GW1-2021-02090_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internr+l Use ONLY:
1.Well Contractor Information: i
Mitchell Dean Cook
FROM TO DESCRIPTION x
Well Contractor Name 1 U /0 7• ft- J4 ft. I
2043 A J Procec_5*1119 -3/5'& 3/4- ft.
NC Well Contractor Certification Number Irt�:+rr Ot`10 eej.011 ::foxi5m`L1`t s MORE_ f E.
Qti e FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. to- ft q6. ft. 6-- In'. 'OR—Z we
• Company Name :�1�l "-,� ?L�!* 11ySr0—,,:� G-*.,.. "" '�
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 0A III 1 -P ft. ft, in.
LIs1 all applicable well permits(I.e.County,State,Variance,Injection,eta)
fA ft. in.
3.Well Use(check well use):
i?1sfS QIt �`i..r:• ;?fj,a'r."A:=rrA'�\:SFr;;l}f''1.y.�;' .``�z ..� :.:�.r�- ••s"'L"+k �.a�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A ricultural ft. ft. in.
g OM icipal/Public
❑Geothermal(Heating/Cooling Supply) IBRasidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '8 '" A'=_ ''=' =-1=' �. •'' _" 4•a - .f%
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri stion ft. ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery ' ft. it. o P
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Reniediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
ft. it.
❑Aquifer Test OStormwater Drainage
ft. ft.
OExperitnental Technology ❑Subsidence Control
ts'�'a❑Geothermal(Closed Loop) ❑Tracer FROM TO DES CfiR_I TON(color,
color berdn soil/rock
_ grain
.aiz.
etc.)
❑Geothermal Heatin Cooling Return ❑Other Lxplain under#21 Remarks) ft. ra
ft. ft.
4.Date Well(s)Completed:07-Ol-21• Well ID# Al,A. fp &
So.Well Location: ft. ft.
,41, ft. ft
Facility/Owner Name Facility ID#(if applicable)
i tt. ft.
15�D Sk eG h�flt /Pc� fA ft.
Physical Address,City,and Zip
=21:4 ,� -- k`i !.u'ih+.�Z''<d_+�y`; ;,N`:�}l� `'::l .���tt 5i i •:rr'7:"::y:._y-
✓44caf, ,�58d5/367/ C
County Parcel Identification No.(PIN) C
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latliong is sufficient)
t
°3 50 ,41 ' LQ, R?f N -93°.23 6 itvZ w
�n� Signature of Certified Well Contractor Date
6.Is(are)the well(s): �`-anent or ❑Temporary
By signing this form,1 hereby cerio that the wells)was(were)constructed In accordance
f with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or ON.-- copy of this record has beenprovided to the well owner.
If this Is a repair fill out known well construction information and explain the nature of the
repair finder#21 remarks section or on the back of this form. 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.
For multiple injection or non.water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: .355 (ft.) 24a. For AD Xells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdlfferent(example.3@200'and 2©100') construction to the following:
10,Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
#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
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
13a,Yield(gpm) /jO Method of test: Air I!ft 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.
Farm GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Res Iurces Revised August 2013
' V

m r�� Macon C o u n t y NEW WELL CONSTRUCTION
Ea��d Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Israel Lopez EIRM 021521-P M33M 024121-S
Single-Family Well Residential 6582513671 EM 0.25
• • 140 Skeenah Road
• 441S to R on Addington Bride Rd. to R on Skeenah Rd. just before Morrison Church Rd. to L at 140.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram Not to Scale
The old well was abandoned without a permit Skee
Owner stated that he placed about 18-feetof _ �� 4dhRod
Clean fill into the old well.
Unknown length
1' Existing system
i Three lines
8
15, New Septic tank
PL
60'
158'
PL Cedar
v v
m 3
by
PL N
Proposed New Well
3'
I
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 03 THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: .3/17/2021 Charles Womack, REHS 1300 uthorized State Agent