GW1-2021-01731_Well Construction - GW1_20210305

CONSTRUCTIONWALL
ForintensillU..ONLY,
Thu form can be cued for aiugle or multiple wets
1.Well Contractor Information:
Mitchell Dean Cook
ES', k
FROM I To ]DESCRIPTION
Well Counsel.,N.. IL
2043 A rL ft.
NC Wall Con"Met Certification Number m
FROM TO I DIAMETER THICKNIESS MATERIAL0 . ft. T _1:�;
Dennis Holland Well Drilling, Inc.
Company Nam.
I.A.ViNEK CAST NCrOwittraigifiTiseeitheeta-I Added—lab`)
2.Well Construction Permil Mom I TO DIAMETER TMICKIvESS I MATERIAL
'Aa 0 e ;z ft. in
List all applicable usullperears(i.e.County.Suits, parlance,Injection,too)
In.
3.Well Use(check well use): S('llisp
Water Supply Well: Mom TE�DIANIETfR SLOT SIZE TIiCKNESS MATERIAL,
ClAgricultural CMUlicipalsublic r. fs In.0(jeothennal(Heating/Cooling Supply) gRefid;rlial Water Supply(single) ft,
Obidustrial/Cornmerciall 011tesidonlial Water Supply(shared)
ClIrrigation -NIVERIAi DLPIL(_tMtP�rNILP[ql)&�ANII�IINT
Non-Water Supply Well: ft. ft. V
IM_o_nilo_
rig_ iRsecove ft
y
rj.ctiTs 'IF
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DAquilcr Recharge OGroundwater Rinnediation 4 - -ollutiIX
DAquificr Storage and Recovery ClSalmity Barrier Mom TO ft. I MATERIAL EM PE"ACEMEMW M Do
D.0Aquiflar'I'mid I
OStornswister Drainage fL Ift,
DExperimentalTechnology OSubsidence Control I
-120,DRMLING'LODI�atfachuddiaboul 8 cons""Is"
DGeothermad(Closed I.Alop)
urracer FROM I TO I DESCRU'DION rnlvr laud4vas,,oll/rock top,ends also,tic.)
DGeothermal(Heating/Cooling Return) ClOther(socillain under 021 Remorks) is. f,
4.Date Wallis)Completed: Well IDN
Sa.Well Location:
ft. fL
/y,
Facility/Owner Nam. Facility IDO(ifeliplicable)
ft.
Physical Address.City,mid Zip —21—,REMARKS
Comity Pascal Identification No.(PIN)
Sh.Latitude and Longitude In degrees/minuttalseconds or decimal degrees: 22.Certification:
(ifwell field,one latillons is sufficient)
&S Jam'
`
N - aR
Signature k)fCciliBed Well Contractor Date
6.Is(are)the well(3): MP15smarsent or OTemporary By signing nuis form, !hereby certify that the andl(s)vw(were.)comasocird in accordance
with 13A JVCAC 02C.0100 or 13A NCAC 02C.0200 Wall Construction Standards and that
7.Is this a repair to an existing well: 0Ym; or -Phif'o copy of1his record has beenprovideds,the well owner.
ffous,is a repair,filtoulknown well construction information andepholn the moors of the
repair under#21 rentanksection or on his back atihisfiorm. 23.Site diagram or additional well details:
You may use tile back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-tvarer supply wells ONLY with the scone consinuction.you can
mlow,one form. SUBMITTAL INISTUCTIONS
9.Total well depth below land surface: 30S (ft,) 24a. Fyr Ali Wells: Submit this form within 30 days of completion of well
Fa?--ItiPlewilslisf-itdepfhsif&ff.rc.r(,sample.3@200'ond2@100') construction to the following:
10.Static water level below top of using: /6 (ft.) Division of Water Resources,Information Processing Unit,
l(veater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter; 6' (in.) 24b.For lailction Wells ONLY: III addition to sending the fern to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:.Rotary construction to the following:
6 c Insists,salary,cable,direct pink etc.) Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Air lift 24c.For Water Supply&Injection Wells;
Also submit one copy of this torn Within 30 days ofcompletion of
13b.Disinfection type: H & H Amount:12 oz. well construction to the county health department of the county where
constructed.
Form GW.I North Carolina Department oflurvirmiment and Natitual Resources-Division of Water Resources Revised August 2013

0W.,
Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINIQNG WATER WELL
Stan McLean/Valerie Arnaud 020821 P ex sting
Single-Family Well Residential 6583401641 1.22
147 Lake Ledford Road
441S> Belle Dowdle> R @ Lake Lefdford Rd> # 147 on left
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Click to enter text
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Diagram (Not to Scale)
II —�
147 Lake - E
Ledford
a
Lake Ledford A
79" +too'
Text Box
Ir '
xy=35* 7'39.886"N
r 83*24'9.36" W
_4.
r
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 try 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 Q8 THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 2125/2021 Harold Faircoth, REHS 218' 9k� Authorized State Agent