GW1-2021-00401_Well Construction - GW1_20211230

r
WELL CONSTRUCTION RECORD For internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland 14•WATERZONES
FROM TO I DESCRIPTION
Well Contractor Name j6' t / ft
2178 -A 3 t. cM ( j
NC Well Contractor Certification Number IS.0UTER.CA8WG for mutd-cased: eus UR LINER`it a hk
FROM TO DIAMETER TH[CIQVESS MATERIAL
Dennis Holland Well Drilling, Inc. k. 5�ft. ; io. S _ �l PVC.
Company Name 16..1NNER'CASlNG ORTUBING` eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,— State, Injection,etc.)
ft. f4
3.Well Use(check well use): t7..SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply), []Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial umtesidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation_ ft. ft. �t
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. D ft. ' _ h QG
Injection Well: fa ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.it:'a ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stomtwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING.LOG:attach additionafsheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardness,sorUrock size eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ft
p ft. ft.
4.Date Well(s)Completed: ) '1 S a. Well ID# /"r ft fr. _ r
Sa,Well Location: ft ft DEC
:3pkn N`itA•1- kAirhej1eA4a4n5 At JA ft. ft. 1-1041
Facility/Owner Name Facility 1D#(Applicable)
ft. ft.
o-ff COW td& a . II'd •,- Leeia tome, ft. ft
Physical Address,City,and Zip
21.REMARKS
.co,/L1 &5 9,631:�7?&4
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific ' n:
(if well field,one lat/long is sufficient)
2>D��l�
Signature of Certified Well Con for Date
6.IS(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certoi that the well(s)was(were)constructed in accordance
with I SA 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 FINo 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1%or multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. C� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ✓ (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 te+200'and 2 a 100') construction to the following:
10.Static water level below top of casing: lb 10 t (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use'+ _T 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 611
(in.) 246.k g
For Infection Wells ONLY: In addition to sending the form to the address in
Rota 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
m 139.Yield(gp ) lip Method of test: Airlift 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. 6
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I

..._. -;T_..____--_.__.._.-.._.......
4tute.Fry t3
, „ Mator County
o �_ NEW WELL CONSTRUCTION
d `Pule Health CONSTRUCTION AUTHORIZATION
�'d • a's PRIVATE DRINIQNG WATER WELL
John David Adams and Michelle Adams • 09092 •
Sin Le-Family 1-P N/A
Well Residential • 65801-P 1.3
• Off Coweeta Church Road and Lecia Lane
Turn onto Lecia Lane off Coweeta Church Rd. roe on immediate right.
Permit Conditions
Well shall be constructed in compliange with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
EMAILED Diagram (Not to Scale)
10",' PL
X Y ,'Prop sed
as 35 04'14"IN e rea
Q° 83 24'01"W 10'
GrJir `
Ce 168' die
IP
I
I
I
PL
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(act 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: 11/19/2021 Charles Womack, REHS 1300 01LJAuthofizedStateAgent
t