GW1-2022-06873_Well Construction - GW1_20220719

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WELL CONSTRUCTION RECORD
"M LOTM can be used for singlo or multiple wolls For Internal Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
FROM
Well Contractor Name "'Tn':'i�:i.., 't::, `€if:i.*','•se`'.S,x"4.:, ::t`:c::2{F
TO DESCRIPTION
2043 A T
NC Well Contractor Certification Nwnber
i 12:'4' ,[r •ftir?milfi c6k .ltid .(1 Et1 tt' 71cti6 e'1fiaT
FROM r0 DIAMETER THICKNESS MATERIAL
:..
Dennis Holland Well Drilling, Inc. -
ft, F ft. i� in.
Company Name
1:4 YhM`ItIG'i1 171rx: U.004�'"
/��� FROM O MATERIAL 2,Well Construction Permit#: DIAMETER THICKNESS
fez[r� T ft. ft in
List all applicable well permits(i.e.County,.State,Yarlance,injection,etc) _
ft. ft. in,
3.Well Use(check well use): u
r".f7;'.��RkFIYs"f'; ;i+'. s: :+:�sr:•: a,• r`-s. ..:..:.....:...•.... ..
Water SupplyWcll: FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL.
❑Agricultural 13Municipal/Public ft. ft. in. I
ClGeothennal(Heating/Cooling Supply) VR61idential Water Supply(single) ft• rt. in. i
❑Industrial/Industrial/Commercial Counm C7Residetltial Water Supply(shared) 'Bt+�R''Ufi��<'`+�?',''i. '.i`'t.:" �s°.v.•ri::�%.r_ :?"iF': .4.•,.;:"".�
;'3.. .. xisi'-.c`:; �:i','�s�:r';;;�ri�`:i :.?;..,...,•r„�•,_:,.,•z::..:,c;:...<-.
Qlrri ati0tl FROM TO MATERIALjY' EMPhACEMENTMF,THOD&AMOl1NT
Non-Water Supply Well: ft. rr.
r- G
OMonitoring QRecovery J' ft. ft. ¢
Injection Well: --- ft tr -
DAquifer Recharge IDGroundwater Re � :-.mediation ';i;9..:°S.ND/,(I�A•X Is`i:kc�lti 1,8.:.-1idd'e'•, :•a.;•s'x�;::a��;;,:;
❑Aquifer Storage and Recovery QSalhiity Barrier FROM To MATERL41, EMPLACEMENTMETHOD
13AquiferTest QS ft. ft.
tormwater Duainage
OExperimental Teclulolo ft.. ft.
gY C7Subsidence Control
:2Q:I)R ' NCB?Is<)'(s='a'ac iHaaitoaetislieo'te'ifYri: <9a` 'Y;ie i 1i S ,f'r=':r3;`s;:;'
C7Geothermal(Closed Loop) CI'I'racer FROM TO DESCRIPTION color hacdoe solUrock rein size eta
OGcotherma! Heatin Coolin Keturn) 00ther ex lain under421 Remarks)
tt. ft.
4,Date Well(s)Completed: tWell ID/{�j� T_ --- -
ft.Sa,Well Location:
ft. ft. _
ft. r�. 2022
Facility/OwrrcrName Facility ft.
- ----- - _
• ft, ft.
L)r/= ., 4 dytli -l.,.Arl __ ft. ft .•a .�i
Physical tA: n?,- '%
y I Address,City,and Zip t4 �'. ..1'f:r ,t r�r, -�• li: 'III`
Cowlty Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one let/loag is sufficiont) 22,Certification:
Signature ofCortified Well Contractor Date
6,Is(are)the well(s): InKrImanent or ElTemporary
By signing this fain,1 hereby c"eri that the well(,:)was(were)constructed in accordance
with 1 SA NCAC WC.0100 or 15A Ni 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: QYes or 590r1' copy oflhis record has been provided to the well owner.
/f Nrls is a repalr,fi(I out known well construction information and explain the nature of the
repair under#21 remarks section or our the back ofthisform. 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 ifnece:ssary.
For multiple injection or non-water supply wells ONLY with the same eoru7raetion,you can
submit one form. SUBMITTAL.INSTUCTIONS
9,Total well depth below land surface: __Z5S (ft.) 24a. For AN Wells: Submit this lorml within 30 days of completion of well
For•muhlple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to'the following:
10.Static water level below top of casing: 2J40 r (ft.) Division of Water Resources;Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,!Raleigh,NC 27699-1617
11,BoI ehole<liameter: 6" (in.) 24b.For In'ecti D Wells ONLY: In adiiition to sending the foul to the address in
24a above, also submit a copy of this four; within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
Ox.ougor,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(glim)•__ Method of test: Air lift 24c.For Water Supply&Injection 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 coutlty health department of the coutlty where
`- constructed.
Form OW-1 North Carolina Department ofGnvironment and Nativat Resources-Division of Water Resoiures Revised August 2013

•QtoseCr• f�
Macon County' NEW WELL CONSTRUCTION
' '' Public Health CONSTRUCTION AUTHORIZATION
s ;
�'tl • a' PRIVATE DRINIQNG WATER WELL
WAIr
ndon Hintz • 061022-P • 043922-S
Single-FamilyWell Residential m:agblwim6585270173 18.13
Eddie Bateman Road
ort Road to Jambs Branch to Eddie Bateman Drive to gravel 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.
Diagram (Not-to Scale)
Additional
ermined Well
6 Repair Area
(061022-P)
I UARepatrArea_ I
is' n,
+ 98 Min 1De
o� d
25'Min G
a Proposed �+
o`o Pool p
Dry Well
® 0042122-12
Proposed
3 BDRM
Home proposed
Drive
Proposed
N Garage
W*_ _
E
SProperty Une
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: 6/24/2022 Jonathan Fouts, REHS 1979JW"& *_Authorized State Agent