GW1-2022-08224_Well Construction - GW1_20220428

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
FROM TO r DESCRIPTION
Well Contractor Name — /cj(t. ft. -
2178 -A / 3
NC Well Contractor Certification Nwnber 15.OUTER CASING.for multi-cased wells OR LINER 0 alavliceble
FROM TO DIAMETER THICKNESS I MATERIAL
Dennis Holland Well Drilling, Inc. (� ft. cjft• in. Sp RQ I I P\)
Company Name 16.INNER CASING OR TUBING eotherdral closed-loop)
,- J� �F�ROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permff#:_ _6905_�2J— r _ _ ft. T ft. in. --
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)�- _y ---- --- --- -- --
____ ft. � fL in.
3.Well Use(check well use): 17.SCREEN -1- -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. —ft, in.
OApriculttrral ❑Municipal/Public
OGeothennal(Heating/Cooling Coolin Supply) ft. ft,
( g/ g pp y), ORe.idential Water Supply(single)
Olndustrial/Commercial. esidential Water Supply(shared) A.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑brig lion_ ^` ft. 2J ft. T
Non-Water Supply Well:- -----
❑Monitoring ❑Recovery - ft. aO et. t2t - �-
Injection Well: ft. fL
OAquifer Recharge ❑Groundwater Remediation t9„SAND/CsRAVELTA'CK'if,a licable — _
❑Aquifer Storage a'nd Recovery ❑Salinlly Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. ft.
OAquifer Test OStormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control - -
20.DRILLING LOG attach additional sheets if accessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardnes�soiUrock qp raio size,eteL
❑Geothermal(Heating/Cooling Return) 1-JOther(explain trader#21 Remarks) fL ft. T
4,Date Well(s)Completed: v ,Well ID#_M��T _. _
fL fL
5a.Well Location: ft. ft.
I.t[.Lt [J�— (�U►'otCk +v 1T ft. ft, — /I f��'—
Facility/Owner Name Facility IDII(ifapplicable) ------�� --•--fL t_�_._---_w_._�—_�— 1� 22
O¢-F 61.E nae— Cre-ek__ l2d, ft ft.. -
Physical Addirsss,!Ci�ty,and Zip /, �/� r2l�EKARKS
County Parcel Identification No.(PIN)
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) a 2 ,
W. 1 00- -4��
Sig6uirc o(Certificil Well tontractor Date
6.Is(arc.)the well(s): UlPermanent or OTemporary
By signing this jonn,/hereby certify that the we/!(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction.S'tandards and that a
7.is this a repair to an existing well: Oyes or N14No copy of this record has been provided to the well owner.
/f this is a repair,fill out known well construction information and explain the naahre of the.
repair under 1121 remarks section or on the back of thisfonn. 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 multiple ihh/'eciian or non-wafer supply wells ONLY with the same construction,you can
submit une form. _ ! SUBrVU 'TA_L INSTUCTIONS
9.Total well depth below land surface: �b (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(erample-3@200'and 2.@100') construction to the following:
10.Static water level below top of easing: _ �QQ (ft.) Division of Watcr Resources,Information Processing Unit,
If water level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6„ (in.) 24b. For lniection Wells ONLY: Ill 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
i
Air lift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) f-�_ Method of test:
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: H & H _ Amount: 12 oz. well construction to the county heal I th department of the county where
-'--— __ constructed,
1
Furor G W I North Carolina Department of Envirmtmeut and Nanual Resources--Division of Water Resources Revised August 2013

Y <; vEvv vre ++ra�mcty:sue
SIC I6alth COIF U �N At 692- ft16-
.d , a, EMAIL E� PRNAtE DRIN�QNG WATER WELL
Edouard Duroux • 020522-P • 0208 S
' Shared Well Residential ` 6556645645
• Off Younce Creek Road
28 N to L on Airport Rd.,L on Olive Hill Rd.,to Upper Burningtown Rd.,R on Wilds Cove Rd., R on Younce Creek Rd.,
on L just after 2767.
Permit Conditions
Well shall be constructed In compliance with all NCAC 2C Rules. L
Maintain minimum setbacks as applicable. �,? L B-� t�e fey- Fqsk-=a,
Any questions call MCPH.
Diagram (Not to Scale)
Pl-
107'
Q.
Culvert --
20
I
Prop. Ex. rlvewaY ---a,-.Berqn_
a 3 8%
i •
r-, 25'Nlin 100'min 30, .:
t 511,
---'
l Prop..
100,Min 70'
Area
/
yo'Jv
i_
i
This perinlit 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
drwmstance 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
H 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?(828 49-2490
P�
Issue Date: 2/22/2022 Tanner Stamey,REHS 712AuthorizedStateAgent