GW1-2022-04849_Well Construction - GW1_20220520

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 [ls'(�ft• /)s' ft.
2178 - A ! T —ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi=casod'.wells OR-LINE R.if:a licable —
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft• �Zjet• in. C,
Company Name 16.JNNER CASING OR TUBINW eotherrirat closed loo _ .
—� ^--"- - FROM' TO DIAMETER THICKNESS MATERIAL T
2.Well Construction Permit#: 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 SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Su 1 ft. tt. rn•
Supply): ❑Residential Water Supply(single)
❑Industrial/Commercial. ❑Residential Water Supply(shared) 18.:FSROUT
FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon __ -� -� ft. 3 ;'zV
Non-Water Supply Welt:
❑Monitoring I:]Recovery 3
Injection Well: ft. Jc�J ft.
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL.PACK Ifa" licable
❑A uifer Storage and Recover ❑$a1in1 Ba17if.0 FROM TO MATERIAL EMPLACEMENT METHOD
q g Y tY ft. ft.
❑Aquifer Test ❑Stotmwater Drainage --- ----
ft. ft.
❑Experimental Technology ❑Subsidence Control --
20.DRILLING LOG(attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM 'r0 DESCRIPTION(color,hardness,soiVrock type,Rraio siu,eto)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. --_�
e. ft..
4,Date Well(s)Completed: Well ID//-
Sa.Well Location: (t. ft.
ft. aY�-2
ft. —--
Facility/Owner Name Facility 1D0(if applicable) --- -- '- `--- `
ft. —ft.
ZE-._SL, � ---O---L �---il-=-=f -- � ft ft.. .--��_w rho)4t,tY�7
Physical Address,City,and Zip it.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees- 22-Certification-
(ifwell field,one latlong is sufficiieent)
Signature if CortifiedWell Contractor Date
6.Is(are)the well(s): (OPermauent or ❑Temporary By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with.LSA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
f this is a repair,fill out brown well construction information and explain the nature of the
repair under 1121 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: 1 construction details. You may also attach additional pages if necessary.
For multiple ih jection at,non-water supply wells ONLY with the same construction,you can
submit one form. _ SUBMITTAL I_NSTUCTIO_NS
9."rota{well depth below land surface: (ft.) 24a. For All Wells: Submit this £ohm within 30 days of completion of well
ror multiple wells list all depths ifdierent(example-3@200'rntd 2.@100') construction to the following:
10.Static water level below top of casing: 100 (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 Iniection Wells ONLY: In addition to sending the fonn to the address in
Rota 24aabove, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: Rotary 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)_ Method of test: Air lift -`-- 24c.For Water Su &Neclion Wells:
----- - Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:H & H _ Amount:.1_2 oz. well construction to the county health department of the county where
constructed.
Form GW l North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013

r
Q%Oleer
�m M.a c o n County NEW WELL CONSTRUCTION
o Public Health. CONSTRUCTION AUTHORIZATION
d a° PRIVATE DRINKING WATER WELL
MI
James St.Clair • 081421-P • 082721-S
Sing ie-Famli well Residential 7533173866 5b.58
Off Locust Flats Road
Highlands Road to Walnut Creek to Right on Glenview to right on Locust Flats to end-stay to,right
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
„20' Permitted
- Well Area
(20,x 201
L i (081421-P)
20'�r
p Dry
ve 't00, Draw/
Gully
4
V
O
yo
V
osea V
Is'Mln
Q 120,
Oeryc Large
Poplar 1 �'
Tree Min 102'
V I.�y
98,
V -------------
r`
i
15'Min r �
r IIIF(10-LDP) :so,
V Repair Area
r
90,_------
V
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: 2/2/2022 Jonathan Fouts, REHS 1979 S Authorized State Agent