GW1-2021-02091_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD
For Internal Use ONLY: I This form can be used for single or multiple wells
L Well Contractor Information: �^0Mitchell Dean Cook 2 ` '
FROM TO DESCRIPTION
Well Contractor Name S./O-ft & I
2043 A 'U� Q v 2021 ft ft
jOr �5►►�91�lliZ
NC Well Contractor Certification Number ..e �'IS:gY1fiE1t`�� .(�):fotC'�iul"'......
� 5gC(10Ct FROM TO DL►METER THICKTIESS MATERIAL
Dennis Holland Well Drilling, ��c. D��;z ft • ft. 6" In- oip-a/ P vc
Company Name ';sf' 1 1tCASIIYI"rQ1t7'111311V4i _t'er "l7dt'
FROM TO DIAMETER TAIClOVESS K MATERIAL
2.Well Construction Permit#: -0 2.0-3.2 1- ft ft in.
List all applicable well permits(Le.County,State,Variance,Injection,etc..)
ft ft. in.
3.Well Use(check well use):
.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIINES.s MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) QRi idential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) )
❑Irri anon
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
. ft ft.
Supply Well: � w,
❑Monitoring ❑RecoverY 3, ft ZG• ft
a � —
Injection Well: fL ft.
❑Aquifer Recharge ❑GroundwaterRemediation i9r ' : .� ?VB =P "R is"' i b' •'s_rt" sic r:e4a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ff.To MATERIAL! EMPLACEMENT METHOD
❑Aquifer Test ❑Stomlwater Drainage
❑Ex erimental Technology ft ft
p gy ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ~ ,� :tail�I�S at7�c tLdtlitio.al:eb�ete'i `_- ':
FROM
TO DESCRIPTION teolar.hardnes.%soil/rock type,grain size etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21Remarks) ft. ft
ft ft
4.Date Well(s)Completed:06•-30-21 Well ID# A/.A ;
ft ft
5a,Well Location:
ft. ft
G124w 917 �tCY O],13-t,/ ft. ft
Facility/Owner Name Facility 1D#(ifapplicable)
ft ft
W 9%L1'R 1 1G -4 H G Q Iq� ft ft
Physical Address,City,and Zip
/1d G GOh' ...tyly '��",s ,:,: �ru,-.,c;� e��-C�%tf,� '" .5-•s`= '�.'�`Y f3'..,:.#:.•'Y;?e
��:2ti8/.a9
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� oo 44./.2."N _o03"�2 'S7. 9
�
Signature ofCortified Well Contractor Date
6.IS(are)the well(s): l _ manent or ❑Temporary By signing this form,1 hereby ceriffy that the well(s)was(were)constructed/n accordance
with 15A 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 ADW copy ofthls record has been provided to the well owner.
Ifrh/s Is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hook ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
g.Number wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injeclian or non-wafer supply wells ONLY with the same catsducdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705• (ft) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3©200'and 2(a3100') construction to the following:
10.Static water level below top of casing: go (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: ('Ja (in.) 24b.For Injection 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
I
13a.Yield(gpm) Jr- Method of test: Air lift 24c.For Water Supply&Injection Wells:
13b.Disinfection type: H & H
Also submit one copy of this form within 30'days of completion of
Amount: 1 2 oz. well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resouwas Revised August 2013

Q%Otec
t i
o�*o, Macon County NEW WELL CONSTRUCTION
,� Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
I
d Bilbrey • 02U321-p ( • 021321-s
EjGA
le-Famil Well Residential • ' 6488268124 28.8
Wallalieu Road
Rd to R on Wallalieu Gap Rd to R on Wallalieu Rd to property on right near the end in curve
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale)
85'to top of road bank Well Area 50'
50
boa
Over 100' 157,
Proposed Drive
150'
107'
79' kw QkoQ°s
71' Text Box
i-- 29'
i Repair i
50' 20'
i
N
110,
1P
117' PL
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 of6ntamination. 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]
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Issue Date: 3/11/2021 Justin Mintz, REHS 2177 RG AuthorizedStateAgent
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