GW1-2021-06847_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
�a FROM
WATER ZONEs
Mark E. Holland i
�l\1� FROM TO DESCRIPTION i
Well Contractor Name \\�SfL S ft -P. -:4
2178 -A PQ� �55\r9 5 ft. 9 ft
NC Well Contractor Certification Number (\p�0$C'C\O� IS.OUTER CASING for mtild-ceud!wells OR LINER ifa able)
Dennis Holland Well Drilling, Inc.in`�°�m30S FROM "L TO fL DIAMETER in. THICKNESS `"IMMATERIAL
`7 S 5
Company Name 16ANNER CASING OR TUBING(geothermal closed-loop)
FROM I TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: CJ.�C ram[ L P tL 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 I MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
Geothermal(Heating/Cooling Supply), esidential Water Supply(single sm le) ft. ft
❑ in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD k AMOUNT
OIrri ation_ ft. 3 ft 4
Non-Water Supply Well:
❑Monitoring . ❑Recovery
rft.3fL
� Bell
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test OStormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG:attach addirionaltiheeb if
OGeothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardo so;Vroek type.grain size etc
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks ft ft
fa tr.
4,Date Well(s)Completed: v Well ID# ft ft.
5a.Well Location: i ft ft
Fa,1 - ft ft
Facility/0 ner Name Facility ID#(if applicable) ft. &
fL ft.
Physical Address,City,and tip 21.REMARKS
►- a CC) V-' 655 N 0,93 5?
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)
35° 42, 33 N 13" 2T s-7 ► 6`3 W �! �� Ll o2
Signature of Certi ed Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance
/' with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or W4o copy of this 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: 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
'�77 SUBMITTAL INSTUCTIONS
submit one form.
J
9.Total well depth below land surface: 0 S (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2200'and 2 rt 100) construction to the following:
10.Static water level below top of casing: �o© (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 i
11.Borehole diameter:
6" (in.) 24b.For Infection Wells ONLY:! In addition to sending the form to the address in
Rota 24a above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct pushy 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) Method of test:
Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this forms within 30 days of completion of
13b.Disinfection e H & H Amount 12 OZ. well construction to the county health department of the county where
type: constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

r
�,t OtECr •.
`d<. .'fi Macon County NEW WELL CONSTRUCTION
Q ;m Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Faye Wells + 021121-p ro= existing
Single-Family Well,Residential 6553929388 EM 75.0
+ 61 Windy Farm Road
+ 64W>Old Murphy Rd>Windy Farm Rd> past Church on ri ht> well site above old red farm house
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Three pre-determined approved well locations together in field above Red Farm house.
Click to enter text
Click to enter text
Diagram (Not to Scale)
1 .
l Open Rolling Field
f' Windy Farm
11.. Road
0 Well
Area .
1
4.
1
♦ 1
♦ 1
100'+
i : aOS:WW;ias
EJ
c aimed
Old Murphy Road
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: 3/8/2021 Harold Faircloth, REHS 2189��� Authorized State Agent