GW1-2022-01345_Well Construction - GW1_20220124

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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.WATER'20NES
FROM TO I D98CRI L7 N
Well Contractor Name 551 ft. 660 & 1
2178 -A ft• ft f
NC Well Contractor Certification Number 15.OU.TER.CASING Mr multi-cAsed wells UR LINER'if a ' ble
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. © ft• 1 VG
Company Name 16,.11NNEWCASING'OR fUHING= e6therninlslaeed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 5�4 q 6 3 I (rs g ft. ft. in.
List all applicable well permits(i.e.County,State,variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.,SCREEN
LOAgricultural
ply Well: FROM TO DIAMETER SLOTSIZE THICKNM MATERIAL
ON[unici ublic ft. fLal(Heating/Cooling Supply), sidehtial Water Supply(single) ft. ft. in.UCommercial l7Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 3 ft. r�
'1 Non-Water Supply Well: z
� tt. �® to � ���
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if:'a ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stolmwater Drainage ft. fa
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:'attach odditicAil:sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardness,soillmck type,Zrain size eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. tL
''^7�
4,Date Well(s)Completed: J.—S dQ Well ID# 065 4c�11—5 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
�1�1mc;ll�_�rS . ft. fa ...: .
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
GI i I,e;z Dr.1 U e— ft. ft.
Physical Addres4,City,and Zip 21:REMARKS 'r -"
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35. ! 77.E70 N O a 3Lle6' 16' W _
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby cerii(y 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 ElNo 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,yore can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �p 11 (ft.) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths i(dierent(example-3Q200'and 2@100') construction to the following:
i
10.Static water level below top of casing. / 5 0 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole-diameter: 6 24b.For Iniection 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 27699-16M
13a.Yield(gpm) /.q Method of test:
Air lift 24c.For Water Supply&Injections 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

tote
Macon County IMPROVEMENT PERMIT and CONSTRUCTION AUTHORIZATION
Public Health ON-SITE WASTEWATER
y a
EsCrawlspace
and Lucille Myers,Trustees •• 055421-s 051821-p
Halley Drhre 6594953168 2.42
Highlands Rd W R on Belleview Rd W Haile Drive to lot on L360 Gallons Per Da 3 BR House New Construction
Proposed Single-Family Well/On Site Valid for 60 Months
Pefn*Conditions
Dig trenches level and on contour in location shown. Meet all setbacks shown. Do not remove large stumps from drain
line area.
Dia ram Not to Scale
Garage
. Aroposed
Use
25,
PL 40 25'
1—-_5_0' IP
\� ft//Area
�>R 35' 4 25'
—ter
50 55,
PL
ST E3
100'
a Well
100'
75'tePair _
4�= 75'
51
75'
83' _75,repair 1�15'
IP �(
Halley Drive
i
i
� V
. : . 25"'•Reduction—Gravity; TW Panel Block(PPBPS)—Gravtyy;
IIa Soli Depth: 48(In)Slope: 22-25%1 LTAR:0.4 11 Saprolite:No Type Ine Area:750(ft2) LTAR:0.4 Saprolfte:No
• • 225` 3 9'on center 24"low side 36 Inches Serial Feed 1000 gallon Not Applicable
The issuance of this permit by MCPH in noway guarantees the Issuance of.other permits. The permit holder Is responsible foricheddng with appropriate governing bodies In
meeting their requirements. This pernit Is subject to revocation If the site plan,plat,site or Intended use changes. This permit is subject to compliance with the provisions
of the NC Laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit Construction and installation Rules NCAC,1950,.1952,.1954,.1955,
.1956,.1957,.1958 and.1959 are Incorporated by reference Into this permit and shall be met. Questions?(S?M 349-2490
I
�Issue Date: q' J 26 2021 Justin Mintz,REHS 2177 onked State Agent