GW1-2021-02814_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD /
For IntemQl Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Mitchell Dean Cook
•FROM f TO DESCRIPTION
Well Contractor Name ft. ft.
2043 A .23a ft. ft.
NC Well Contractor Certification Number Off! L13t(t .7N •oiatiftil',. :O 8 .._ s _
FROM TO DIAMETER i THICKNESS' MATERIAL
Dennis Holland Well Drilling, Inc. a • ft. �• ft. ��„ in. PIiL
Company Name Ll''i : • R_ ' LN7Ss O. __ ,(tz t"er
-
2.Well Construction Permit#: _O 5`p'/� j d P FROM tr. TO fr. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc•)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. fa in.
❑Geothermal(Heating/Cooling Supply) PR srdential Water Supply(single) fr. ft In.
❑industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h7l atlOn 9 ` ft. e ft. 643rd Q _
Non-Water Supply Well:
❑Monitoring ❑Recove rY fa ft
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation is;.'�1±1D'[.fI ? :i pg gi t a 1+?b>t' ,.'s � :6
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEt1IENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ff.
❑Experimental Technology ❑Subsidence Control fL ft. '
❑Geothermal(Closed Loop) ❑Tracer FROM TO c)ftDliESCRI PTIO Nts•j 1� '
color,bardn soil/rock type,grain size etc.
❑Geothermal Heatin Coolin Return ❑Other Lxplain under#21 Remarks) ft, ft.
ft. ft.
4.Date Well(s)Completed:L%?-.2,5-&W Well ID# /V ��, ft. ft. �, r
Sa.Well Location: tr. fr
_43_5'e �I ft. ft. r.
Facility/Owner Name Facility iD#(ifapplicable) ft ft. t
11'
Physical Address,City,and Zip fL
- t-nn
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if welt field,one lat/long is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the we11(s): anent or ❑Temporary
By signing this form,!hereby cart jj+that the well(s)was(were)constructed/n accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an eajstiag well: ❑Yes or t'IOAItf-- copy of this record has been provided to the well owner.
If thts is a repaIn jilt out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thlsform. 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: construction details. You may also attach additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same cotlsftedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S�"` (ft) 24a. For A I�Welis: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd((ferent(example-3@200'and 2@I001) construction to the following:
10.Static water level below top of easing: i6 r 00 Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Injection Welts ONLY: In'addition!to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) 30 Method of test: Air lift 24c.For Water Supply&Iglection 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 ow-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I
i i

Qvote��
o Macon County NEW WELL CONSTRUCTION
0
} Public Health CONSTRUCTION AUTHORIZATION
r PRIVATE DRINIGNG WATER WELL
Lawrence Kelly • 050121-p • 050221-s
SlngtewFamlly Well Residential 6553600084
• Off West Dills Creek
64 W to Lon West Old Murphy Road to R on West Dills Creek to R just past 1049 West Dills Creek Rd
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well head must be constructed In accordance with Macon County flood plain ordinance.
Click to enter text
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Diagram Not to Scale)
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Repair Area PL I
50' 20' Large Poplar
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'50' Sr i_- Q 60' ---1 50, f
Well Area
60' 50'
50' Proposed Drive 40' proposed
sed 5 i
_ ' �_---`----------- ------ -- ------ ------ 45'
- Small
Woods Line 135' Woods Line - - __ IP stream
1
v •\ 1
Feld \
h \
Cre K
i'
This permit is valid for a period of five years except that It may be voked 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 protects r l 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 O{•ovlde protection from possible sources of contamination. Flow volume(well yield)Is NOT
guaranteed at any site by MCPH. i
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEF R.E FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PL MP INSTALLATION. QUESTIONS?[phone]
Issue Date: 7/8/2021 Justin M ntz, REHS 2177 REM Authorized State Agent