GW1-2022-08214_Well Construction - GW1_20220428

WELL,CONSTRUCTION RECORD f For liaenml use ONLY
J'his tbrm can be used for single or multiple wells I
LI.Well Contractor Information:
Mark E. Holland 14.WATER ZONES
DESCRIPTION--_._--------'--.-.�_._._____.____..
Well Contractor Name L ft. Q ut ft. C
NC Well Contractor Certification N)unber is.OUTER CASING for multi-cased;wells OR INNER if a lieablc
_ -..__.__(_._.. -._._ 1 -..-.�..5 r.�..__....__._._
FROM_ _.r0 _ -_ DIAMETER TIIICKNF,SS MATERIAL
Dennis Holland Well Drilling, Inc. R__ C Kp v -- --
® ft. ft. _ in.-SDA-?.I_.Company ---_.-
Name T—� 16.INNER CASING OR TUBING ebthermat closed-loolr
L `\ FROM DIAh FMR THICK.NF.SS MATERIAL- _
2.Well Construction Permit#: � !,. ft, in.
l,t.st all applicable well permits(i.e.County,State. Via imtre.Injection.etc.% --'----_.._..._......------- _.._.............
._!-..-_'--------....._
ft ft. in.
.3.Well Use(check well use): ----_...-._.__._....------_.--_--_..-__.._...__;:._._.--- --._..._..-----..._- ----.'---------.__..._...
17.SCRF:F;N vx^
-----__--._._z..-�...�.__.-_._...�.__.__..._____ p-ROht TO DIAM F:'fER i, SLOT ti1ZF. 'fHICKNF:SS MA'I'F.RIAI,
water-Supply wen: ..___.-...___..---._..__ ...-----._..-_ _�.
❑Apncultural OMunicipal/Public fr. ft. in.
❑Geothennal (Heating/Cooling Supply) ❑Residential Water Supply(single tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1�8.GROUT �.-
' _IYIATFRJA'L_ - F,MPhACF,M F:NT METt1gD&AMOIJN'f
❑lrri aton /S !L ft. ��Jf�. /��
Non-Water Supply Well: _____.____.-. _._.- ._ ___.___ .__%_.. _.-.._------..
❑Monitorint ft. fl. A.
1
ORecovcry __--_. _-_-_,-
IRjeon Well: ----- --_T�� -- ft. ft,cti
0Aquifer Recharge ClGroundwater Relnediation 19.SAND/GRAVEL.PACK(if applicable
FROM_ 'PO MATERIAL EMPLACEMENT METHOD
0Ayuifer Storage and Recovery OSalinily Barrier ft.
" -- ft.
❑AyuiterTest 08tormwaterDrainage __ ___._._.____.._.____._._- _ _.---.___... _._-___.----'_-_
ft. fL
❑Experimental Technology OSubsidence Control _.__.-.T__.___.____:...___..
20.DRILLING LOG_,attach additiouai n s
OGeothermal(Closed Loop) C:1TI'aCC.r FROM TO _ _ -UESf.RIP'rION(color,Ita)dne� v 7 gram sin,err-)
LIGeothennal(Heating/Cooling Return) 00ther(explain under#')_I Remarks) _
-- - -
4.Date Well(S)Completed: _ Well IllN - fL ft. - - - --u--- ----- - _._-__
Sa.Well Location:
ft. ft. Ir.) MA �� �s�iyt�]'._I �' --
N_- ft. ft.
facility/Owner Name Facility 160(it applicable) _.-._--.--_.___-_.__...__-.:....-_...-.._._._--.--._--._.-----.--_-.---_----_..__.._._--___-____.
I'L ft.
7 ac-k- d 1 _ _. ..._. _...._. ... - _.._.___ ._.._ __. - ._._.__..... ..
-.___ -
Physical Address,City,and Zip 21.REMARKS
MC-�--�-L--- 7 20,053 _.__..._.__._----.___...____.._ ._.____.___._..--------------
Colulty Parcel Identification No.(PIN)
56. L,atitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
.`iignattuc olY:crtilicd ell 'ontractor Date
6.Is(arc)the well(s): (11Permanent or ❑•I'emporaty
lJy signing this Jahn. l hereby certify that the well(s)N'ay'(N'e!'e)constructed in accordance
N'ith l.iA NCAC 07.0.III00 or l SA NCAC 02C.0200 Well Consrrucrioa S'mndards and that a
7.Is this a repair to an existing well: OYCs or P3No copy of this record has been provided to the well owner.
