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Home My WebLink AboutGW1--06508_Well Construction - GW1_20231013 1 RECORD •---- W>rTaL CONSTRUCTION R + __ This toms can be,used for single or muttiplr.wills For luterngl Use ONLY: -_ - - ^-- ^-__ _ 1.Well Contractor Information: Mitchell Dean Cook -______ _ __ • ls'ell Co Iactor N-r; ---- - -_ . . _- -• FROM 2p :r;. t:;1:: � iU i t DF SCRIP770N ` 'NC Well Contractor Certification rt. f t. f _ -" -- Numbar #S:<?nlJtPfSl2i;G. ` i' `a.,.--r .-I . .J��S!r;`I.(agrml'irtif9�(�},WE�18 S.(` Rf'- .�__�._.. Dennis Holland WellROM _: TO ) :IaIN t( 1)1t7('caATE A:: :..:;,:$;°, ::--: __ —^�-^ Drilling IncinC`��^^--•—•- v .-- _ _DIAMETER _ THICKNESS MATERIAL Company Name :1 - fl - t fL /�[ la. �F,p .__.._ 2. ' 11IIV�Cs?(kBo.Oiecui`til;clgieil-loop]"�,:F:$<�<;<-;:;,;.,;. .,:_- Well Construction Permit#: ' FRoht - �- s. .: :.>.,...,:;:... ...:... .: -.._.._TO DIAMETER. THICKNESS MATERIAL-•' List all applirnble well permits(i.e,County.: "' --- ---- - ,'rate, Vrrrrnnrr..h jerrfon,ere.) -."'-_..-- to. 3,Well Ilse(check well use);• fr• - ---•- Water Supply W-dl'__'.'"' ----__------ ------- 117',�5(�'RF7N: ^z: - -.`�._,-�4._-,.;.� -- FROM ^.PO::+. �•-DIAM ETER!—,�.S t.OT.SIl EE_ -'J+.-�..:: %::ir'.;:" .•. :':'c`'°" ClAgrieulhtral -R. fr. ,-, _, tVT`'RIICKNESS MATtiRIAt. °Mon icipal/Publ ic f_7Geothennal(Heating/Cooling Supply) -- L. Rnsid trial Water Supply(single) ft• fr. ia.C,-"•— -'-'--' -'--~" Ohtdustrial/Commercial i esrdeatiat'Water Su))I ri18�. R'l')ll.• u . _ -- Iasi I I Y(shared) .._ .;ar'>-.?t?fir I(r1 FROM . ., ..a-..—�_ ,—•••,_ TO- . htA_TERfAf� F.MPLACEMF._hfl�AIF.77f(, _._AMOUNT Nnu-Water Supply_Well: - __.____^..__ __-.- -_,___.., 7 r fr. �� ft. ..._... . PAN��<x - � s�- [")Monitoring ----._.f ft,.__.. r rt. ` -_. . __ . ._.��.__._r=/?z._._G'.'.. Injection Well:."- ._-----•[:JReoovery._-------...._.- ,-- __ UCv'.._%' ___._.___ �..1r_wc.0__�_-4f __..0 .11 t' ft, . ft.- (.7Aquifer Recharge C7Groundwater Re;mcdiation `:1:9:$A'Nn Gl;A1�F"ipq _ CIA uifer Storage ^1''.:. GIC(MATE I •q geand Recover• ____ To Z - _ ":`:<;%: s 'i ia` ., y C7SalUlily 13affiCf - -.__. _ MATERIAI. ' V�EMPLACEMEN'MFTIFJD^•'-' °Aquifer Test fr. 'ft. C1Storntwater Drainage -•—. w —_ .- f_7fxperimental'ibclmolo ft. ft. gy °Subsidence Control r2I01).R ()!(atjncl itiiilitirial:vliej r - r.] eotheanal(Closed Loop) (Ifm c l.J(iCOlht:rrilal�l{e-�hll,/(;001111 RCIUI'll moM______Ti �pFtiCRrPT10N(Co benle eoiUrock t Pei � z i .t ?�+ Y &rein aiu cic. - - ), DOther(explain under/121 Remarks) f'• -ft. 4.Date Well(s) ft• �, . Completed;c9 .Wen Inn _IV � a ---- rt. ..,._..-_ft. ------.. --- - -_---•---__'--_- tie,Well Location: -w. _ _ 7=E ,,,.. s ^� •---^- ._._._ .__._._. �6�.�A_t,,.<_'.t:-,-.t:c if•:^_.___- ft, ft.- s,,," `.4'1, .:._____-_-._._............._._.- 'Facility/Owner Name ---- ��3 Facility IDN(if-applicable) _._. _..____...._..._ ..--_•----•-•---._ .__.____ J^ _----.._. `IZ.7 -. 'rt.�7-t;t7}i-- - Physical Address,(:it -...--....--•-._--..-._-_ _.-. ft. ft. ! .- :a! iL�C i City, z12F7i4A 4.4 -,. Caimty _ __-.-__._._._...___....__ Parcel identification No.