GW1-2021-05614_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Intomql Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCREMON
Well Contractor Name ft.
ft.
2043 A
ft.
............
NC Well Contractor Certification Nutuber
FROM TO DIAMETER'
I THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. U if,, in.
Company Name ;AQAN.
2.Well construction Permit#: Y _Z i FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
I ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
ClAgricultural OMunicipaVPublic ft. in.I I
Meothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
�� nl
01ndustrial/Commercial PRCidential Water Supply(shared) W'R
_01rriLation FROM TO MATERIAL EMPIACEMENTM 01)&AMOVNT
Non-Water Supply Well; A ft. ft
ft. ft.
1ACEMENT METHOD&AMOVNT
ClMonitoring ORecovery
Injection Well: ft. ft.
OAquifer Recharge ClGroundwater Reniediation
DAquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. ft.
13Aquifer Test OStormwater Drainage
DExperimental Technology CiSubsidence Control ft. ft.
Meothermal(Closed Loop) ElTracer N4
FROM TO DESCRIPTION(color,bardnah soilfrock type,grain size,etc.)
OGeothermal Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: ell ID# ft. ft. !C_
ft. ft.
Sa.Well Location: ft. ft. OCT 1- 7021
A A
Faciffty/OwnerNaine Facility ID#(if applicable)
ft. ft.
A M Al 7- 4�,-zyQ & ft. ft.
Physical Address,City,and Zip
ve--
County Parcel Identification No.(PIN) ':)_/ , 5
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattiong is sufficient)
Signature F—ce,.r+
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ZFef�manent or OTemporary By signing this form,I hereby cerio 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: OYes or gMirr-_ 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 tinder#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.Number of wells constructed: 1 You may use the back of this page to:provide additional well site details or well
For multiple injection or non-water supply wells ONL Y with the same construction,you can construction details. You may also attach additional pages if necessary.
submit one form, rr SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24a, F2r Am IV_ells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3@200'and 2@-100') construction to the following:
Division of Water Resources,Information Processing Unit,10.Static water level below top of casing: (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For InieStion 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
1
13a.Yield(gpm) AW 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 GW-I North Carolina Departwent of Environment and Natural Resources-Division of Water Resources Revised August 2013

.� 5�A-7
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Macon County L NEW WELL CONSTRUCTION
E r Public Health -__� CONSTRUCTION AUTHORIZATION
PI IVATE DRINKING WATER WELL
Eugene Mason (Sell '), Derek Edwards(Buyer) • 0811521-P TT Existing
Shared Well, Resident C— -"'----- NINE T B A EM TBA
• • Off Arland Mountain Road
' 28N to L on Bennett Rd.,to R on Rose Creek Road,to R on Arland Mountain Rd.,to )rop�on left.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Shared Well requires a 100'setback from any part of the septic system
Diagram Not to Scale
Existing Well IP
PL
100'min
IP
� A
^0
S�M�n oSPa
i 70' O
70 70 6 ' . IP
150100'min
t P Proposed Shared Well
PL
✓\ d. \
` Psf
- PL
N
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: 9/15/2021 Charles Womack, REHS 1300O�Jj"'& uthortzed State Agent
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