/(thin is a repair,fill out known well construction information and arpluin the noture of the
repair under#21 remarks section or on the back of this jortre 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 ___L_ construction details. You may also attach additional pages ifnecessaly
Far nndtiple 11yectinn ar nam-water supply wells OA' Y with the same curtslruction.You can
.suhmitoneJtnn. 5UBrVUTl'AL,INSTUCT IONS
9.Total well depth below land surface: C 24a. For All Wells: Submit this form within 10 days of completion of well
For nn ltiple wells list all depths ifdiffereru(avan)ple.3@V00'and)@-0100') construction to the following:
10.Static water level below top of casiug:._-____5---_ �-,(ft) Division of Water Resources,Information Processing Unit,
IJwater level is ahow casing,use 1617 Mail Service Center,Raleigh,NC 27699-I617
11. Borehole diameter: (in.) 24b. For Inieclion Wells ONLY: ';In addition to sc;nding the:than to the address in
Rotary 24a above, also submit a copy of this form within 30 days of compir-tion of well
12.Well construction method: ry ConstuCton to the tbilowing:
(i.c.auge.i.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
/ Air lift 24c.For Water Supply&Injcctionl Wells:
".
13a.Yield(gPm)_ iL_- ---.----- Method of test: _-----------....-------- - i _._
Also submit
one copy of this form within 30 days of completion of
I:it).Disinfection type:H-& H Amount:_12 O7_.. well a)ostrkiNion to the county health department of the county where
—._...,.__.__..__... _...__..___-.---_--- constructed: I
Form GW-I North Carolina Depanmeni of Envi)ann)cut and Nattual Resourr.cs--Division of Walol Resources Rcs'ised August 2013

_............ ..........._
i
E(v�°`PC,•m Macon COU n t y NEW WELL CONSTRUCTION
a Public Health DONSTRUCTION AUTHQRIZATION
d •`a' PRIVATE DRINKING WATER WELL
Jayne C. Bullls 090171 P
- --
INTE
' ' Sin le famll Well Residential 7 ,22.789053 0.57
-�_.._ ._ . Y__._ .:..._... ----
• • Off Buck Creek Road
_.......................___._.. ------ ------ __....._........_..._..._........_......._.:. ._. ...: ....... ......._;_.._...._........_.._._.........._.........-.........._........_-------........
iDIRECTIONS J_l-lighlands Rd., to L on^Buck Creek Rd_, to site on R, just before Dills Rd.
F'eimit cooditions
Well shall be constructed in cornpliance with all NC:AC 2C Rules.
Maintain rninirrtum setbacks as applicable.
Well is not to be subjected to vehicular traffic.
Any questions call MCPH.
Diagram (Not to Scale)
9
(luck Creek Road -- '
-- ---
------------- _ ...._- -...----.-,
Power. .. _y_._.---------.._._ OSWW•;y- `� Ex.
_-----.._---_--_-' it2177 Buck
Pole 750' Driveyvay --- '_— - Creek Road
[-—A
ell Are __ _-_.__....♦
25'N1in
♦ v Eluc:k Creek
' = I
F-•-•-._._.-._ U
a
a
a.
This permit is valid for a period of five years except that it may be revoked at any time it it is detennined that there has been a material change in any fact or
circumstance upon which the permit is issued. well location,installation,111d protection must meet:slat.regulations.The.;yell shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the welt indicated by raCPli is to provide protection from pos,;ble sources of contamination. Flow volume(well yield)is N01
guaranteed al:any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BF APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL PLACED IN-1-0
SERVICE. PLEASE SCHEDULE:A WELLHEAD INSPECTION AF FER PUMP INS TAI_LAT10N. QUESTIONS?L,( 28 2490
Issue Date: 10/21/2.02.1 Tanner Stanley, REHS 2711 .::. _ orliYtate Age.fit
t