GW1-2022-05993_Well Construction - GW1_20220617

i
I
q V U&J., CONSTRUCTION RECORD ForlutcntaF1; ONLY^_-_-
Phis for can he used for single or multiple wells
I.Well Contractor-Information:
Mark E. Holland 14.WATER ZONES
TO DESCRIPTION
Well Contractor Name
2178 - A
NC:Well Contractor Certification Number iS-C)U'CF,R CASING(for multi-cased'wells)(.)R L.INF:R(if a liceble�__,__-_.-,_.._,
FROM I TO I DIAMETER_ - CKNESS M I L
Dennis Holland Well Drilling, Inc.
Company Name 16.INN6R.CASING Olt
FROM TUBING(peothermel closed-loo�s�
TO DIAMETER THI(:K.NESS MAl'ERIA I.
2.Well Construction Permittl: ft. ft. in.
List oil applicable well permits(i.e.County.State. Variance..Injection,etc.) - ...-__ __-.---_.._.._........_................_.._�_.__�__....;.. --...-.._.___.._...__....-
❑. ft. in.
3.Well Use check well use):
------- ----- --- ----'- -'--------- -
( ) 17.SCRF:F:N
Water Snp1)IyWell:
in.
-- ^��-- ----"_^M- FROM-_ TO . DIAME:rER SLOTSIZE TIIICKNF:SS MA'1_F.ItlAI.--_
ft.. -- —_
❑Agricultural 0Municipal/Public, _ _-. _ ____-__._- _______._.__._._-.-
ClGeothennal(Heating/Cooling Supply). ❑Residential.Water Supply(singlo) - - _ -_•-_.-_ ___-_.___ --__ _.-_-_.---
C1111dusti ial/Commercial I&Sidtattial Water Su I shared 111.GROUT
h'RO 1 To MAT' AL F.M PLA(:F.MENTMET"FIUD&AMOU f
Olfl i'a110n ft. fl.
Non-Water StlPpiy Well: -- )--- - ..._'
ft, ft.
[lMonitoring ORecovci
Injection Well:
CAquiferRec:harge ❑GroundwaterRemediation 1:9.,SAND/GR_ 1'.BAC�K,ffe
_-To _ _MATERIAL _-
-
❑AquiferStorageand Recovery ❑Salinity Barrier -
DAquifcr Test OStorn)water Drainage -----..----._....-.-•----.--_.._--......
Cllixperinlelilal Technology llSubsidence Control -------
2(1.URI1.,I,1NG LOG(attach additional sheets if
OGeothermal(Closed Loop) 01 t:'rcer FROM _ _I�0_ DESCRIP'r1ON(color,hatdncss soiVrock tr ain siu_e+y)-•_
1:.3Geothernial li
(Heating/Coolin Return) CJOthcr(explain under#'21 Ken)arks) n. ft.
. .-.-------------------_--_----- -
0�-o(�-Z2 N�q ---
4.Date.Well(s)Completed: Well Illlf '.._..-.-fL- ---...--�•-fr._.._-.__._._.._._-__-.........___.._...---._._.__._._--_.._..---._._.._...
1.7
5a.Well fation: n. fe.
facility/Owner Nat Facility IDII(il'app cable) - -�ft.
TV-
physical ':ss.City,and Zip � an;:i..__
Comity Parcel identification No.(PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifc tn: ^M
(if, JI fteld,one Ian/ n+is suflicicnt)
,�
-- -_ iigt auuc ul Certified Well :unuactoi Date
6.Is(are)the well(s): daPcrmanent or C1Temporary Uv signing this Jnrnh, I hereby certify that the wells) tuns(were)constructed in accordance
/ with IJA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction.Slnndards and rhar a
7.Is this a repair to an existing well: ❑Yes or A0 copy of his re.rord has been provided an the well owner.
fthis is a repair,fill out known well construction information and etylain the nonure of the.
repair underh l remarks section or on the back ofthisfionn. 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: consu'uclion derails. You n)ay also attach additional pages if necessary.
!iu nniltiple h Jection or non-water supply wells ONLY with the same construction,you can
!� S1113M1T1'A1,INSTUC'I:IONS
.submit one fornn.
9.Total well depth below land surface: _' `� --(ft.) 24a For.....
All Wells: Submit this form within 30 clays of completion of well
For nndriplr.wells list all depths ijdiffrrent(r_rarnple- 7( 00'ordJ.L/00') construction t0 the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:•_ _-M_� D _ (ft.) 1617 Mail Service Center,Raleigh,NC:27699-1617
if water level is above casing,use
�i° 24b. For. Injection e Wlls ONLY: In addition to sending the form to tile,address in
11.Borehole diameter: (imJ
--" 24a abuvr„ also submit a copy of this form within :10 days of complchun of well
12.Well construction method: Rotary - construction to the hollowing:
(i.e..finger,rotaty,cable,direet push,etc.)
Division of Water Rcsourr.rs,Underground Injection Control Program,
FOR N'A'1'F,12 Sl1PPL.Y WF..1.1.;S ONL.Y^ -- - 1636 Mail Servicc Center•,Raleigh,NC 27699-1636
I
Air lift '24c.For Water S!t IXA Injection Wells:
13a.Yield(gpm)_ Method of test: Also submit oat: copy of this fpnn within 30 days of completion of
2 0'T_. well I:oustruction to the county health department of the.county where
13h^Disinfection type: ^& -.____.---- Amutmt: -----^ constructed.
Form Gw-I North Carolina Dvpaimicut of Environnu:ul anel Natural Resources--Division of Waler Resources Revised August 201:1
I

?1 ILED 4/14/2022 TR
Y NEW WELL CONSTRUCTION
r Public Health CONSTRUMON AUTHORIZATION
PRIVATE DRINKING WATER WELL
EKathy D.Hart(current owner),Jim Sumpter(Buyer) • 111621-P • 114521-S
Sin le-Famil Well Residential ' 7520483440 1:98
Off Turtle Pond Road
Highlands.Rd.,to R on Turtle Pond Rd.,to L at fork before bendy Orchard Rd.,to immediate left across from Retreat
Lane.
_Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale),
1
Bri
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a \o\
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Chi d\
,
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,
,
Proposed
15 mar
10 min
50'min
l 50'min�82' 82 78
52'1
1 i \5 , N
RA
PL 10'mi -�
45, Monument
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 factor
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]
Issue Date: 4/13/2022 Charles Womack, REHS 1300 01UL A uthodZed State Agent ..