GW1--06291_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well ontractor I orma Aon::/q/ ': Y+ ,y �yM I •
-V/ exr r', _ WYa.YI}7 4Q+,'+s}i. ..i` S"{SgSilYri.'.`Ii z:I ool iseFYw•:i3:i iy%i...:' z;.:j4:<;
FROM TO DESCRIPTION
Well Contractor Name
It. ft. `
136 -A ft. ft. l
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• NCzll Contractor Certification Number _ y + t 'R""'"` 34
� •..1'.€ I)iD�l�,If�ABf�l�f((oS� �.11,'•�t:�t1(iveil�)`Q�P•�1�,(If?` lY�'kl`e�A::.,,:=:..,:,,.•,;_.
SJ�l V'1)am / '_I J , FROM TO DIAMETER THICKNESS MA{T�ERIAL
/ / 1 �� ft. ft. Zt11,' ln. . .0g.�-1 Y)1C
Company Na e / /� al$M00si0 401601 t0..0iftgei ilfo1iT an) ;rtaTiR�i .1•81i isil
2.Well Construction Permit#: I "1 �4� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) h•. ft. . in,
3.Well Use(check well use): ft. ft. In.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. . ft. 1 in.
Geothermal(Heating/Cooling Supply) IEResidentlal Water Supply(single) ft. g, , in.
Industrial/Commercial 11,Residential Water Supply(shared) �XBiT �O� « / R Waig F ,rFF ;s51> U t xgiat+4
.
Irrigation FROM TO MATE Ar` EMPLACEMENT METHOD&AMOVNT
Non-Water Supply Well: a it. �b ft. hC t- e, /5 ts -tog-re-al
/ o GU'P .
Monitoring ,Recovery . . ft. ft.
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation r119 SMIO �OLIpay/}t 1¢edle r1ryi ,4�t, h.,&'lY„; " ;s..2,j
Aquifer Storage and Recovery ` OSalinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • ; `. DStonnwater Drainage • ft. ft. ,
Experimental Technology . \' QSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer t fiiDRIlit.`.GeO (a(ta`b)i/o'd'dliilfndl?iffit It ec.§iea y)h r %ti+'• iF ±i=li p= `,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO' DESCRIPTION(wlor,hardness,tolUroek type,grain else,etc.)
A. 0 f. 54 ft. I�_ir rr_Jay -
4.Date Well(s)Completed: %"-a`5aOWell ID# �l6j fL 51,4jft' 1fl�i 9'G A/ ��``e,
ft. ft. ,
5a.WeeJlll Location: •
124(w o 6eLio r l e t ft. ft.
Facility/Owner Name Facility ID#(if applicable) f' ft' f r F
• fir {
-{- � 4 i4.+... .._P a} '!,� A��' ..
/0 /D ' a-rilUA f-. Dii 1365Sen'er ( Vy n • SEP 6 2025
Physical A dress,Ci ,and Zip . i vu ft.
tt
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• •
(if well field,one let/long is sufficient) 22.Certification: ! • .
3�1105 N - 91,1ggog1. w q -ts— 3
i ' Signature of Certified Well Con tor Data
6.Is(are)the well(s) Permanent or•CITemperary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or yip, with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
f/Ihis is a repair,flIl out known well construction information and explain(he nature of the copy of this record has been.provided to the well owner.
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.For Geoprobe/DPT or Closed-Loop geothermal Wells having the same
construction,only 1 GW--1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f, ,SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For muhlple.wells list ail depths(f d(,7erent(example-3@200'and`` 2@100) construction to the following:
10.Static water level below top of casing: ' Z',6 (ft.) Division of Water 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 Infection Wells: I i addition to sending the form to the address in 24a
- above,also•submit one copy ofthis form within 30 days of completion of well
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12.Well construction method: C IQ 1"'/ construction to the following:1 ,
(i.e.auger,rotary,cable,direct push,ate.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) `/ Method of test: it-)N 24c.For Water Sunuly&I k iectlon Wells: In addition to sending the form to
I , the address(es) above, also tiulimit one copy of this form within 30 days of
13b.Disinfection types CL i1/t P/VI N., Amount: 2Cty3 5 completion of well construction to the county health department of the county
1 where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

icrt
e,Y �o, Macon County NEW WELL CONSTRUCTION
Public Health
C . CONSTRUCTION AUTHORIZATION
w a° PRIVATE DRINKING WATER WELL
APPLICANT/OWNER -William&Elizabeth Simonds LOG# 070823-P OSWW# Ex.
INTENDED USE Single-Family Well, Residential PID # 7523592912 ACREAGE 1.0
LOCATION -.110 Laurel Canyon Rd
DIRECTIONS Highlands Rd to Walnut Creek Rd, L onto Ledford Branch Rd, L onto Laurel Canyon Rd; property on L.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Reference 051823-S(reconnect)for septic design.
Diagram (Not to Scale)
Qo�e Septic lines
�� oae` _' nder came
a��e\CP O70 55 caper
N.
7' %-2' 0/d O
��, Well Area house
Q� .
I Cr. /
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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.
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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?[phone]
Issue Date: 8/7/2023 ...Jeremy Pless, REHSI 31574,�7.-- .ti— Authorized State Agent