GW1-2021-03068_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD For Interngi Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Mitchell Dean Cook s' ; . _ f
PROM TO DESCRIPTION
Well Contractor Name ft. eQ6• ft
2043 A ft ft }
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Qennis Holland Well Drilling, Inc. a - ft 75 • ft. 600 ; in. Q2/ PvG'
Company Name f'.a ; , IIiJfxt2 z• f i
TO
2.Well Construction Permit#:_mod L� FROM/ -/� & tr. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(l.e.County,State,i/ariance,Injection,etc.)
i ft ft. in.
3.Well Use(check well use): i'1.
Water Supply Well: FROM To i DIAMETER SLOTS[ZE THICKNESS MATERIAL
❑A cultural ft. ft in.
!� ❑M��unicipaVPublic
❑Geothermal(Heating/Cooling Supply) 2ICgidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO❑hri alien MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fr. .6 S AvziAdd
❑Monitoring ❑Recovery ,3 • ft .24•' ft A 1j& /-
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fr. TO fr. MATERIAL EMPLACEMENTMETMOD
❑Aquifer Test ❑Stormwater Drainage
ft. tt
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Lon
p) ❑Tracer
FROM TO DESCRIPTION color,hart!uM sollfrock type,gmin she,etc.)
❑Geothermal(Heating/Conlin Return ex❑Other lain under#21 Remarks) fr. to
ft ft
4,Date Well(s)Completed: 06-J7-.2 Z Well ID# /V,4,_ ft to
$a.Well Location: ft/ ft.
A__apOla M 1�� �G� _.�[�� ft. ft PifC(tY'�3tt0n fOCO
MM Unit
Facility/Owner Name Facility ID#(if applicable) ft ft
Physical Address,City,and Zip _
•..1`e i..,�,,._t:T•�i•�j`-' 4: ' z,<�'=-E�`. >,'?''!r, r:fi` - 1-, ss�i-'��•'r'
/K ce e.&h
Comity Panel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
41 a 5 ", 9.Z E N _8: �e�i.Z r�/ t -?44,< Wlox
J4•� 6'ri�i�" �sr G�iU +G6
Signature of Certified Well Contractor Date
6.Is(are)the well(s): llWi`rmaneut or ❑Temporary By signing this form,I hereby cerlo that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to as existing well: ❑Yes or MPW'- copy ofthis record has been provided to the well owner.
(f this Is a repair,ffll out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For muhiple injection or non-water supply wells ONLY with the same consducdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .$a it _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{fd/fferent(example-3@200'and 2@100') constriction to the following:
10.Static water level below top of casing: 7,0 (ft) Division of Water Resources,Information Processing Unit,
ffwarer level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Iniedon Wells ONLY: Iniaddition to sending the form to the address in
Rota 24aabove, 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
! ` I
13a.Yield(gpm) 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.
Form OW-1 North Carolina Department of Enviroamentand Natural Resources-Division of Water Resources Revised August 2013

Q,cote r �.
M a c o n County NEW WELL CONSTRUCTION
o ' Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Aaron McFarlane • 040621-p • existing
.Single-FamilyWell Residential • 6591035843 5.0
• 1245 Hickory Knoll Road
' • 441S> Riverside> R @ Hickory Knoll> —0.75 mi. right turn before Gene McDonalds drivewa >thru gate not locked
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Pre-determined approved new well location marked with blue flag up into camp site on right hand side near shed.
Click to enter text
Click to enter text
Diagram (Not to Scale)
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— 4
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S 3 56.928 N
Proposed
Well 27' e'd,'. 83*22'41.946" W
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100' 56' �.
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118'
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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.
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: 6/9/2021 Harold Faircloth, REHS 21 AuthoiizedStateAgent