GW1-2023-02869_Well Construction - GW1_20230418

WELL CONSTRUCTION RECO.RI) ---
llus form Olin be used for single or muitiple.walls For Interngl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook V. A'"
FROM
Well Contractor Namo T hiµ ,., .�•.' •;>,,... y, t r•. i
F1'
O DESCRIPTION
2043-A 2 --
3 8o'rr. 3,9
NC Well COnlrRctQr Certification Nuinbor i SS O 1 Nltt(}' y i f'
*FROM TO _ -DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o • rl •rr. Ian _ pvc
Company Nern° ti '' ltt.>A�INSt:'!i's'Lrt•1. 251 > : ,1 'ehie[cl 5T5 i:..•: :--,:,..
FROM` 7'0 TH
2,Well Construction PerDlit#: DIAMETER ICKNESS MATERIAL•�(,•�,����_P ___ ti, '• '�"fit, in. -"--'-
List al!npplirable we!!permits(i.e.,County,State. Parlance,Injection,etc.)
~� ^�
3,Well Use(check well use.): fr. ft. M.in.
Water Su pply Wdl;
FROM TO DIAMETt:R SLOT SIZE I THICKNESS I hATERIAL
DAgricultural UM�uunicipaUPublic
CJGeothennal(Heating/Cooling Supply) 021 osidential Water Supply(single) fr. Tfr. '°• "
0111dlistrinl/Commercial :fsflrCS 4L+:. riy' ;,.?: fr.. try, .o• 5••:;,;.t::
ClKesidential Water Supply(shared) Ri7:;.n� .�y :`r-I'r::<�,.:.r;�::...:.t,t..,:�,z:,:<.,;,:'?�•;M•.•;•�..� s �,�;�.•;.,: .;
MITI otiotln - FROM- TO_,••,-, MATERIAL. EMPI.ACEMlENT METRO &A OUNT
Nao-Wa ter.Sllpply Well: " Q • ft. 3fr. DL
CJMonitoring [:J 3T�ft~ ft.
. .
� s,2ros�i /_-- ,g__ �
IirJec then Welt: --
ft. ft.
[]Aquifer Recharge G70roundwater Renicdiation
0Aquifer Storage and Recovery ❑SalhlityBarrier FROM TO MATERIAL EMPLACEIIfENfME'[7[On
tr, Tft.
0Aquifer Test 0Stormwater Drainage
DExperimentul Technolo
BY (]Subsidence Control
(:]Geothermal(Closed Loop) [T1 Q" . ?%N. 'tQ(s•',�t(ric tG'a do"'ill. I'''ts!iflb"a ary.'s' .
Rleer AROM TO _ UESRRIPITON color�hazdnV^30ILfrock IYER,grainAze etc.
I7GCothermal Ileatin Coolie Return [aOther cxplainwlderH21 Remarks) ft. ft.
Cum ft.
4,Date Well(s)Completed;
D.�-.G�_2_3We11
So.Well Location:
Facility/Owner Namo Facility IDH(ifspplicable)
�" Q ft. tL
Physical Address,City,and Zip
M1i I Y� •-y.: ':C:t': '�':` ,Li: •"'"•�4�`6'i:'!•`�•hGa�+'�•`....w:'+''.....
Colulty Parcel Identification No.(PIN)
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �-
(if well Geld,ono lat(long is sufficient) 22,Certification:
35 1.6 _/o N .a 44 'J?_2 �w
Signature of Certified Well Contractor Date
6.Is(are)the well(s); C�maucnt or L7'I'cmpor•a,y -
0y signing this jonn,I hereby rerio that the well(T)was(were)constructed in accurdonce.
with ISA NCAC 02C.0100 at-ISA NCAC 02C.07,00 Well Construction Srandarelr and that a
7.Is this a repair to an existing well: Dyes or FNo copy oj'diis record has been provided to I&well owner.
If this Is a repair,flll out known well construction information and explain the nature of the
repair under 021 remarks.section or on the back of thisform. 23.Site diagram or additional welt details:
You may use the back of this page to provide additional well site details or well
S,Number of wells constructed: Construction details. You cony also attach additional pages if necessary.
For mrdtiple in
or non-u:nter supply wells ONLY with the sane.catcsbrrction,you can
submit one form. SUBMITTA_I,INSTUCTIONS
9,Total well depth below land surface:_ q^_ (ft,) 24a. '9r We�: Submit this form within 30 days of completion of well
Parhnultiple wells list all depths rfdljfrreni(example-3«,200'and 2@100') construction to the following:
10.Static water level below top of casing: //O ' " (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,Ilse."•F" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter:6a .� (in,) 24b.Eg n'ect qM We11s ONLY: III addition to sending the form to the address in
Rota 2.4a above, also submit a copy of this form within 30 clays of completion of well
i..Well construction cable,
method: Rotary constnuction to the following:
(i.c,auger,rotary,cable,direct push,etc,) �-"� � -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; ^�
1636 Mail Service(:enter,Raleigh,NC 27699-1636
13R,Yield(gPm)_.3.Q__,_• _ Method of test: Air lift 24e.For Water Supply&In'ecdon Wells:
]3b.Disinfection type: H & Also submit one copy of this form within 30 days of completion of
Amount:•�2 OZ• well construction to the, county health department of the county where
constructed.
Focal QW-1 Nn,1h('arnlinn flnne.hnnnr nrl7n.n rnnmmv•n:l U•ti,rel 17.,e.............n:..,".,,.,..e 11I,..,,.u""".1 ' D-1—A A--9n14

QtotiA�r•
`d i11ldELiin`rc Health County
° Puri
�� NEW WELL CONSTRUCTIlEN
CONSTRUCTION AUTHt)i2 z-A If31V
PRIVATE DRINIQNG WATEi2 WELL.
;r + Lisa Leatherman + 121022-P `040122=S
5ih�`1e-Famii Well Residential ' 65" 369380 "5 98.:
a -150 Leatherman Place
"' 281V to L on Leatherman Raby Road bear L at 1st intersection then left onto Leatherman Place just i5ast 290 bear left-again 10 site.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum'setbacks as applicable.
Dia ram Not to Scale
a�
PL
mat
a PL �A °gea cQ°
IP
eP r 70 Permitted Well Area
(75 x 40')
�� v�i o '` 70 '0%� ��`•�s
�(12I022-P)
in 87 a O • �.
Existing Power Box �)
Shared Well . >s>•���f
>100' Barn
18 78'
160'
i
_ I
PL
N
I
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 fact or
clrc'urnkince 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.
-kWELLHEAD`COMPLETION.INSPECTION MUST BE APPROVED BEFORE(FINAL POWER IS GRANTED OR THE WELL IS.PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP NSTALLATION. QUESTIONS?[phone]
i
Issue Date: 12/19/2022 ' Jonathan Fouts,REHS 1979 uthorizedStateAgent
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