GW1-2022-05997_Well Construction - GW1_20220617

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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.WATFR ZONES i �-
FROM TO T DESCRIPTION_
Well Contractor Name ft. ft. �.
2178 -A ! ft. ft.
NC Well Contractor Certification Number 15..OU'PER CASING.for mtilticased we11s'0
R LINER iS.a licablc !�
FROM I TO DIAMETER THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. ftl ft. in.
Company Name 16.INNER CASING OR TUBING `eothermal closed-loo
'L PROM TO' DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2 —& � ..2,2417�'II.x.3�1 R. _ ft, io.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)_ -- -- —
ft. ___._ Ct. in•
3,Well Use(check well use): 17.S(:REF:N�_-�
ater W Supply Well: FROM TO M DIAMETER SLOT SIZE. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in
rN'I.n-Water
eothermal(Heating/Cooling Supply), ❑Residential Water Supply(single) ft. ft, tn•
dustrial/Commercial. ❑Residential Water Supply(shared) IS.:GROUT
FROM TO MATERIAL EMPLACE.MENTMETHOD&AMOI/NT
ri anon_ ft. ft.
Supply Well: ft. ft.
onitoring ❑Recovery
Injection Well:
❑Aquifer Recharge OGroundwater Remediation I9..SAND/GRAVEL.P:.'CK;fapplicable) T
❑Aquifer Storage and Recovery ❑Salinity BalTier FROM CO MATERIAL EMPLACF.aiF.NTMETHOD
ft. . ft.
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control - — -
2.0.DRILLING I;OG attach additional sheets-if necessary) _
❑Geothernal(Closed Loop) OTracer FROM 2r0 DESCRIPTION(color,hardness,soillrock type, size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft' ft.
^/ ft. ft.
4,Date.Well(s)Completed: Well IDH_! ft. — ft.
M
Saa.W� aell yLocationn:: ft. ��ft. ` JUN
m E'1= fJ1 G&-yA_, n
;t'7 ft. ft. —
Facility/Owner Name Facility IDII(ifapplicable)
LE A4 et r Pyw ce_'C_� ft.
Physical Addrus,City,and Zip _ 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cc ti atio ^M
(if well field,one latllong is sufficient)
qU N ol"3-,23 W v�'192 ,
Sf1mahtre ofCcrtified Vell CoiTtractor Date
6,Is(arc)the well(s): ftlPermanent or ❑Temporary
dance
By signing this form,I hereby cerli that the well(s)was(were)constructed in accor
with 15A NCAC 02C.0100 or 15A NCAC 02.0.0200 Wall Construction.Standards and that a
7.Is this a repair to an existing well: OYes or ONO copy of(his record has been provided to the well owner.
)f this is a repair,fill out)mown well construction information and explain the nature of the.
repair tinder 921 remarks section or on the back of thisforni. 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.
For nudtiple h jection or non-water.supply wells ON1,Y with the same contraction,you can
/'� SUBMITTAL INSTUC"LIONS
suhnrir ane form.
9. Coral well depth below land surface /6D D (ft.) 24a. For All Wells. Submit this form within 30 days of completion of well
Far rnrdtiple wells list all depths if dierem(evarnp!-3@200'and 2@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 abope'casing,use"+ 1617 Mail Service Center,Raleigh,NC>27699-1617
11.Borehole diameter: Err (in.) j
246. For In ection Wells ONLY: In addition to sending the folln 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 Wafer Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp tt'''' Air lift 24c.For Water Su &In'ection Wells:
)
m 13a.Yield _ h"'Method of test:
- Also submit one copy of this form within 30 days of completion of
lab.Disinfection type: H Amount:_1 Off• _ well construction to the county health department of the county where
�— constructed.
Form GW-I North Carolina Department of Environment and Nanu-al Resources--Division of Water Resources Reviscd August 2013

`�wIY I
Jackson County Department of Public Health
^YA4MOry 538 Scotts Creek Road, Suite 100
coU� Sylva, NC 28779 Well Perm �
i `ae°,Su` phone: [phone] FAX: [phone]
Reference Number: Permit.Nuinber: 2021-22417-9-11739
I FAIN: 7544-03-1842 Application Date: 2/15/2022
Owner: MELANCON, MARK J City: LIVINGSTON TX
Address: 159 RAINBOW DR #5902 Zip Code: 77399
Lot Number: LT B4 OFF PINE CREEK RD
Service Type: IP / CA/ OP/Well Permit Bedrooms:
Directions To Site: 107N; LEFT ON PINE-CREEK; FOLLOW SPLIT TOWARDS WALNUT CREEK; LEFT
ON WALNUT GAP RD; LEFT ON SUNDANCE LANE; FOLLOW TO #109 ON LEFT,
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Fee: $1,040.00 Receipt: _
EMS: _�� TlS /gSYT Issue Date., .Z ► 2
EHS: Approval Date:
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Signature: Date: j
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