GW1-2022-10744_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD
Tlds form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook sg N'r1TFR,7(§IYEs f
RIP77
Well Couu FROM TO actor Name ft. ft. DESC ON
2043 A rr. ft.
NC Well Contractor Certification Nmnber <. .:I5 (IUTFR.(,AS1NC, for multi cL�¢tl1,w'ells nitshlNER,
FROM1f TO DIAMETER THICKNF,S.S MATERIAL
Dennis Holland Well Drilling, Inc. fL rt
in.
i .
Company Name 16 i1VPIF R C q SINir UK P1llt B1104hermal'Zlpseit!q�
FROM 7'0 DL1hiFTF:R THICKNESS ... MATERIAL 2.Well Construction Permit#: 6cl 2 l,Z,p2 $ _ ft, It.
List all applicable well permits(i.e.County,Slrne, Variance,111jection,etc..)
3,Well Use(check well use): w
Water Supply WeIL FROM r0 DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricult ral limun-icipal/Public rt. fr. in.l
DGeothermal(Heating/Cooling Supply) CaRe.-sitlential Water Supply(single) fr.
❑Industrial/Commercial 13Residential Water Supply(shared) lti•;�Rf2UT,
C]Irri ation
FROM TO MATERIAL- I EMPLACEMENT METHOD&AMOUNT
ff. �>
Non-Water Supply Well:
um-onitoring C1Recovery i ft, 9 t ft
h ?r IL c
Injection Well: ft. fr.
❑AquiferRecharge OGroundwaterReniediation 19,S'`iVi)/C1tAYE1+PAG1ci"tf+a Iicib.'c ;.:,
DAquifer Storage and Recovery ❑Salinity BarrierFROM TO MATERIAL EMPLACEMENTMETHOD
OAquifer Test OStormwater Drainage ft, fr.
❑Gx erimental Tecluiolo ft. ft.
P gY C]Subsidence Control
DGeothermal(Closed Loop) ZO.DR11 LIN.(,`. h'(t'aifactii9dtittronal`sliects'ffHere ha
C1 I'IdCer FROM TO DES CRD'TION color bards soiUrock type.grain size eto.'
DGeothermal Heatin Coolin Return) DOther explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 2 ll ID fr. ft.
G5')-'>>e #
fL ft.
So.Well Location:
ft. ft. U_
Facility/OwnerNatne
Facility ID#(if epplicablc) ft' ft.
Physical Address,City,and"Lip ?21.;REMA'RF�j„
Comuty Parcel Identification No.(PIN) 52,2" PLC
5b,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(irwell field,one lattloug is sufficient)
Signature_ofCertified Well Contractor
6.Is(are)the well(s): &Pe manent or L7Tcmporary
t?y signing this jean,!hereby certify that the well(.)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC'WC.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or Lr Nut- copy of this record has been provided to the well owner.
lfdds is a repair,fill out known well construction information and explain the nature of the I
repair under#21 remarks section or on the back of this form. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submi(one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:
(ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferetu(example-3@200'and 2@ 009 construction to the following:
10.Static water level below top of casing: '221 (ft.) Division of Water Resources,Information Processing Unit,
If uvater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (iu.) 24b.For In'ecti n Wells ONLY: In 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: ry 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
13a.Yield(gP m) Method of test: Airlift 24c.For Water Supply&Injection Wells:
Also submit one copy of this fornf I within 30 days of completion of
13b.Disinfection type: H & H Amount:.12 oz. well construction to the county health department of the county where
_ constructed.
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Perot GW-I North Carolina Department of Iinvironmeut and Nat ral Resources-Division of Water Resources Revised August 2013
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EMAILED 8/1/2022 7 /
Q'TRABY
• ,�3 m c_U n o u n t y IMPROVEMENT PERMIT and CONSTRUCTION AUTHORIZATION
r d Public Health ON-SITE.WASTEWATER
Q�d ago
• •• • Grant Stiles ^__---_- -_-_-_ --�_-�__'_--------_-�-'�^_ . . 022122-5 • • 0211.2_?-P_---
Off Wide Horizon Drive beside 1949. - y- -Y - • 6593037205 0.62.
1EffiCrawlsr)ace
4415 to L on Wide Hori on Dv _z ri a to R at 1949bear h.ftaftercoming up hill to new site.
240 Gallons Per Day _ Two Bedroom _ New Construction- Proposed Single-Family Well i Of_f_Site- . •, Valid for 60 Months ^-
Permit Conditions - ---1--
A NC Certified Septic Installer to ensure all applicable setbacks are met.
Contact Health Department one to two days prior notice for final inspection.
Water supply line must be kept a minimum of 10 feet from all parts of the septic system.
Dia rani Not to=Sale -
) /
5�oad Proposed
pcce5 We Large Poplar corner in tree
PL
X '
�• so-
�, -85•
95'
35', a
PL 62'
70'
- 15'
Fki �27'
y.7
�P
N
• 4 P1 259io Reduction-Gravity; 25%Reduction-Gravity_;
Type Ila Soil,Depth: 48(in) -Slope: 16-21% LIAR:0,45 Saprolite:N Type Ila Area:533(ft2).. _ LTAR:0.45 .I Saprolite:N
• • • •
•' • 132' I 2 9'on center 18"low side 36 inches Serial-PVC 1000 gallon II Not Required
- - --- — — -�---_ --_—_.J----- -----— --- ___._.1 -----J
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 permit is 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. uestions?t8281 349- 490
Issue Date: 7L8I 02Z Charles Womack, REHS 1300 .,•_.- _.,:. Authorized state Aoe;ft