(PM) . _ Sb.Latitude and Longitude ID degrees/minutes/seconds or decimal degrees: i (if'vellle field, /o}ne lat/long is sufficient) 22.C;rrti(icatiou: l • Mauantrr.of Cnnified Well Contractor Date 6,is(are.)the well(s): fegr.ninancut or °Tempor:aty By signing this form,l hereby eet•th that the well(s)was(were)constructed in accordance with ISA NCAC 02C.0/00 or l.fA NCAC 02C.0200 Wc11 Construction Standards and that 0 7.Is this a repair to an existing;well; °Yes or o copy aphis record has been providers to the well owner. If this is a repair,fill out known well construction inforntation and explain the nature ofdn: repair under 112i remarks section or on the hack of this•fornt. 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 ____ __ _ crntsltucliun dcluils. You ntn�also attach additional pages if necessary. For multiple injection or tan-water supply wells ONLY with the sane construction,you can submit one form. fNS'1'UC:TlONS l' 9.Total well depth below land surface: J ___._ __._, •� (fr.) 24a. For All Wells: Submit this than.within :10 days of completion of well For multiple wells list all depths if-different(example-.1@100'and 2@/00') construction to the following: 10.Static water level below topof casing: I '6:- _ c� (ft.) Division of Water Resource's,Information Processing Unit, If voter level is above casing,use"'t'" -^ -- 1617 Mail Service Centel,I2aleigh,iYC27699 1617 • 11.Borehole diameter:6,t.--_ ono 20, FRI' Injection Wells ONLY: in addition to sending the form to the address in Rotary - 24a above, also submit n copy of this forms within 30 days of completion of will 12.Well construction method: construction to the following: . (i.c.anal:,rotary,cable,direct push,etc,) -_ __.__ ___-__-__ ______ ____,_ Division of Water'Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: - I636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpnt)__ ' _ Method Air lift 24c.For Water Su Ip,I,y&Injection Wells: of test:•__._�.._..._,_.__... " Also submit one copy of this form within 30 days of completion of 13b.Disinfection type: H H Amount: 2 OL. well construction to the county health department of the county where .__-_----. _....R.__._...... -- -- .--._ __ _.__-- ._____ - - constructed. Fomr(iW-I North Caroline Dena:uncut ofiievinmment and Nalvral at:sanners:-Division of Water Rasnun.os j Revised Anvils!2011 • y a��a cr �; Macon County • NEW WELL CONSTRUCTION o r �� Public Health CONSTRUCTION AUTHORIZATION 40 • a' PRIVATE DRINKING WATER WELL E y'AILED APPLICANT/OWNER John W. Fowler Trustee LOG# 011021-P OSWW# 012521-S INTENDED USE Shared Well, Residential _ PID # 740.8762955 ACREAGE 0.64 _ _ •LOCATION Ri•ht before 8746 Dillard Road DIRECTIONS Dillard Rd. (1061, R to #8746. Driveway is right before Antique Barn (#8716), location is at the bottom of driveway. j Permit Conditions Well shall be constructed in compliance with all NCAC 2C Rules. Maintain minimum setbacks as applicable. ' Y Any questions call MCPH. Diagram (Not to Scale) • Dillard Road ------ — — _ __7 _ q Antique Barn I #8716 Dillard Road p pa'Pa. Ro ao, ed IP , QvoPos to 6� - - 56.- PceaS Septic Area _ Soil Road For#8716 _— --ram and#8746 >100' Mit -8-- per owner - #8746 1_ -- �� `^_ 4-__ Dillard --' pi_ Proposed Road Well Area 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 MCPII 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. QUES IONS? (8 349-2490 Issue Date: 11/23/2021 Tanner Stamey, REH 2712 _. Authorized State Agent ✓