GW1-2022-03658_Well Construction - GW1_20220321

a
WELL CONSTRUCTION RECORD For Intorngl Use ONLY:
This form can be used for single or mulliple wells
1.Well Contractor Information:
Mitchell Dean Cook a:vt'
FROM TO DESCRIMON
Well Contractor Name 'ft z t ft.
2043 A ft. ft,
NC Well Contractor Certification Number `1 :�0 •1 Ri+"'$ titintiTeay1; c ': .(? .IiIS. 1 if:' cAb l+fix-°•'•`-'• : .{;•s c ;::
FROM TOI DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. a- ft. . ft. „ in. �r_2r Y�
Company Name <.I'4'' *It'CA§IIiJSr.':U �l!$ �Sr a"t a inaT''Iolelt lfj. Y"t vA>._
FROM TO DIAMETER THICKNESS (MATERIAL
2.Well Construction Permit#: 6 O / ft. ft,
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 1 SLOT SIZE THICFaIFSS MATERIAL
OAgriculhrral OMunicipaVPublic ft. tr. in.
OGeothermal(Heating/Cooling Supply) 52Ke—sidential Water Supply(single) ft. ft: in.
Olndustrial/Commercial OResidential Water Supply(shared) S; Oiflt } ' Xi"• rs r==r:1�? ?,
FROM TO MATERIAL EMPI-CEMENT METHOD&AMOUNT
❑Irri ation te D t it. ft. _ *
Non-War Supply Well:
OMonitoring ORecovery fa :,, fc
Injection Well: ft. fr.
0Aquifer Recharge OGroundwater Remediation :i9 "; /, ;+
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
OAquifer Test OStormwater Drainage
ft. ft.
OExperimental Technology OSubsidence Control
O:bR 40#I:h_ts'ti a8 b'dihoile►:AT�:ie,i ,o...•f tl` c xl .?:�. 11.:''F'
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardaM solitrock type,grain size etc.
OGeothermal Heatin Coolie Return OOther(explain tinder#21 Remarks) ft. ft.
ft. M
4.Date Well(s)Completed: 02- %22 Well IDfl /i%1A • ft. ft
Sa.Well Location:
ft. ft.
RQ e2 h /Ina s r. A• rr. tt
Facility/Owner Name / Facility IDf!(if applicable) ft. ft. MAR ,-
—6e LVtsre/S L"e- 7L �lFl�� /Qvclr� h. ft.
Physical Address,City,and Zip yR
{q ,(3 grfl i4 1T,A /•�f .[}.� ..f/trt 1J .15.a:��} .1.i..n:.�•
•�r?�f�Y L 1LQ�� �I©( Gem
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)
3 5°. 155, N w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): anent or OTemporary, By signing this form,1 hereby cerrfy that the weli(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or ti?46t - copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the mature of the
repair ender#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 construction,you can
submit one form. SUBMITTAL,INSTUCTIONS
9.Total well depth below land surface: 5�30 (ft.) 24a. Egr &H M11i Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(rt)l00') construction to the following:
10.Static water level below top of casing: --Q 7 (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.Egr InjeF(ion 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
(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)!� Air lift 24c.For Water.SupHly&Infection Wells:
Method of test: ,.
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.
Fomi GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Rcsotu+cos Revised August 2013
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1

Qtote�t
o� Macon County NEW WELL CONSTRUCTION
;' Public Health CONSTRUCTION AUTHORIZATION.
'v a' PRIVATE DRINIQNG WATER WELL
Ronnie Massey IMOTM 062021-P . N/A
Single-Family Well Only setbacks Residential MINE 7523398096 EM 2
• • 68 Windswept Rid a Road
Walnut Creek Road to Left on Ledford Branch Road to Left on Hidden Trail to Windswept Ridge Road to#68 on Left
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum.setbacks as applicable,including 50'minimum from septic system components.
Diagram (Not to Scale)
r
Permitted .
Well Area '
(062021-P) ,G.- 't
40fe�d
t~ Ora
0 ,�anK
39' 6S%pas a°ad
!y. 19% j; # i e
QAt�i' r stump0
a9
e
N
S
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.
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: 9/3/2021 Jonathan Fouts,REHS 1979 Authorized5WteAgent