GW1-2021-03342_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD
For Intem4l Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
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Mitchell Dean Cook ifVWA;-E�. o�rEs. 4�:rt�:�:. �4�..., i �� �� ���� TtAs
FROM I TO DESCREMON
Well Contractor Name J401,
•ft
f
2043 A tt ft
NC Well Contractor Certification Number 15,U(JTERSC�A$INfr foxsm"u7tt ckla`ed. $lla Qlt{LINER;if 612 ,_„t
FROM I TO I DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 6- ft. • ft. 6"; in.
Company Name 16 71�1NER CASIIyG,OR_[1$IN� '�ofher elbs'edrloo`''s" mot,°fi
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: d 3/'q Z ft. ft. in.
List all applicable well permits(I.e.County,State,Variance,Injection,etc.) ft ft in.
3.Well Use(check well use):
i7.SCREEN
Water Supply Well: FROM I TO I DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in j
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. & m
❑Industrial/Commercial esidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑I ri ation , ft. .5 ft o �N Non-Water Supply Well: oft ft
❑Monitoring ❑Recovery cap 0
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation r 1?=5Afi1D/a .YEL_�»AIC*f a livable rs t��z . : ;"
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL M EMPLACEENT METHOD
ft. tr.
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
20..D1tiGI.jIVG,tibG'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harilum soiltrock type,araw sae etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) ft. fa
ft ft.
4.Date Well(s)Completed:d5 fl- Well ID# Ab ZA• tL fa
5a.Well Location: ft. ft.
ft. rt.
Facility/Owner Name Facility ID#(ifapplicable) ft ft IuN
1 G 53 /g�®/, GA,.U�� ft ft J n
Physical Address,City,and Zip f+SSif1g
1'J'i cI•oath 64 g3 SSS 9 3 7 -
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if w ,ell field,one lat/long is sufficient)
3S�' 8 J t 8.Z N 8 2/ r 53-h 8&' W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): immanent or ❑Temporary
B3'signing this form,!hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Tfq copy ojthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 go • (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: l Q (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
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13a.Yield Air lift 24c.For Water Supply&Injection Wells:
(gpm)�0 Method of test: �
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
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Qtote�r
•m Macon County NEW WELL CONSTRUCTION
CERTIFICATE OF COMPLETION
Public Health PRIVATE DRINKING WATER WELL
1 CC3S,LLC Chris Cook • — —
• • 1653 Clarks Chapel Road ' ',6593555937 7 8 4
Shared Well Residential
' • 64E> Belleview> Clarks Chapel > R @ Simplicity Estates s/d -
83°21' 53.388' W 35°8' 35.682" N
As-Built Diagram (Not to Scale)
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Clarks Chapel
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xy=35*8'35.682"N
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i R2* 71 S2 20R-IA/
w New Shared Well
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• Bentonite Slurry Depth: 20 ft Method: Pump Cap:Cement 0-3 ft ate 5/11/2021
SDR21 PVC w/Coupling Depth: 130 ft Diameter: 6 in 6 : H Fairclot
' Height in Vent: Y❑ N0 Seal: YO N ... . .._ _. _
.01073 (2) ❑ Date: Depth: ft Yield: gpm Static H O Level: ft Permit # 0
.01073(3) 0 Date: Depth: ft HP: Cert. #
Dean Cook _ _ _ Cert. # 2043A �Partial�Date_ u8�.___—_.._—__
• _ Final Date: B
The well owner shall not place potential sources of groundwater contamination closer to the well than the separation distances specified in 15A NCAC 02C. This well was
constructed In the designated area and according to the well construction permit and the Private Drinking Water Well Rules. QUESTIONS? [phone]
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Issue Date: 7/9/2014 Choose an Agent... � ! —Authorized State Agent
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