GW1-2021-03341_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD For Interngl Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Mitchell Dean Cook 9; ;+ : or7Es �xiY: � i .: ¢. 3 :
FROM TO DESCRIPTION
Well Contractor Name ^ft 1 ft I '
2043 A -o ft. ski •tt.
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NC Well Contractor Certification Number 1SsO�1znERtt".$Yl!i.
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. it ft. -- i in
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Company Name 20 RCdSIIY(irbl3e'1UEIPT(i[ $lithe 1`t` r ro` -�
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. !in.
3.Well Use(check well use): _
Water Supply Well: FROM TO I DIAMETER !SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) GR6tdential Water Supply(single) ft. &
❑industrial/Commercial ❑Residential Water Supply(shared)
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation , r ft. �? ft �oQ,,
Non-Water Supply Well: ft .ft
❑Monitoring ❑Recovery 9
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation I,:,"1QR/, 'ti\! 1LFP:CK.` f. "
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage to ft
❑Experimental Technology ❑Subsidence Control _
d9iitlf$I:IllltiilbG' Now".a l efd'if a" ieia°, �v'.
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,haWnem,soillrock type,araLn size etc.
❑Geothermal (Heating/Cooling Return 00ther(explain under#21 Remarks ft. ft
ft ft
4.Date Well(s)Completed: 43-2o-_II Well ID# ft ft
So.Well Location: h. ft @�
Facility/Owner Name Facility ID#(if applicable) It ft 3 2
1
f/j ?"4 geoga! J ft ft I�
Physical Address,City,and ip
ly1 C.t C cd
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) r
3 S /Z `Il�Os.L N S"1'- / C9 G .. �Jcl W �S•-n?.d '� J
Signature of Cortified Well Contractor Date
6.Is(are)the well(s): rmanent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 191Yo copy of this record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
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:Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J ® (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: 70 - (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 Iniection Wells ONLY: in addition to sending the form 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 5 Method of test: Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz• well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

Qtoteer
Im Macon County NEW WELL CONSTRUCTION
o �d Public Health CONSTRUCTION AUTHORIZATION
'd • a' PRIVATE DRINIQNG WATER WELL
Eric LiBasci NET 012221-P Vl
021-S
Sin le-Famil - ' •Well Residential 7506004579 •
• • Off Holly Hills Vista Road
5 Iva Road turn onto Holly Hills Vista Road go to end of pavement, turn ri ht onto drive for#427,prODerty on right.
Permit Conditions
Vllell shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale).
IP
77' gOCesS
Rona
A
^°a
°s
P
air
10A0 �60 10' 25'
P 20' /YOu'OPsea 2F----S �"_-: 15
>100' t___i Approved Well Area
PC�
A
30' '
1051. � 90, 115'
Repair Area 90,
PL
60A\
IP
45'
PL
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-QR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELL INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 3/2/2021 Charles Womack, REHS 13.00 Authorized State Agent