GW1-2021-03343_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Intemll Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook 14 .WATERZ0NES
FROM I TO DESCRIPTION
Well Contractor NameIt.
2043 A rL rL i r
NC Well Contractor Certification Number I5.'QUTER CASING for'mulh cased;wblls,OR LINER if a" licabk..''
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. < fL -ft.
Company Name 16:'sl NER"CASING ORTUBING eothertnnl cloeed hw
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: [1 C7� / "/� ft. fr. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ff. in.
3.Well Use(check well use): „17:;SCREEIY. . ;f: r
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural OMu//nicipaVPublic ft. fL Ia.
❑Geothermal(Heating/Cooling Supply) Bidential Water Supply(single) ft. ft. in.
Res
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.;GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri anon ✓ fL fL
Non-Water Supply Well: r'
ft. fL
OMonitoring ❑Recovery
Injection Well: ft. fL
OAquifer Recharge OGroundwater Remediation :19.SAND/GRAVEI:PACIE'666 ticetilc
EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R TO. tr. MATERIAL.
❑Aquifer Test ❑Stormwater Drainage tL tL
❑Experimental Technology ❑Subsidence Control
i20:DRIL'L1NG`IOG'etftYah`iaildtNontil'eLeeta ifiiecessa t,;;`
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION color,hardnen,soittrock type,grainsne etc.
OGeothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) fL fL
ft. N
4.Date Well(s)Completed:05_ 1 Well ID# /y-`,!L
rL ra
5a.Well Location: ft. YL R�
e
JED
Zvi�,r ' d- L c� t i1 �!`�',h�~ 7 7 i/ ' 3�..r ft. fL
Facility/Owner Name Facility ID#(ifopplicable) fL ft. Ni IN
w qo
1_ zy ,r e) L
Physical Address,City,and Zip -it.REMARU n " * j�•.; .
D\N'RZ E!-"
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lattlong is sufficient)
Signature of Certified Well.Contractor Date
6.Is(are)the well(s): Offs anent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 _- copy ofthis 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 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Well: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: �Q d (ft.) Division of Water Resources,Information Processing Unit,
lfxater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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I I.Borehole diameter: 6" (in.) 24b.For Ioiection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above,also submit a copy of ttiis form.within 30 days of completion of,well
12.Well construction method: construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen'ter,Raleigh,NC 27699-1636
13a.Yield(gpm) j Method of test:
Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form Iwithin 3`0 days of completion of
13b.Disinfection type: H & H Amount: 12 OZ. well construction to the county health;department of the county where
constructed. iI
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

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Q�pte�+
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o�•m Macon County NEW WELL CONSTRUCTION
�d Public Health CONSTiRUCl-ION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Mark&Laure Frank _ • 030621!-1,__ • 112820-S
Single-Family Well Residential ' _7520418634 7.58 _
• • Turtle Pond Road
' • To Highlands,enter Turtle Pond from Dillard Road, lot on left on Driveway for#1080
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale)
s
House in place
s0'
Large Large
Poplar Pine
transformer 100, O] Q
�4 50
ED-
ST 18' 60'
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Repair Area l
L------------
55'
N Over 100'
Neighbors Well
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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. j
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. UESTION ?[phone]
is
Issue Date: 5/14/2021 Kyle Jennings, REHS 2142 Authorized State Agent
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