GW1-2022-08213_Well Construction - GW1_20220428

WELL CONSTRUCTIO RECORD
This form can be used for single or multiple wells For Intemrtl Use ONLY:
L Well Contractor IDformatiou: i
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Name 60 ft. / , ft.
2043 A Oa05' �D �fL
NC Well Contractor Cortification Number i`rl`.Si:O T•BR�'°$1N ,:foriiWtr.eb8 1,.'e. 101ie1a1N t ifi'"' kqb a;. ,, ' ,;';:
FROM TO I DIAMETER THICKN99,,1 MATERIAL
Dennis Holland Well Drilling, Inc. o • rt 7a • ft. d.• in. vc
Company Name E`R CA$TNIi t31t°TU$. Cs eot'e inaltM"`¢7di1 0 ` '
;..16 0 x,
FROM TO DIAMETER THICIQVESS MATERIAL2.Well Construction Permit ill ®�a 7„Z)/ -A tr fr.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in
3.Well Use(check well use): e
.17!rt(1tRFit1 3 55,iWW
WaterSU fill lyWell: FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL.
❑Agriculhrral QMunicipaVPublic fr. tt. in.
QGeothermal(Heating/Cooling Supply) AR-c—sidential Water Supply(single) Fr. ft. in.
01ndustrial/Commercial QResidential Water Supply(shared)
FROM. TO MATERIAL EMPLACEMENfMETHODdAMOUNT
fNou
tiontr.Water Supply Well:nitoring QRecovery 3 ,ZQ' ft. �t' Well: ft.ifer Recharge OGroundwater Remcdiationifer Storage and Recovery OSulinity Barrier FROM TO MATERIAL• EMPLACEMENT METHOD
ft.
ifer Test QStormwater Drainage
erimentul Technology
L7Subsidence Control
QGeothermal(Closed Loop) 07'racer FR.DRiI41NCSGtTG'atta¢
FROM TO DESCRIPTION color hruda rolUrock taro uu cic. ,
QGeothermal Heatin Coolin Return 00ther(explain under#21 Remarks) fL rt.
ft. fA
4.Date Well(s)Completed: 2 Well IDt't Al,1A.
ft. ft.
Sa.Well Location:
ft. fa
JA. ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Yl .S`JQJ^/i�� .0iv� ft ft
Physical Address,City,and Zip
777
County Parcel Identification No.(PIN) `
rfi I^
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I
(if well field,ono lattloog is sufficient)
,' ? TfC�I Pni'J0(1t,�T
3 XCTM
5'0 9 '413. N S'�° /9 dos /9 w 2¢,0J G 3 -.2 49,2-Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): *ftrmanent or ❑Temporary
By signing this form,/hereby cert fy that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: LlYes or k@AiS`
with 1 SA NCAC 02C.0100.or 13A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
If flits Is a repair,fill out known well construction information and explain the nature of the
repair tinder#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.
For multiple injection or non-water supply wells ONLY with the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3Q (ft,) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10,Static water level below top of casing: /S (rt,) 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" (iu,) 24b.For Iniec,(ion Wells ONLY: in addition to sending the fonn 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: ry construction to the following:
(i.e.augor,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)._oL9V 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 county health'department-of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resotucos Revised August 2013
f ';

Qioteer
i
Macon County j NEW WELL CONSTRUCTION
E ONSTRUCTION AUTHORIZATION
d PUbIIC Health C
PRIVATE DRINKING WATER WELL
Rondal Chase Holland • 030721-p • installed
Single-Family Well Only(setbacks), Residential _ _ 75104824157 EM 5.0
• • End of Sherrill Drive
64E> Beldon Rd> L @ Sherrill Dr.> to the to
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. '
Pre-determined approved well location marked with pipe and red cloth to the right of house pad.
Click to enter text
Click to enter text
Diagram (Not to Scale)
Proposed
HoUePad _ - - - - - - - _
77
Proposed New Well
xy=35* 9'43.734"N
83* 19'20.19" W
100+'
Installed
OSV✓W ,
i
Sherrill Drive
Beldon Drive - - -
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 of1contamination. 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: 6/3/2021 Harold Faircloth, REHS 2189I Authorized State Agent
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