GW1-2022-08905_Well Construction - GW1_20220912

WELL CONSTRUCTION RECORD
Ibis form can be used for single or multiple wells For Interngl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Clank
FROM TO DESCREMON
well Contractor Name f,. J , fL
2043 A rt. fA
NC Well Contractor Certification Nmnber fr :•C ;,r;"•;;;,:
oimwtr
FROM r0 DIAMETER THICKNESS MATERIAL _
Dennis Holland Well Drilling, Inc. rr. �.,' 1n. S-. -�I eve
CompanyNarne ">It'(jA9[P1rr't�ll• G`/ " dii.e inal?cl4JL�i15B kf:, .}. .. '
FROM TO DIAMFTER THICKNESS MATERIAL
2.Well Construction Permit#:,�_�d2 1�d,2 -� fr. ft. in.
List all applicable well permits(i.e.County,.Stare, Variance,Injection,arc.)
ft. ft. in,
3.Wel
l Use(check well use): MEN
r
Water Supply Wcll:
FROM TOLL DIAM`F,TKR ,•SLOT SIZE THICKNESS NIATERIAII
❑Agriculhual C7MunicipaVPublic ft. ft. in.
00cothermal(Heating/Cooling Supply) ftlTe—sidential Water Supply(single)
LJlndustrial/Comm ;ercial r�8 rsRf)U.?f,
[]Residential Water Supply(shared) . . ._: ...<.,. � .a:<.., •..,,.. _.. r,t-_�.::_:;::�.
aIrrl at1011
FROM TO ~ MATEKIAL I EMPLACEMENT AMOUNT
-- ©, ft. , ft.
Non-Water Supply Well.
M
o
n
i
t
o
r URecove 1L ft.
ry
Injection Well: ft. fr. 06
0Aquifer Recharge (7Groundw ater Remediation `..'U.)1%?PAGIt
OAquifer Storage and RecoveryFROM TO MATERIALEMPLACE111FNTMETLOD
ClSulinily Barrier fr. "ft.
OAquifer'fest DStormwater Drainagc
DExperimental TechnologY [.7Subsidence Control ft. ft.
Cl(ieothermal(Closed Loop) z
"2Q)zllRi�GiY.f L.<)'s)titf''c i6ddilon l:efi'eef"s'if n' :5e«,';;;
p) C1�hmCef FROM TO D&SCRE!"'ITON color bardne solUroek t rain size cit.)
CDGeothermal(Heating/Cooling Return) CJOther(explain under#21 Remarks) ft. fr.
fr. ft.
4.Date Well(s)Completed: e39-07-.7-2. Well ID# 'V.��q
' ft. ft.
Sit,Well Location:
ft. ft.
' Jke Al /A ft, ft _
Facility/Owner Name Facility ID#(if applicable) -- __ _ __ �_ +•�� � r,
fa ft.ft. _— - S
Physical Address,City,and Zip ;21'sRE�IAitK; Frj
/ `rytn' r
County Parcel identification No.(PIN)
Sh.latitude and Longitude in degrees/minutes/seconds of-decimal degrees: 22 CeMificatioD: i
(if well field,one ladloug is su ,fficient) i �C+
f ..2 3r1 N o W
Signature ofCoitilied Well Contractor Date
6.Is(are)the well(s): immanent or DTcmporary -
By signing this fo,in, I hereby Teri fy that the well(s)was(were)constructed in accordance
with I SA 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 ZXe- copy of this record has been provided to the well owner.
1f this is a repair,fill out known wet/construction information and explain the,nature of the
repair under#21 remarks section or on the back of thisform. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUIIM7TTAL INSTUCTIONS
9,"total well depth below land surface: �Q, � (ft,) 24a. For AM Wells: Submit this roan within 30 days of completion of well
Par•multiple wells list ail dcpihs ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:��� (ft.) Division of Water Resouf ces,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 Injection Welly ONLY: In addition to sending the form to the addrass 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.nugor•,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service(,'enter,Raleigh,NC 27699-1636
13n.Yield Method of test: Air lift 24c,For Water SupVIX t&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 GW-I North Carolina Department of Environment and Natural Resources--Division of Wafer Resortrccs Revised August 201.1

Qiote�r
0 •m M a c o n C o u n t y NEW WELL CONSTRUCTION
C a Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
Bruce Willix _ • 082122-P • On File
Single-Family Well Only Residential 6 5 8 619 5. 4 7.85
• • 871 Sunset Trace Trail _
' • Lower Burnin town-871 Sunset Trace Trail
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable, including 25'from building perimeters and 50'from septic system.
Diagram (Not to Scale)
� 1
w e
Qto
z o
IP
e
16'
O e
o, c
901, G ;90'
Oe 17OSeptic
15 Tank ' c
pace I,
Well® ;"_-.-----35
Permitted
Well Area
(082122-P)
(35'x 5')
Driveway
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: 8/26/2022 Jonathan Fouts, REHS 1979 L�MG tCtnf7ri�5, Authorized State Agent