GW1-2022-03656_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Weil Contractor Name /5'0tt• 9 c/• ft-
2043 A C5e. Zgl•ft.
NC Well Contractor Certification Number 15 QUTLR 4�A3)riYC for;mi ltt ebsglt 'cUa Ok>IiINER',
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o •tr -ft. 6�. ;o. SL�?_.21 ve
Company N.. 16 ih1N)rIi CtASIIY(rOR T11$AVG` cothe mal;clwca=lo3"' >:', _ __
FROM I TO I DIAMETER ! THICKNESS I MATERIAL
2.Well Construction Permit#:C2�1(,6 41-Z 1 - /' to rL in.
,List all applicable well permits(i.e.Counry,Stare,Variance,Injection,etc)
fL ft in
3.Well Use(check well use): 7..F5:GREENt _ ,
Water Supply Well: _ FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public tt. fL in.
❑Geothermal(Heating/Cooling Supply) fWtEe—sidential Water Supply(single) tr. tL io.
❑Industriai/Commercial ❑Residential Water Supply(shared) %.•18.., RdUT_ 3:: ?s., :::.. `
❑Irrl at10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. a ft. �, - G7 4
Non-Water Supply Well:
❑Monitoring ❑Recovery .3 ' tL aZ�• tLAgh t
gh
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD `
tr. tr.
i]Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DR LG1N.ty GQG.at(aclCI-Me,ogalilheefs'if d"i'esse
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardaM soiVrock ram eve etc.`
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) tr. ft.
tr. fa
4.Date Well(s)Completed:03-D&-z0'Vell IDt`t_ N A - � fa ft.
Sa.Well Location: ft. to _
A =,k ft. rt
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. '
MAR 2.1
130 6- 7-a -Ne Ann./ ft. ft.
Physical Address,City,and Zip 21<RE1V1Al2ICS lit 7 i,{ t. r. : `'
Cowuy Parcel Identification No.(PIN) C r / /
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
4'
(if well field,one ladlong is sufficient)
03 'D a N -g3 15 2� w o3-oS3-,�2•
Signature of Certified Well Contractor Date
6.Is.(are)the well(s): rffe manent or ❑Temporary
By signing this form,1 hereby certfy that the well(!;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 WN10 copy ofthis 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cons&ucdon,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface:'' .3.0-5 r (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-3@200'and 2@100') Construction to the following:
10.Static water level below top of casing: 6.S' (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: 6" (in.) 24b.For Infection Wells ONLY: Inladdition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) /40 0 Method of test: Air lift 24c.For Water Supply&Ipjection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: H & H Amount: 2 OZ. well construction to the county healtli department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resoiurxs Revised August 2013
f
i

Q<�te�r
Macon County NEW WELL CONSTRUCTION
o
r Public Health CONSTRUCTION AUTHORIZATION
'a a' PRIVATE DRINIQNG WATER WELL
Antonin(Tony)Aeck • 040421-P • Q41321-S
Single-Family Well Residential ' 7 5`2 0 6 0 6 7 71 22.51
• • 1305 Turtle Pond Road
' • Highlands Road to Right on Turtle Pond Road to 1305 Turtle Pond Road on Left
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 100'from septic system components.
Diagram Not to Scale
Drive Goss:
0"Deep Min.
Large OR
Pine Tree D.O.T.Traffic
Ex.D 50,rive * 7 Lceek
��Rena 50' A s 'o
� q•„�•t, Z02, '��;ne ca°.off
10�1Mn �5'Min
2•
ny"
epar`4ne
0 •�
d
!L I m Parking/Drive p
•e —125' h'°�OiOo
d
I o des
a
I �a
100'Min
Parking
P,,pOSed rive N
10' Permitted W E
Well Area
10'`__i 040421-P)
Large 10' (10'x 10') •S
Pine Tree
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 fad 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. I
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]
Issue Date: 6/18/2021 Jonathan Fouts, REHS 1979 WI( h?AM1 Di►t5 Authormeof State Agent
I