GW1-2021-07849_Well Construction - GW1_20211102

I� I a 'WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemgi Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Name
2043 A eft .rL
NC Well Contractor Certification Number i215i QOl1lg13++' t to7Ai illl q'U i'f 1'- b e?c r
FROM TO Dennis Holland Well Drilling, Inc. DIAMETER THICKNESS MATERIAL
o, ft. - • rt. _ ,,
Company Name :`lkvl I RFCASINfs O zP[113 �`*"aQt"r'a'cl' ii-o' .� f' Ia173F.L .' tsC
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 4/2.2. /- /l ft. ft. in.
List all applicable well permits(i.e.County,Slate, Variance,Injection,etc.)
& ft in
3.Well Use(check well use):
Water Supply W¢II: FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) tt. ft in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) : / R >J'P t•' .- ".� ".. °: ;a' s <�,:' 4;,,. :.rri:
OIrri ation
FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr.
❑Monitoring ORecovery t ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier ,FROM To MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStormwater Drainage
OEx erimental Technology ft. ft.
p gY ❑Subsidence Control
`':.9��R..`I:• GS+LOGI;iitf'�1[fii' tiogel.A�eet9,i `. �1` ,:?3�,n:,�'_3=�;�?;��sr,5
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCREMON color,hardy w solUreck type,erain size etc.
❑Geothermal (Heating/Cooling Return ❑Other explain under#21 Remarks) tt. ft.
4.Date Well(s)Completed: Well ID#�-•/ ft. ft. r'
5a.Well Location: ft. ft
fL
�A Eli-I AYes all k ft. ft. a
Facility/OwnorNarnc Facility ID#(if applicable)
r ft. ft.
ft. ft. ,.. .. „ .
Physical Address,City,and Zip
Ma sad, 5 7h' 78q
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one la tlong is sufficient)
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): QNee'rm auent or OTemporary
By signing this form,1 hereby cert fy 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 +4b; — 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:
You may use the back of this page to(provide additional well site details or well
g,Number wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injeerion or non-wafer supply wells ONLY with the same eonsdueNan,you crap
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:r3 (ft.) 24a. For AU Wejlla: Submit this form within 30 days of completion of well
For multiple wells list all depths tfcUfferenr(example-3@200'and 2@100') construction to the following:
i
10.Static water level below top of casing:_ d (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: 6" (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
.Well construction method:
Rotary 24a above, also submit a copy of this form Within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
F
OR /
R WATER"P` JLYCWELLS ONLY: 1636 Mail Service Centelr,'Raleigh,NC 27699-16636
Yield(gpm) Method of test: Air lift 24c.For Water Supply&Injection Wells:
13b.Disinfection type: H
Also submit one copy of this form within 30 days of completion of
H Amount: 1 2 oz. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Nanrral Resources-Division of Water Resources Revised August 2013

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a,
Qiote�r
Macon County 7
NEW WELL CONSTRUCTION
s ti Public Health t m ,CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
r Marianne Baliles • 091221-P • 102116-S
Sin le-Famil Well Onl setbacks Residential 6578927089 1.31 Ac,.—Y. _y setbacks R_._..._—__......_... ...-....__.............._........ - — ---_
• • 179 Baliles Hill
' • 28N>drive up hill behind 8101 B CitY Road
� __--.-- —Dson— ----......_...... —................
— —
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 50'minimum from septic system components-
Diagram Not to Scale
IP
PL
IP
i
21'
Car- I I PL
Port c ,�
2 BDRM LJ
IP o
Home 14 1 -& I' IP
P ole Dec. 39 10 /
111' 4 /
76, ; o /
P � ♦� PL
L
20'
I
82'
Permitted
Well Site `IPA' ,
091221-P)
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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 i
circumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.'me 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. ESTION$? [phone]
A-?Lq CJ7 L '
Issue Date: 10/20/2021 Jonathan Fouts, REHS 1979 Authorized State Agent
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