GW1-2021-06850_Well Construction - GW1_20210429

WELL.CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
i
1.Well Contractor Information: ;
ONES'
Mark E. Holland '�� 14:WATFRZ
FROM I TO DESCRRPTION; �
Well Contractor Name 'gao ft.
2178 -A 9 201� ft. tL i
NC Well Contractor Certification Number �� Vn 1.5.0UfER CASING &i ni. ulti-cased wells:Ok*I:iNER ifa l cab
PeQ�sgn9 FROM ft TO __ ft DIAMETER,n1 THICKNESS MATERIAL
Dennis Holland Well Drilling,-Inc: ti�on d(io p (PC SD - Cg
Company Name �(1 Q 16.INNER CASING OR`TUBING'. eothtrnf il.elosed-loo' l
f FROM TO DIAMETER THICIQVESS MATER L
2.Well Construction Permit#: / y 3 ft. ft. in.
List all applicable well permits(i.e.County State,Variance,Injection,etc.)
ft. ft. 'in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPrtblic ft. ft, in.
❑Geothermal(Heating/Cooling Supply). ❑Residential Water Supply(single) fr. fl. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS::GROUT 1 I
FROM TO MATERIAL' I EMPLACEMENT METHOD&AMOUNT
❑Irri ation_ fa ft.
Non-Water Supply Well:
tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer-Recharge ❑Groundwater Remediation 19.SANINGRAVEI.PACK(if-'applicable)
FROM TO MATERIAL J EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g, ft,
❑Aquifer Test ❑Stormwater Drainage
ft. ft. -.
❑Experimental Technology ❑Subsidence Control
20 nlu[; nvGI:ov.anach::aaamaoalsueetg:ifaeccs9 _
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color hardness soil/mck size eta
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks)J ft. ft.
& ft.
4,Date Well(s)Completed: Well iD#--�,
ft ft.
5a.Well Location: / to ft
,/V�!"T ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
/� ` � ft. ft.
I2 1 J)41i /h 1 _� c��• ft. ft.
Physical Address,City,and Zip 21.MMAM
1;n -750 17116-0o
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: n
(ifwell field,onelatrr Q(long is sufficient)
3 5 )0`T 13 1( N !� 3 b I g t /7 t f w ��
Signanue okertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I 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: OYes Or , 171No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the. T
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: 1 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. f SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (100 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@ 00'and 2 a 100') construction to the following:
10.Static water level below top of casing: (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:
61' (in.) 24b.For Iniection Wells ONLY: hi addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPpi.Y_WELLS ONLY: 1636 Mail Service Center,
13a.Yield(gpm) Method of test:
Raleigh,NC 27699-1636
I Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form Jwlthin 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz• well construction to the county health;department of the county where
YP constructed.
Form G W-1 North Carolina Department of Environment and Natwal Resources—Division of Water Resources Revised August 2013

Qtotecr '
.m Macon County NEW WELL CONSTRUCTION
o '
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Christofer K. Britton • 110320-p • existing
Single-Family Well Residential `-' 7501714280 1.29
• ' • 661 Still House Road
' • 441S>Tessentee Rd> L @ Still House Rd> —0.6 mi. # 661 on right visible•from,road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Maintain new well construction within pink flags well area chosen by owner.
No know contingencies upon well area at the time of well site evaluation.
Click to enter text
Diagram (Not to Scale)
StillH House Road
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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: 11/16/2020 Harold Faircloth, REHS 2189!' �J*f- Authorized State Agent