1i1 :.s;�: S_; :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL `
❑Agricultural OMunicipal/Public ft. fa to.
OGeothermal(Heating/Cooling Supply) ttlResidential Water Supply(single) ft ft- In.-
❑industrial/Commercial OResidential Water Supply(shared) ")$ ' 'Utt; ".•;F xlv N-.3,;.k <,ay?
❑Irrl at10n
FROM TO MATERIAL EMPIACEMENTMETHOD&AMOUNT
Non-Water Supply Well:
'Monitoring ORecovery ft �O ft, sr/atirt� —b4 Peer,l°
Injection Well: & ft.
OAquiferItecharge C30roundwaterRemediation >=;i9x: /(i '.•,; Ii??RAC�Kr't+a �` a
OAquifer Storage and RecoveryFROM TO MATERIAL EMPLACEMENTMETHOD
OSnlinity Barrier ft. fr.
(]Aquifer Test OStornwater Drainage
❑Ex erimental Technology to fL
p gY ❑Subsidence Control
20 DR '1N(<T b ati a±addifio""Is7ieefs'ri a': �` j;OGeothermal(Closed Loop) OTracer FROM TO DESCREMON color h4rdaM solUrock typl,araln stir etc.
OGeothermal(Heating/Cooling(Heating/Cooling Return ClOther(explain tinder#21 Remarks) ft. ft.
' fr.4,Date Well(s)Completed:Q3!-1-1,2 Well ID# IV.1A ft.
ft. ft.
5a.Well Location:
ft. ft,
112 Lblb .!Uk ex I et- ft. fL MAR 21
Facility/Owner Name Facility ID#(if applicable)
'' ft. ft.
Lam_1' :MLA IP t v P v � 0•11— /Jo/>-�a d, ft. ft.
Physical Address,City,and Zip
4dQ CDh 62S766 yL J 2*i 2
Cowty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: `
(if well field,one ladlong is sufficient)
N 1,1' !Z} 7 Z 92 3 w fin. �.6�_za -N (7
Signature of Certified Well Contractor Date
6.Is are the wells T
( ) &YFermanent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed in 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: ❑Yes or [+fNo copy of this record has been provided to the well owner.
If this Is a repair,fill out known well construction information and explain the stature of the
repair tinder#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: constriction 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 farm. SUIIMITTAL INSTUCTIONS
9,Total well depth below land surface: r (ft.) 24a. )iol' All Welts: Submit this (form within 30 days of completion of well
For multiple wells list all depths ttraYeerent(example-3@200'and 2Q100') construction to the following:
10.Static water level below top ofcasing: (pt, Division of Water Resources,Information Processing Unit,
ifwaterlevel is above casing,use"+" ) 1617 Mail'Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6a (in,) 24b.For Ioieclion Well 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: 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) O Method of test: Air lift 24c.For Water Su ,W&Injection
—� Also submit one copy of this forum within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well constriction to the county health department of the county where
constructed,
Fort GW-1 North Carolina Department of Euviroument and Natural Resources-Division of Water Resources Revised August 2013
I

Q<ote�tJEMAILEDI
.m Macon C o u.n t y NEW WELL CONSTRUCTION
"o ' CONSTRUCTION AUTHORIZATION
Public Health PRIVATE DRINIQNG WATER WELL
t Dalton Shuler • 122021-P • 123621-S
Single-Family Well Residential ' 6574111947 2.65
• • Lot 4 River Run off Cliff Dalrymple Road
P
c • 64w to L on Patton Rd. to L on Cliff Dalrymple Rd. to L at 1st fork to River Run bear right at fork to lot on left.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
t
h Diagram (Not to Scale)
r Q�
7 N�
F Pl-
~�OF
h
li
NN 50'
a� Shallow to r 40'
C�A
Proposed House Fa 9
2"i
..20' h rge \ `�
;p 0 a�� e >100' \
► d. \
t Q° �J 87" 7 `
osed�t �` 62' 58, 34
QcoP ` 62' \ `
Large Tree
\ Additional \ ,-
ti3 5o",Repair Area `� -` 90'
50" Evergreen 10'
` 1 Dogwo
R n PL
N= RNet
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This pentnit 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 regulatlons.The well shall be inspected and approved by Macon County
a 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.
r,
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]
Issue Date: 1/5/2022 Charles.Womack, REHS 1300 Qwly w uthorizedStateAgent