GW1-2022-08226_Well Construction - GW1_20220428

i
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 ft. ft.
2178 - A rt. fL
NC Well Contractor Certification Number 15.OUTER CASING.for multi cased wells-OR LINER if a licable
FROM TO DIAMETER; THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. fr. - 3Ff1. to in. 5DR 2-I "e
Company Name 16.INNER'CASING OR TUBING`weothermall closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit tt:_A� UP ft. - M ft, in• -�
List all applicable well permits(i.e.County,Stare, Variance.,Injection,etc) in.
3..Well Use(check well use): 19.S(:RKEN i - -�
Water Snpply Well: PROM TO^ _ DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Apricultural ❑Municipal/Public
OGeothetmal(Heating/Cooling Supply) residential Water Supply(single) fr. T ft.
❑Industrial/Commercial ❑Residentiai Water Supply(shared) 5.GROUT
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri
Non-Water Supply Well: 7 - -----�
❑Monitoring ORecovety �tr. ao ft.
injection Well: _ft. R.
OAquifer Recharge GGroundwater Reniediation 19..SAND/GRAVEL."PACK iUa licable T
OAgttifer Storage and Recovery OSalinily BatTier FROM To MATERIAL EMPLACEMENTMETHOD
ft. ft.
❑Aquifer Test OStotmwater Drainage
ft, ft.
ClExperimental Technology ❑Subsidence Control —
20.DRILLING LOG attach additional sheets if aecessaty)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color hardness,soilfrockg2eyrainsi c ac.
UGeotherniai(Heating/Cooling Return) 00ther(explain under#21 Remarks)
4.Date Well(s)Completed: Lf-A��ell IDfi_ --ft.
-rL
5 Well Locati
nc r. branct- -.91A
Facility/0 wner Nam �A Facility 1DN(ifapplicable) ft' i1
---'--'--'— - --� :A -�_--
W �� �V V1 1 __ �__ _ _� -ft. ft
. it.t. �.���;?E�I (p
Physical Address,City,and Zip 21.REMARKS
c.vr �p5 101
County Parcel Identi6cati(n No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certify tion ^�
(if well field,one lat/longiuffic'cut)
15 N _ -�,55Z330 W - -- s-1
ttmat u.of Certified Well Contractor Date
6.Is(are)the well(s): (OPermanent or OTemporary
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02.0.0200 Well Construction Standards and that n
7.Is this a repair to an existing well: OYes or [?]No copy of this record has been provided to the well owner.
lfihis is a repair,fill out known well construction information and explain the nano•¢of the
repair under#21 remarks section or on the back of thisfornt. 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 necessaiy.
For multiple h jection or non-water supply wells ONLY widt the same construction,you can
suhmituneform. n� t SU_B_MI_TTALI_NST_UCTiO_NS
9.Total well depth below land surface: L --(ft.) 24a. For All Wells: Submit thisform within .10 clays of completion of well
For multiple wells list all depths ifdierent(araurple-3@D200'and 2@100') conshuction t0 tile.following:
10.Static water level below top of casing: 11 _ (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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
Rotary
12.Well construction method: constiuction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Uuderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield
(gp m) Method of test: Air lift -_ 24c.For Water Su &Wection Wells:
Also submit one copy.of this form 1within 30 days of completion of'
13h.Disinfection type: H & H .,_., Amount: 12 oZ well construction to the county health"department of the county where
-
constructed.
Form GW-1 North Carolina Department of Environment and Nanual Resources--Division of Water Resources Revised August 2013

1/18/2022 TR
Macon o u n t y NEW WELL CONSTRUCTION
° Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
James C. and Julie K. Branch (Formerly Gary and Mary Tyre) • 090120-P • 082920-S
bn1gie+amjiy Well Unly tsetoacKs), Resioentidi = b54b/U2bU9 1.%J
• • Red Wolf Run
28N> Airport Rd.> Olive Hill Rd.> Upper`Burningtown Rd.> L on Ray Creek Rd.> L on Red Wolf Run. 1st lot both
sides.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
This is a redrawing of the original permit issued by Darrell McDaniels,and is no longer employed here,who did not save it.
Dia ram Jot to Scale
l
NO
000,
PL
Marked Hickory
IP
r- Pcea y.
EtePaa ea lA�
\tia\aC 63'
18 5' Red Wolf Run
2
52' �e\\Pjeas
I �PPP�oJea aid 2 / • /,,-'- - � %�
/;1Low wet area with springs
3
PL 7
--------IPL and Creek---
' N
it
fill
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: 9/3/2020 D it McDaniels, REHS 2552 Authorized State Agent