GW1-2022-04850_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:, -
Mark E. Holland 14.WATER ZONES
_ —T- FR.( t -✓ TO_...__.._ _DESCRIPTION -,_________.-,—.�--_._..___
Well Contractor Namc —l_ ft.
NC:Well Contractor Certification Ntunber IS.UU'GER CASI G Cfor multi-cased_wells),OR LINER Sif ap Heable) -_---_
FRO _ TO DIAMETER --�{-;T�-IIICKNE'S MATERI\L
Dennis Holland Well Drilling, Inc. �M ft: --� " ft. in. 1 ,
Company Name 16.INNER CASI G U :eo[her�mJa�lJclosed-l/o�oJ[_
FROM TO .D1MfE'I'ER THICKNESS MATERIAL
2.Well Construction Permit H: l I ft. ft,
List all applicable we-Il permits(i.e.County,Slate. Variance,hjection,etc.) R•_ _-`�"-"'-ft-•• --------"in. _____-• ---- -----
3.Well Use(check well use):
Water Supply Well: T F'ROM� TO _ DIAM F:rER SLOTSIZE THIC Vs. MATERIAL
❑Agricultural ❑Inlcipal/Publir, - -- -- -�_ ----'- --- - -----------
❑Geothermal(Heating/Cooling Supply) 70sidential Water Supply single in.�
Lllndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL F•MPLACEMENTMETIIOD_&AMOUNT_
❑11'rigah011—., __ .. ..-_-`_T (t. (t. —. .—
Non-)�aterSujrpiy Welt:
- -- f-- ..� - 7
❑Monitoring ❑Recovery ft- ft. NN
Injection Well: �- '---- ---' '-l- H, ft,
❑Aquifer Recharge ElGroundwater Reniediation 19.SAND/GRAVF,I,.PAC K if a ticable FROM TO MATERAAI. EMPLACHMENTMETHOD
[-]Aquifer Storage and Recovery ❑Salinity Barrier _ _._
ElAquiferTest ❑StonnwaterDrainage - _..--._.._____._._._____—.•_-.. _____ ._—_-_____ ____.
ft. ft.
DExperimental Technology ❑Subsidence Control — ---- •••--
20.DRILLING 1,01, Alin additional sheets if nccessa —
DGeothennal(Closed Loop) 01'raeer FROM TO DESCRIPTION(rotor,hardness,soiVracktlpe,Erainsiutetc.j—
f_1Geothermal(Iieating/(ooling Return) ❑Other(explain under H21 Remarks) h ft.
ft. ft.
4.Date Well(s)Completed: Well IDH �� ------ _._._._
ft. ft.
5a.Well Location: f- ft. ft.!
, r -- n
1djeX1 ZQ ft. ft.
Facility/Owner Namc Facility IDU(it'applicablc) -ft:- ------rL------ �A - � u--- --- -------
Physical Address,City,and Zip
21:R6MARIGST��_ —�a wr57
Yk. cil
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconits or decimal degrees: 22•Certi c 'on:
(if well field one lat/long is sufficient)
_ _ -iigt n e of'e ti led-W ell4)nactorDate
6.Is(are)the well(s): 911'ermanent or OTemporary
By siRn:ng this Jorm, !hereby rem that the well(,) was(ioere)constructed in accordance
N,iih 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and[hilt a
7.Is this a repair to an existing well: ❑Yes or VINO copy of rhis record has been provided to the well owner.
//'this is a repair,fill out known well construction information and explain the nature of(he
repair under il2l remarks section or on the back of rhisform. 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: 1 construction details. You may also attach additional pages if necessary.
Isar multiple injection or non-svmer supply wells ONLY+vith d+c same anutruc6nn,you can
submit one form- SU_13M1'fTAI,_INSTU_CT10_NS
n I
9.Total well depth below land surface: V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list ail depths if thereon(Trample-3@(2UO'and 7.@000') collstiuction t0 ale following:
10.Static water level below tocasing: Z� (ft-) Division of Water Resources,Information Processing Unit,
P of -If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
6" (in.) 24b. For Injection Wells ONLY: In addition to sending the foot to the address in
_
24aabove, also submit a copy of this form within :30 days of completion of well
I2.Well construction method: Rotary _ consrurtion to the following:
(i.e..auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER St1PPI Y VEL,IS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.ForrWWaterSu I &Injection Wells:
13a.Yield(gpm)___-� ------------ Method of test: . '
Also ,abort one copy of this form within 30 clays of completion of
13h.Disinfection type: Amount: �2 Off•
H & H well construction to the county health department of the county where
_-•_,__ _
Fenn GW-I North Carolina Department of Environment and Nanual Resources--Division of-Water Resources Keviscd August 2013

Qtoteor
�"•7 'm Macon County IMPROVEMENT PERMIT and CONSTRUCTION AUTHORIZATION
E r Public Health ON-SITE WASTEWATER
ffJeremy Decker •• • 030722-5 110321-P
5 Muskrat Road • • 6553662291 1.95
4W on Murphy Road to R on St.'Johns Church Rd.,to L on Muskrat Rd.,to 55 on right.60 Gallons Per Day Three Bedroom M/H - Addition to Existing System
rawlspace Proposed Single-Family Well/On Site - Valid for 60 Months
Permit Conditions
The certified installer has two different pumping options to choose from depending on tank hole wetness.
A grinder pump may be used to go into two 1000 gallon septic tanks,first one without baffle;and second with regular.filter.
An effluent pump with first a 1000 gallon septic tank and a 1000 gallon pump tank to be p mped into a.distribution box.
The old septic tank is to be pumped out,crushed and filled in to abandon and a new distribution box installed
Contact Health Department for final inspection one day prior and with questions. Waterproof tanks may be required.
Diagram Not to Scale
Neighbors Well
>100'
Previous Septic Denial Letter
Neighbors Log#110821-S Unsuitable
Septic System PL Soil Wetness Area pr0p0SedM/y
r \, Propose prive
S Min
Old ST
100- To be abandoned 10-
Approved Well Area PrOposed 74, IS�• �°
I ExistinL 5- En
Grave top Of c frO� Y
110, 60' �LS ip�S Ut9rdge
a 25" 'S�,Gravel
a� 25 Existing I-,, 50' `%
D Residence Apep `
Re SH
v 20' Existing Power Pole r Pd '
ar i
125'
�J
- N
• • 25%Reduction—Effluent Pump; T&I Panel Blockl(PPBPS)-Horizontal—Effluent Pump;
Type IIIb Soil Depth: 40(in) Slope:10% LTAR:0.4 Saprolite:No Type IIIb Area:300,(ft2) LTAR:0.4 Saprolite:No
CONSTRUCTION TOTALLENGTH • DEPTH WIDTHDISTRIBCTIPN
•' • 74' 1 9'on center 18"low side 36 inches Medium D,-Box 1000 gallon 1000 gallon
i
The issuance of this permit by MCPH in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in
meeting their requirements. This permit is subject to revocation if the site plan,plat,site or intended use changes. This permitlis subject to compliance with the provisions
of the NC Laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit. Construction and installation;Rules NCAC.1950,.1952,.1954,.1955,
.1956,.1957,.1958 and.1959 are incorporated by reference into this permit and shall be met Ouestions7 RM,349-2490
Issue Date: 3 4 2022 Charles Womack,REHS 1300 Authorized State Agent