GW1-2021-00233_Well Construction - GW1_20211213

t
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemgl Use ONLY:
1.Well Contractor Information:
Mitchell Dean Cook g o»� ^rY t�y L" Y,;r t• Ae✓.}�. �... �i:).if .y=MATERUL
FROM TO DESCREMON
Well Contractor Nameo 2043 A ft.NC Well Contractor Certification NumberOM TO DIAMETER THICKNESS
Dennis Holland Well Drilling, Inc.
Company Name
s. .'e��IIY_CxiQ.•>.•.�.� t i.: .e'k " ;`r�,�f:,. ,u r• .�laR3d
FROM TO DIAMETER THI ESS CKN MATERIAL
2,Well Construction Permit#:�:5 „� � �_ fA rt. In.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
fL ft. In.
3.Well Use(check well use):
Water Supply Well: 1,ate :' E IY •':>_'_`:=s=<a, F; ;<<b'rt+�,d,vWORN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipaVPublic fr. rr in.
OGeothermal(Heating/Cooling Supply) l dential Water Supply(single) ft. ft. t°•
OIndustrial/Canmercial '
CIResidential Water Supply(shared)
e u. tip. i 4 rRi:f('.a r:` i•x i t
❑Irrl at, FROM TO MATERIAL EMPI.ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft.
OMonitoring ORecovery fL r ft.
Infection Well: & fr.
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery
❑Salinity Barrier FRDM To MATERIAL' EMPLACEn1ENTMETHOD
OAquifer'fest ft• fr.
❑Stormwater Drainage
❑Experimental Technologyft. ft,
OSubsidence Control
❑Geothermal(Closed Loop) OTracer
FROM TO DESCRIPTION color Garda solUrock rain size etc.
OGtiothermal ffleqin Coolin Return ❑Other(explain under#21 Remarks) ft. ft,
4.Date Well(s)Completed: Well ID# ft. fr.
ar . .f.
. _
.Is.Well Location: rt. ft
fr, ft.
Aa enah fr. ft.
Name ft.
ID#(if opplicable) I
ft. ft.
ft. ft.
Physical Address,City,and Zip
...' i,,-:" ,`•;�_�_ cG.i it: ;,.`l3>:.':',:s`r�:i'1_,'tT,s}:-�%'�.i'v.°_isrit"-;?.t{41t•'��` ••'•(
2/ 7 2 2
County O i�6 Z d : s
Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: -
(ifwell field,one lattlong is sufUcient) 22,Certification:
9Jr��,7/ 7Aytt� N
Signature of Cartified Well Contractor -Date
6.Is(are)the wel!(s):A4157manent or .OTetnporary
By signing this form,I hereby certo that the wells)was(were)constructed In accordance
7. with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
f Is this a repair to an existing well: OYes io d explain
copy ojthls record has been provided to the well owner.
1f thus!s n repair,JIlI out known well construction information and explain the nature ojthe
repair tinder#21 remarks:section or on the back of thlsform. 23.Site diagram or additional well details:
8. You may use the back of this page to provide additional well site details or well
For multiple Injection or non•warer supply wells ONLY w h h the same consbueNon,you can Number wells constructed: construction details. You may also attach additional pages ifnecessary.
F
submit one form. SUBMITTAL.INSTUCTIONS
9,Total well depth below land surface: .24yr (ft.) 24a. or a Is: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlWrent(example-3@200'and 2 a 100') construction to the following:
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. or In Wells ONLY: In ad
action idition to sending the form to the address in
.Well construction method: Rotary Rota 24a above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cablo,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ 3 Method of test: Air lift 24c.For Water SuP&&Infection Wei Is:
13b.Disinfection type: H & H
Also submit one copy of this form within 30 days of completion of
Amount: 12 oz. well construction ty the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Ltuvironmeot and Natural Resources-Division of Wator Resou I s Revised August 2013

Q�otecr.
o .m Macon County NEW WELL CONSTRUCTION
Em Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Aaron Garrett • 051321-P • 053821-S
Single-Family Well Only Residential ' 6513417733 1.13
• • Beside 1904 Water Gauge Road
' • From Franklin Hwy 64 W to R on Rainbow Springs Rd just after passing W old Murphy Rd on L L on Water Gauge,lot is about 2 mi.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 50'from all septic components and honor road right of way.
Diagram Not to Scale
Neighbor's well
Permitted Well Area:
1'off, 5'x 10'along P
Une (051321-P)
/ \ Wo IP
Wti?o IP
/ �}�Q / � � 'S01 min• � �S'M/n -
/ D-Box
nYUne i E �i C °
ono, i p m
IP � !' 4i'V
N
W� •'E
�W
I
Neighbor's
well&drive IP
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: 6/24/2021 Jonathan Fouts, REHS 1979 Authorized State Agent
I