GW1-2023-02870_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORI) -
'fllis fort can he used for single or multiple wells For himm4l Use ONLY:
i
I.Well Contractor Informaliou:
Mitchell Dean C ook 14 WA'PEt'l�NF
R'cll Contractor Nam,; FROM_~ TO _ _ DFSCRIPT90N -
2043 A
NC Well Cowractar CCrtlftcaIion Number --
15 OU7tPRU�ING(f�trintilh-ck.�Sd�w.Clls ()l2L1NF1�7t[0�1 irkble)���T
Dennis Holland Well Drilling If1C. FROM TO DIAMFTF,R 7TIICFCVESS MATF.ft1AI '—
�^t n 2, rt . . w.-m
Company Name,. ,_. 4 •.. IQ .2 P
, 16 fi!(N�R CASI7Vl;OR;IiF113IlYG etilho tool clwed]b8 '
FROM 70 MATERIAL_-
2.Well C'onstructiou Permit#: _ -•- -••-•---- -
DIAMETER TNICKNE,SS MATERIAL _-�
Q �1T2; - __List all applicable will perntifs(i.e.(:aunty,.S'rarc, Vm•tance,InjeeNmn,err..)"--""--�--'•'-_. ...--__ •—_,._ -.
3.Well Ilse(Check well use): fr. - ft,----^-in. -
- _
Water Supply WcIL -- F7tOnt 70
_ �_ 111A�1FT_FR Sl_OT SI?F, 1'H ICKNFSS MATERIAL��^
C1Agncullural ("Nill,ir.ipaVPublic fr. -^R in." -T
f]Cienthennal(lleating/Cooling Supply) UResidrntial Water Supply(single)
0111dustfial/Celttrnercial "'�'---•'-';.._•-n--=-;•^__
l!7 -lZolential Water Supply(sherod) IA tyROU7 ^;:;•` ?;.<s�'-r -,
rriC1lltl011t�M. �0 M_•�" AIATEHIAL FMPLACF,MF._NTM6TNOD;&AMOUMr'
Nou-Water Supply Well: - _-" - - ft. 3 fr
C.1Monitnring []Recovery ft. r ft.
Injection Well: --- -- -- - �hu'•i �P
BAquifer Recharge ElGroundwater RemediationT'`"T' T TAG rfapphraM
OAquifer Storage and Recovery ClsalutltyBarrier FROM - -TO - MATE;RLU; _ FMPLACEAIFAYrhffil71OD
IJAgitifarTest „ ft_ -ft. -
CL,tornmater Drainage
[.IFxperintentltl'reciul0lo ft• - ft_- '-"-"--'
6Y f:7SubsidanOc Control _
I geothermal(Closed Lon ;.20'llRfL'131N(,[OG eriactiihddtnoaal:sk tfjnece se
mcer
FROM TO_ _ IIF:bf RIS''ftUN IeolorLhard!,easAsollfrock ly(m.gl
L]Geothermal Ilcatin�CoolingRcuirn) ["lOther(cxplainwulerN21 Remarks) fr. R.
4.Date Well(s)Completed: . we Inn"..�__f _._._...� ' _ft.
rt. rL
5n,Well Location:
Facility/Owner Name Facility Ina(ifapplieable) ------._ ___AP.R-
fl. ft.
146
Physical Address,City,and'lip -
�11'tHFMA•1iKS 5�:
Cowlty Parcel Identification No.(PM)
5b.Latitude nod Longitude In degrees/minutes/seconds or decimal degrees;
(if well field,one lat/long is suffiricnQ 22,certification:
- - _ Signature ofCcniGed Wrll Contractor Dolt
6.Is(are)the well(s): kfit a mauent or- []7'elnparnry
(ry signing this form, I hereby verb that the well(s) was(west)constructed in accurdom r
xilh 1-5/1NCAC 02C.0100 orISA NC'AC 02C.02.00 Well Construction,Smnrlarrls unri that a
7.Is this a repair to an exisHug well: UYes or .14<0 copy oj'this record has been provided to the,yell owner.
lJ flits is a repair,fill out knonwl wcil construction it jorrnarlon and explain the nature uj the
repair under#21 remarks section at,on the back Qf 1his form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
tl.Number of wells constructed: constntclion details. You may also attach additional pages if necessary.
For multiple it jecriwn or nun-wafer supply hells ONLY wit-h the Sallie construction,you can
submit one jurnn. sU_13MIT'I Al.[Ns'fl_1_CTI_ONS
9.Total well depth below land surface:_ �D _ 24a. For AC" ells W : Submit this thrin within 30 days of completion of well
Ftn•muldple wells A.rt all de/rrhs ijdijjerwu(example-.t@200'and 2@ 00') � construction to the following:
10.Static seater level below top of casing: J 9O �T-^^� (ft) Division of Water Re.sout•ces,Information Processing Unit,
ffworer level is above rasing,use".t'. 1617 Mail Service Center,Raleigh,NC:27699••1617
11.Borchole.cliameter: 6 (iu.) 24b. Feu In1_eehl a We-Hs ONLY: ill addition to sending the form to the address in
Rota •1.4a abovt:, also submit a copy of this tbnn within 30 (lays of completion of well
12.Well construction method: ry -^ construction to 111L following:
(i.e.auger,rotary,cable,direct push,etc.)
__• Division of Water Resources,Underground Injection Control Program,
FOR b1'A7: R SUPPLY WFIA S ONLY: 1636 Mail Service(.enter';Raleigh,NC 27699-1636
13n.Yield m _---_" Air lift _•_, Alsors submit copy of this weals:
(gP ) �Q._.._..-- --- Method of test: ... - --- - -. ...._._ � �1 X_ -InlL_�-
H & f'i 'hin 30 days of completion of
13b.Disinfectiou type.: Amouut:_�2 oz. -_ well construction to tile, county health (iepartnient of the county where
constructed.
Fola C'W-I Nonh Cnrolbm Depaitmcut ofBuvirouutenc and Natural Resources--Division of Waier Resources Revised August 200

4� v
`A •m Macon County
E a Public Health
o r ,
'd NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Joey Dykes • 031423-P • 021312-5
Shared Well Residential ' 6584097756 EM 0.75
• • 16 Pinecrest Circle
Pressley Rd to Pressley Circle to Wildwood Acres Rd to R on Pinecrest Circle
Permit Conditions o
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from all septic system components.
This well shall serve less than 25 people or 15 connections.
- --—^---- -- - - Diagram Not to Scale -�-- - -- -- � — -�-- --- -
Fk yp
nle
Pt
f Sy reSeptic
1
f
f �
! SySteem rnpt-
Ic^ f Ex. Dykes
' Residence >loo'
f IP
-- Fk ISI
—,- owe
�i-- brave d vir a �_ 85'
J
Pinecrest Circle o-` Proposed Well Area
(marked with Blue Flags)
cb; -- —-- - — -- — 3'x3'Area--- — -
C 10 10o min
A \ i
i
Shed
Ex. Home
90, p4 N
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
circumstance 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.
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? 28) 349-2490
Issue Date: 3 28 2023 Josh Wilson, REHSI 322?tilk
Authorized State Agent