GW1-2021-00433_Well Construction - GW1_20211206

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'WELL CONSTRUCTION RECORD For Intemgl Use ONLY:Tom`
This form can be used for singlo or multiple wells ! �1I
1,Well Contractor Information: RN-^. .,t s t ii 1 {:" 1<,•( �r 1`'t '" •Y'C71'a't$+i=3�I545 r 'yti
` t-7.' DESCRIPTION
Mitchell Dean Cook FROM To
ft.
Well Contractor Name
ft. ft. i
... , .R , ' .�),fbnfii'i551'
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
ft. . t ft. • ;: iir.
Inc.
•� �• � �
Dennis Holland Well Drilling,
Company Name FROM TO DIAMETER THICKNESS MATERIAL
_ ft, ft. in.
2,Well Construction Permit#:lei 9`2 il
List all applicable well permits 0-County,State, Variance,injection,etc) ft. ft, 1n.
y. tt. 'EIw.1si?!' ':;-;risst{:r,.';�';
3.Well Use(check well use): FROM To DIAMETER SLOT SIZE 44IICKNESS MATERIAL
Wa 11 ter Supply Well: ft. ft.
❑Agricultural ❑Mun'cipal/Public fL ft I°
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) <a $� u a e,,4 i+�sr
OUNT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL t EMPLACEMENT METItOD&AM
ft. ft. P — -
❑Irri ation `
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ; sr .s_5.iz>e'4a�`�4}Y :'_2' :Y ?4'.
❑Aquifer Recharge oGroundwater Remediation 119�`' � .�l'i A NIATERIAL�1 c s:,v .EMPLACRIFNTMKIi
FROM TO
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft.
❑Aquifer Test pStorinwater Drainage ft, ft.
❑Experimental'Cechnology ❑Subsidence Control f 4.I�< (/+ti)' ut . liad Ho.91.8 iet6li a`:'15 zrzo'1`{ ,),ss-;rs,
C1TraCCr FROM TO DESCRIP170N color hardy aolUrock rain size etc
❑Geothermal(Closed Loop) ft. ft.
❑Geothermal Heatin Conlin Return ❑Other ex lain tutder#21 Remarks) fr ft.
4.Date Well(s)Completed: 1/-2i4-Z Well ID# iV /.4 ft. fa
ft. ft. �
Sa.Well Location: ``
/V• /A : ft. ft.
/Vta l-t'-hc cw /trrfh/h-i3�i �O
Facility/OrvnerNmnc Facility lDN(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip
Cowrry Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient) � jt4_ -/
�� N `2 Signature of Certified Well Contractor Date
6,Is(are)the well(s): ermauent or ❑Temporary By signing this form,i hereby cent fy that the welJ(sJ was(were)constructed r accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
f this record has been provided to the well owner.
7.Is this a repair to an existing well: Dyes or E -' copy o
if this is a repair,fill out known well construction information and explain the nature of the 23•Site diagram or additional well details:
repair under#21 remarks section or on the back of thisform. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed: �For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL.INSTUCTIONS
submit one form.
(ft) 24a. For Ail a Is: Submit this form within 30 days of completions of well
9,Total well depth below land surface: construction to the following:
For multiple wells list all depths ifdii erent(example-3@200'and 2@100')
' . Division of Water Resources,Information Processing Unit,
(ft)
Ill.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
H 24b.Fr,r infection Wetly ONLY: In addition to sending the form to the address in
11.Borehole diameter: 6 (in.) 24a above, also submit a copy of this fonts within 30 days of completion of well
12,Well construction method:
Rotary construction to the following:
Underground Injection Control Program,
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Air lift 24c.For Water Su &In'ectibn Wlls:e
13a.Yield(gpm)
Method of test: Also submit one copy of this form within 30 days of completion
well construction to the county health department of the county where
13b.Disinfection type: H & H Amount: �2 o• constructed. C
Revised August 2013
cat of Environment and Natural Resources-Division of Water Resources
Form GW-1 North Caroline Departm
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Q�c�ecr
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Macon County 1
NEW WELL CONSTRUCTION
E Public Health 4CONSTRUCTION AUTHORIZATION TION
1 PRIVATE DRINKING WATER WELL
WMatthew Robinson • 101921-P • Existing I
in le-Famil Well, ResidentialLots 13 & 1469 Panorama Ridge, Lot 13 and 14
8N to L on Airport Rd.,to L on Jacobs Branch Rd. to L on Lee Tallent Rd., o L on Panorama Ridge to 169 at end.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
EMAILED Diagram (Not to Scale)
IP
90'
PL
IP
75' 55,
XY
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35 12'39"N
Proposed Well 83 24'21"W
100, i
25'
X 50' Existing ST
Lot 13
o Lot 14 a ;
V. ,Q
Rio 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 I
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?j(828)349-2490
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Issue Date: 11/19/2021 Charles Womack, REHS 1300 a—L".Wd
Authorized State Agent
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