GW1-2022-03207_Well Construction - GW1_20220310

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For lntomgi Use ONLY: I
1.Well Contractor Information;
Mitchell Dean Cook
FROM TO I DESCRIPTION
Well Contractor Name a' ft. / " ft.
2043 A
-ft. ,ft.
Ne Well Contractor Certification Number foe iul .` i' s'r(1 j t jX xvri•;.,:+.. ;:;..:;.OUm1s•Ric�'" Z: cab b�::.� ,..�:#,.
FROM TO DUMF,TER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a ft. S-ft. In.
Company Name •.2/ /0 V e
't ;:! �`t?a&[rls w.
PROM TO DIAMETER THICKNESS -MATERIAL
2.Well Construction Permit#: �//.S� -� fr ft in.
List all applicable well perm/ls(i.e.County,State, variance,Injection,etc.)
3.Well(Ise(check well use): ft. ft. win.
Water Supplye1`.$rt<Itli'1$.A5f"+. iS[r,•:';i.i.i':::i'�_" :f-•,��%.. .�.;. •:$ . ...,.; ,
Well:
FROM TO DIAMETER SLOTSI2E THICKNESS MATERUL
[]Agricultural C7MunicipaVPublic ft. ft. In.
[]Geothermal(Heating/Cooling Supply) QR6idential Water Supply(single) tr. rL In.
❑industrial/Comm N '
C1Residential Water Supply(shared) �•'� '' .. :�;,.:'.':i:<�.Lt;'i.�-i�� ;.g,:.';:+:faJ.;•:�^:.:;sis�>�.:.�
FNon- ater
FROM TO MATERIAL EMPLACEMENT METHO &AMO(INT
I ft. - ft.
Supply Well:g 011ccove fL fLrY ell: ft.charge []Groundwater Ren(cdiation y
1.`;i,:k 1S/,O ip.: Kr-f+A,::l d-•,<;i w G%cr".:a<s„>ti?j.:s•, . .,.o;:;,•
[]Aquifer Storage and Recovery ❑Salinity Barrier EOM To MATERIAL I EMPLACEMEW METHOD
ft. tr.
OAquifer Test OStormwater Drainage
CIEx erimental Technology ft. tL
p gY C7Subsidence Control
[]Geothermal(ClosetlLoop) C11'racer ' Q:b 'G�I1N(1`Lti(r/a er ih"dit'io etrdti''fe:•i" '"'8a''%i<-',•}';��,<���rfi„�-_�.rr:��+i�� .�5
FROM TO DSSCRH'TION icelor baz4M solifrock typl,grak size etc.
[]Geothermal Hcatin Coolin Return 00ther(explain under#21 Remarks) fL ft.
4,Date Well(s)Completed: ft. ft.
ft. ft.
5a,Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
It. ft.
Physical Address,City,and Zip 6
W Mom
gm
5 5So S' S 7
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certtficatioo:
(if well field,one lat/long is sufficient)
3
° 4 t w 5 , a 7 l `..zL�gR. A�� L q ?... A 3 S
Signature of Cortified Well Contractor Date
6.Is(are)the well(s): 1' ragnent or []Temporary
By signing this form,1 hereby term that the well(s)was(were)constructed In accordance
�� with 15A NCAC.•02C.0100 or 15A NCAC 02C.0200 Well Construction Siandards and that a
7.Is this a repair to an existing well: OYes or ON--- copy of this record has been provided to the well owner.
If ihls is a repair,fill ma known well construction Information and explain the nature of the
repair under#21 remarks section or on the back of Ihisform. 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 hyeetion or non water supply wells ONLY with the same construction,you can
submit one form. SU73MITTAL.INSTUCTIONS
9,Total well depth below land surface: (ft,) 24a. 'o W1 Submit this form within 30 days of completion of well
For multiple wells list all depths if differenr(example-3Q200'and 29100') construction to(lie following:
10.Static water level below top of casing: .JO (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699417
11.Borehole diameter: 6" (in.) 24b.E-pr Inlet tign Wells ONLY: In addition to sending the form to the address in
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.ouger,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)�}�; Method of test: Air lift 24c.For Water Su &In'ectiou Wells:
Also submit one copy of this form with(n 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.
Fomi GW-I North Carolina Department of Enviroument and Natural Resources-'Division of Water Resouiroos Revised August 2013
l

t1 'Macon C o u`n t y NEW WELL CONSTRUCTION
a public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
r r Stephen M.:Baldwin • 011522-P • 053421-S
Sin le Famfly Well Residential ' 7540578567 0.58
• • 2041Noodland Hill Drive
' ' Highlands Rd. to L on Mirror Lake Rd., Ron Hicks Rd. Ron Woodland Hill Dr. to #204 on L.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules, .
Maintain minimum.setbacks as applicable.
Any questions call MCPH.
Diagram (Not to Scale)
W ProPoseel
IP Prope Well Area
7 KYl/ryo 5'x y
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SAP
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I st`e� c�0.a IP
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d - so-Aft SIT: I/ry r
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se 0 es
a -
�r Aaova��5 M`� eW en ne t 6p epsl borin
q0%' SS tr1 �; Hirai;ryn9
0 I ?'1 ac � RehaJ�grl'd
s
IQ,lyin
P IQ,
ropertY Line Mln/�2,?
i �epp
EX 2 SORM IPPoyer JarydMijJ n'p
(Gravel) Box ��a° 3 e
OP on File �o
(Russell Cochrane) ro
N
This permit is valid fOC a period Of fiVC 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 QR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?(828)3 2490
Issue Date: 2/22/2022 Tanner Starney, RE/HS 2712 .tiiP' horiredSfateAgent