GW1-2021-07780_Well Construction - GW1_20210809

i
t r
WELL CONSTRUCTION RECORD For Intemgl Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information: C
,
Mitchel! Dean Cook -t�',{ •%��: . ��:r-t°:t.:i.���,.Y,>��,�>�,;r:::��'�;�.•;�v.,��:�;�:t'•$�':_�.:����r•�{�,�:_`_.:.
FROM TO DESCRIPTION
Well Contractor Name r ft
2043 A
,�,:7.5ifL 2 7�
NC.Well Contractor Certification Ntunbcr
FROM I TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. lvGa�
Company Name SAT Ye��S..HP _ <,
FROM. TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tr. ft.
List all applicable well permits(i.e.County,.State, Variance,Injection,etc) in.
3.Well Use(check well use): ,
Water Supply Well: FROM TO I DIAMETER SLOTStZE I THICKNESS MATERIAL
QAgriculhtral OMunicipalt'Public ft, ft I in.
QGeothermal(Heating/Cooling Supply) Oft1sidwial Water Supply(single) ft. Ca in.
Obidustrial/Commer Ial Q ReSidential Water Supply(Shared)
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Qirri ation £t. ft. 1 12 Non-Water Supply Well; it fu lt� _` 'c
CfMonitoring ClRecovery 624), 2:
Injection Well; ft. ft.
OAquifer Recharge QGroundwater Remediation ?14 + /,' :iE:?1'A' ,'£+a{" ea g` {3 _ *<=�';1 'y;4^d£�t
,
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO ft. ft. MATERIAL EMPLACEMENT METHOD
QAquifer'rest QStormwater Drainage
iL ft.
OExperimental Technology QSubsidence Control
QGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardy sol0reck type,grain Size etc.
QGeothermal Heatin Coolin Return QOther explain under 821 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed;Ole-O-t—1 i Well H)#
ft. ft.
Sa.Well Location; ft, ft.
u a GSM c: ft, fa AU
Facility/OwnorNarno Facility ID#(ifepplicablo)
ft. ft. #7vffi' Unit
£t WR Sedon
Physical Address,City,and Zip '?t'`< •
Zoo c:1/1 -s
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell fiend,one
latttl'ongisysuufficient)
j
i N -9 .?-2 0 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): glfler'�auent or OTemporary By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with I St NCRC OZC.0100 or i.SA NCRC 02C.0200 Weil Consnuctien Standards and that a
7.Is this a repair to an existing well: []Yes or jl!1 oo copy ojthis record has been provided to the well owner.
If this Is a repair,fill our 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:
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: G`r (ft.) 24a. For AM Weill: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffferent(example-3@200'and 2@100') Construction t0 the following:
10.Static water level below top of casing: (ft.)
Division of Water Resources,Information Processing Unit,
I}water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For In'ect' n 3yeMg ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12,Well construction method: construction to the following:
(i.e.eager,rotary,cable,direct push,ote.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gp m) Method of test: Air lift 24c.For Water SuRply&Injection Wells:
T_
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 licalt(i department of the county where
constructed.
Form GW-I North Carolina Department of t3uvironment and Natural Resources-Division of Water Resources Revised August 2013

Qiote<,."
•m Macon C o u n t y NEW WELL CONSTRUCTION
r Public Health CONSTRUCTION AUTHORIZATION
�'v • 317 PRIVATE DRINKING WATER WELL
W64W
n and Judy Kirkland (Seller), Mary Jane Branch (Buyer) • 041921-P • 043521 S
le-Family Well, Residential • 65'74501854 4.28
sent address is 2826 Patton Road to L on Louisa Cha el Road,go to stop sign at Patton Road roe Is direct) across the road.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Maintain at least ten feet from water supply line from the septic system when trenching to open area below wooded area.
Diagram Not to Scale
as
Qo
Qa�OKI you
4
q
,, oL %70,
a
Q %
IP '� ° %\70 dy \ Nd
04. ,
% N6 % ,--30'
�� N� �� ✓o ota
\ 9 `, O. Garage
� N
, n
,, N l�
,
25'
PL a`: O`- Shallow soil0,1
8�R o 1l Open area
Eo : 96' Pt
:c
t
Proposed s
t v a`I
4 Bedroom 62' 62 se d Hof a
, 20��gr
�_
�e
IP
e� a�
32' P�oQ P
13'
Concrete Monum ty
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: 6/11/2021 Charles Womack, REHS 1300 Authorized State Agent
t