GW1-2022-06050_Well Construction - GW1_20220629

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W.ELIJ CONSTRUCTION RECORD
I1ris form can he used for single or multiple wells For luternai Use ONLY:
I.Well Contractor Information:Mitchell Dean CQOiC A�:1YASGER�7l1NESz';�`. ,>-,._.=';'.::;`';«>,,;;,,::?s:{� ii=si�`dz;'. ;t,�`sc.:.. •:.;�:a
' FROM TO DESCRUM&
Well Contractor Name ft. tt.
2043 A e ft. ft,
NC Well Contractor Certification Nuinber s.a$:^t1U 1?NR'GAS Y don imii7tic�3glSp'Ilu'L(?�2,1)It�E t fP" ic8b eii= i''=%t3:a ic:'i'
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland W@II Drilling, Inc. a, rt, rt.
Company Nmnc ilb .NF R}GjASIi!ICs O1 TU$TNPr collie'h�al;closedzlbo '; ;?ti :'.:;;,
FROM 7'0 DIAMETER THICKNESSMATERIAL
2,Well Construction Permit#: ar /0-�-,�, •,-/-' fr. R. in,
List all applicable well permirs(i.e..County,Stale, Variance,Injection,etc.)
• tt.3,Well Use(check well use): ft. in'.d
Water Supply Well: iRo
ppy M TO DIAMETER SLOTSIZF, TIiICKNESS -MATERIAL,
❑Aoculhual C]Mw' ipal/Public a. rt. in.
CJGeotherrnal(Heating/Cooling Supply) csidential Water Supply(single) it• ft. in.
DIndustri .
al/Coo gsr x, rtt= ,:r,:,
C f`
.��fc.
t sidential Water Supply(shared)
- >-.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTJ:
L7lrri anion ® , ft. ft' c
Non-Water Supply Well:
C3M r7 onitoring DRecove �' it ft.
e C+ Gs
Injection Well:
DAquifer Recharge L3GroundwaterRemediation :1,Qr; " D/..� A�! x;'iPAGK rfia 'lica'g'F^ " = +- '*""•
❑Aquifer Storage and Recovery LISalhtity Barrier FROM TO MATERIAL, EMPLACF,IIIFNPMETHOD''!
ft. ft.
El Aquifer Test ClStormwater Drainage
ft.❑Experimental Technology OSubsidence Control ft.
00eothermal(Closed Loop) ClTmcer "'20�RII'L7lYSij?[<1S i attaahikdaitinaal eheeta ifln cue
FROM TO DESCRIPTION color barrio soi0rock rain size cle,
❑Geothermal LleatingCooling Return) 00ther(explain under#21 Remarks) fL ft.
fr. ft.
4,Date Well(s)Completed:G— Well ID f _
— -- ft. ft.
50,Well Location: _
ft. ft. �°k.� IF I
c
Facility/OwuerName Facility ID#(if applicable) ---
ft. ft. UIy A+ 07
h. ft.
Physical Address,City,and Zip
A-4 q G�� A...�....�...�...-.� X? / ...a /(� ��•' i t:r'L•'�ri u�1 itr��: i'4�J'✓:�ti' :3T
County Parcel Identification No.(PIN)
5b,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at11orlg is sufficient)
-35"11 `57 N 83002 �4 f 7 _-W
Signature ofCortified Well Contractor Date
6.Is(are)the well(s): (rmaneut or L7Tcmporary
By signing this joimi,1 hereby rerlfY that the well(v)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 a•15A NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: CIYes or W4-0 copy of this record has been provided to the well owner.
Ifdils is a repair,fill out known%let/ronsimcilon information and explain the nature of the
repair under#21 remarks section or on the hack of thisform. 23,Site diagratn 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: j (ft,) 24a. For Ali Wells: Submit this form within 30 clays of completion of well
1'ormultiple.,wells list all depths ifrlifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" Ofi.) 24b.For Iu•ec ion Welk 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: construction to the following:
(i.e.anger,ratary,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 Supply&In•ectlOD Wells:
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.
Form OW.I North Carolina Department of Environment and Natural Resources—Division of Water Resmirocs Revised August 2013

R�°teal.
oA Macon County NEW WELL CONSTRUCTION
o r 1 as:.Public Health �'- 7L7 1 9 CONSTRUCTION AUTHORIZATION
as •:�' PRIVATE DRINKING WATER WELL
Fdo 042122-P s. 043922-S
° Well Residential 658527017318.13
an Road
acobs Branch to Eddie Bateman Drive to ravel road.Stay left at Y to to
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 25'from building perimeters.
Dia ram Not to Scale
Qo
Additional
Repair Area
11A Repair Area
94! Min
O O 25'Min ¢
as � Proposed ro
0 oak Tree Pool O
une 3
' Permitted
25'Min --- Well Area
t (042122-P
Proposed (20'x 20')
3SDRM
Home Proposed
Drive
Proposed
Garage
E
*e -
Property Una
�y�ne
4�
This permit is valid for a period of fire 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: 5/13/2022 Jonathan Fouts, REHS 1979 ,quthorizedStateAgent