GW1-2022-04310_Well Construction - GW1_20220428

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WELL.CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland 14.WATER ZONES
FROM TO DESCRIPTION�_��
Well Contractor Name i 50ft. )51
ft. C -T
2178 -A 33 -ft. 33&-_
NC Well Contractor Certification Nwnber 1$.OUTER CASING for multitnsed wells)UR LINM;R(if a liceble� .
FROM TO , DIAMETER' THICKNESS I MATERIAL_
Dennis Holland Well Drilling, Inc. p ft. I ft. 5 a11 PVim-
Company Name 16.INNER CASING OR TUBINMeeothertnal closed-loop)
I FROM D1AME'rER THICKNESS MATERIAL _
2.Well Construction Permit#: � �•l ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc) - - - -- - - -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO - _DIAMETER y SLOTSIZE THICKNESS MATERIAL�4
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gricultural ❑Municipal/Puhlic �f, Ttt. i"
eothennal Reatin Coolin Supply) Supply(single) ft r"•
( g/ g pp y): DResid Rtial Water Su I sin le)
ndustrial/Commercial esidential Water Supply(shared) 18.GRUUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
rri ation_ _ ft. ft.
n-Water Suj,piy Well: - A
ac
❑Monitoring ❑Recovery ----
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL.P:AC'K(if applicable
DA uiferStora Storage OSaiinit Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
9 g Y Y ft. e.
DAquifei Test DStormwater Drainage - --
ft. ft
DExperimental Technology ❑Subsidence Control
20.URILI.iNG LUG attach additional!sheets if necessary)'
DGeothennal(Closed Loop) 071•acer FROM _ _ro DESCRIP'riON(color,hardness,soilfrot�p�rti" -
DGeothermal(Heating/Cooling Return) FJOther(explain under#21 Remarks) _ ft, ft, ^
/ ft. _ ft
4.Date Well(s)Completed: "T '^ Well IDH_
ft. at
So.Well Location: i R, ft
6
Facility/Owner Name Facility ID9(ifapplicable•) '_-ft.- -'"--'"ft.
�.� ��-� �" _3,�. �eayhe•� g ��� _ _ _— ft ___--T ftrt
physical Address,City,and Zip 21.REMARKS � `1602S 30 7 �_
�1� is` hi l7q
County Parcel identification No.(PM)
5b.LRtitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif cation•
(if well field,one Iadlong is sufficient)
L,tA k.vI VVJ rz N W -- -- -�
Sihnaturc of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or C]Temporary BY signing this form,i hereby certify that the hvell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0i00 or 15A NCAC 02C.0200 Well Consirucvion Standards and that o
7.Is this a repair to an existing well: Dyes or N71Vo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well consinicton information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
far multiple injection or non-water supply wells ONLY with the same construction,you can
suhmitonefnrm. I SUBMITTAL INST_UC_TIONS
9.Total well depth below land surface: �� (ft.) 249.. For All Wells;+Submit this form within 30 clays of completion of well
For multiple wells list all depths iidierent(ecample-3(a3200'and+2@100')I construction t0 the.following:
10.Static water level below top of casing: l O O (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 In'ection 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:
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(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
Air lift 24c.For Water Supply&Infection!Wells:
13a.Yield(gpm) Method of test:�_— Also submit one copy�f this fond within 30 days of completion of
13b.Disinfection type: H&H Amount:_12 oz. Fell construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Envihonmcni and Nanual Resources--Division of Waler Resources Revised August 2013
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Q'COte�r
0 •; Macon County NEW WELL CONSTRUCTION
' Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Oldfield Mountain Co, LLC • 010821-P • 012221-S
Shared Well Residential 7502343097 MOM 1.5
• • Lots 6&7 Highlands Pass
East Hickory Knoll Rd.,to L on Hickory Knoll Ridge Rd.,right into Highlands Pass,turn left on rd across from meadow,property on
left.
Permit Conditions �-�__�, „•.�— �r.�Q.YL�Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. t�`'[ 9 a _ 4,a C
fag- �► a -a���
Diagram Not to Scale
Iron Pipe
USFS Monument
M-35
11-1975
Approved 20'x20'Well Area PL 40'
190,
Iron Pipe grade area
Xisting
PL
25'min
fo .100 117/d 75", ,-'"%125'
a .-
PL. Proposed House -01
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74' S0 Iron Pipe
50' '
41
Metal Stake 50' ,of'
15' in F
15'min
ry
ower ;
xis in9 rive Cut Vault %
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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 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: 2/5/2021 Charles Womack, REHS 1300 Authorized StateAgent.