GW1-2022-08232_Well Construction - GW1_20220516

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WELL CONSTRUCTION RECORD For hnerual Use ONLY: -This form can be used for single or multiple wells
1:Well Contractor Information:
Mark E. Holland l4.WATERZONF.S -v, — ^-_.:._
DE IP SCRTION____
Well Contractor Namefit. _-_.--._-
2178 _A
NC Well Contractor Certification Nmnbei is.ourER CASING for multi-eased wells).OR.LINERSifa licable - _-_--.
_bROM TO _ DIAMETER Till M ICKNESS ATERIAL- _
Dennis Holland Well Drilling, Inc. ft. 15ft. in.
SOt?�;l
Company Narne FROM ER CASING OR TU.DING tthermat closed-loop
THICKNESS MATERIAL
. . 7 _ .�_
2.Well Construr.6on Permit N:
Gist all applicable well permits(i.e.County,State, Variance.Injection,etc.) -._.—
ft. fit. in.
3.Well Use(check well use): _--- -- - -.....--- - --------- ---- -----— --.....--
17.SCREEN_ _ __.'fER"
Water-Supply WeII; - --�- - FROM_ IAM E SLOT SIZE THICKNESS - MATERIAL__
❑Agricultural ❑Municipal/Public, ft_ TO.._..._--ft_ D
❑Geothennal Hcatin Cooling Supply) ❑Residential Water Supply(single) ft, _ - ft. in. -- -
( [� PPP) PPY(� 6 )
Oh)dusu'ial/Com ❑ 18.GROUT
mercial Residential Water Supply(shared) MATERIAL-_- EMPLACF.MENTMETHOD&AMOUMr
ft.
Non-Water Supply Well: C5;_❑Recovery -
[lMonitoring
__
Injection Well: ---' --- R, ft.
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEI,PACK(if spolicable)- -----_�-- "'
FROM 'f0 R--- MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salu)ity Barrier R - -
❑Aquifei Test ❑Stotmwater Drainage - - - -- ---- - ----- -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal Closed Loop) ( -----z1- -----__..____..___
( I) ElTracer _FROM 'r0_ _DESCR�IP'f1ON(rotor,hardness,soiUrock t7pe�r_ain s'vc_ercl_ _
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under k2.1 Remarks) I
_(I ft. _
fit. fit.
4.Date Well(s)Completed: Well Illtf ft ft
OAK-
_ — —— ----- - -
rt. ft. �Y 1
PaSlhy{/�Owner�Name Facility IDN(ifapplicahle) fit f4
�T�' a rDWOMOG
_ fit. ft. �-�-�-� --
Physic KlAddrcss,- (.'icy,.ytd ZIP
hf11IW/jAlf/11N � � 21.RF.MARK.S
County Parcel Identification No.(PIN)
Sh.I..atitude and Longihide in degrees/minutes/seconds or decimal degrees: 22.Certification: --- —___—� --- - -
(if well field,one tat/long is sufficient) r h b S
�j
.Signalsuc ufCs:rufied Well Contractor Date
6.Is(are.)the well(s): l2lPermanent or 07'emporary
Hy signing this farm, I hereby certify that the well(s) uws(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or ONo copy of this record has been provided to the well owner.
ff dais is a repair,fill oul known well construction information and explain the nature of the -
repair under i121 remarks section or on the back of thisfornn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well sitc details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
for mndtiple injection or non-waer supply wells ONLY with the same construction,you can
suhtnit one%)rnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:- _ .�� (fit.) 24a. for All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdii ferent(rron)ple-3([f 00'and 2@100') construction to the following:
10.Static water level below top of casing: l (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing,use � 1617 Mail Service C'cnter,Raleigh,NC 27699-1617
11.Borehole diameter:.6-- (in.) 24b. For lniection Wells ONLY: In addition to sending the fbim to the address in
24a above, also submit a copy of tliis form within 30 days of completion of well
12.Well construction method: Rotary - Consuuctioo to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Ilnderground Injection Control Program,
FOR WATER SUPPLY WEL.[S ONLY: - -- _^- 1636 Mail Service Center,Raleigh,NC 27699-1636
Air Iltt 24c.For Water Supply&lniectioDkwells:
13a.Yield(gpm)_---= ---------_-.-- Method of test:.--.--------...---.--_--
Also submit one copy of this font within 30 days of completion of
131).Disinfection type:H_& H Amount: 12 oz. well construction to the county heaN tti department of the county where
- - -- ------ constructed.
Form GW-I North Carolina Department of Elnvironmcut and Nat)ual Rcsourcas--Division of Water Resources Revised August 201:1
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Q�ote��
'A Macon County NEW WELL CONSTRUCTION
o ,R Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
r Mark Davis Woody • 040822-P • 084421-S
Single-Family Well Residential 6580189715 9.52
• • Coweeta Church Rd., Shoe Road
Georgia Road to Coweeta Church Road to corner of Shope Road and Coweeta Church Road-House will off Shope Road(to R @ cross
road
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. o
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
Shope Road
Power
Pole �ry�e�ay
3 Ao
Leo yoOye
OR
so. o
06, `.4Q s,6
Prolwd
1 4 cea,fop.M� nor.a
`M 6.,jl9, ��A i Barn
N
��� ss•
Existing Septic Tank oa
1114
�� o Fo
okP^ 2Sg t wm
is
Proposed well Site
ISO'
_ N
_ ---
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.
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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: 5/5/2022 Charles Womack, REHS 1300 Authorized State Agent
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