GW1-2022-09157_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: .
I.Well Contractor Information: j
Mitchell Dean Cook ;t, i ;. , ,•:,r° t r
-'ROM TO DESCRIPTION
Weill Contractor Name s(L
2043 A tt. ft i
NC Well Contractor Certification Nwnber
`3:oXimli7'tiSCb'Gd1, d1Ng i ffr 1" ayr.::{,•:< ;:::
PROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. V,�
Company Name _
16:, F ?GASTi`lf;` .Titllv(;......
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FRAM TO DIAMETER THICKNESSMATERIAL
2.Well Construction Permit#: �Q.��,�,�,- ft. ft. in:
Its,all applicable well permus(i.e.County,.State, Variance,Injection,etc..) � -_
3.Well Use(check well use): ft fr
Water Supply Well: EROM TO DIAMETER IISLOT SIZE I THICKNESS MATERIAL.
❑Agricultural OMunicipal/Public tt•
UGeothermal(Heating/Cooling Supply) csidential Water Supply(single)
0111dustriai/Commercial
R stdenhal Water Supply(shared) :•'' .::_r, :z:.+:,...,a+,>.-, ,, ,,_,,.,�.::,
❑Irri Atletl -- PROM TO MATERIAL•y EMPLACF,MENTMETHOD&A�MOpUNT
Non-Water Supply Well:
UMonitoring URecovery ►tt. Q' rt.
Injection Well: ft. fr.
OAquifer Recharge UGroundwater ?'
,'t;�
Remediation
❑Aquifer Storage and Recovery USuliniry Barrier FROM To MATERIAL EMPLACEMENTMETHOD
fr. ft.
UAquifer'rest ClStormwater Drainage
DEx erimental Teclwolo (t ft.
p BY ft.
Control
UGeothermal(Closed Loop) :2Ri:1i1t ?'IN.ti`[<Y r.'a'ae f6`tlilioitalfeti'ecfe•iflp``"3 `"s[ ;;'' '::
( p) C)Tracer FROM TO D&SCREMON color,hardoe soll/rock type,grain size etc.
UGeothermal Iieatin Coolin Return UOther explain under 421 Remarks) ft• ft,
It fr.
4.Date Welt(s)Completed:©9z/5-z-2Well IDIf /V, A
'`� --- ft. ft.
-- <q, .-c
So.Well Location: `� _
- ft. ft. G,5za.+il:. Y •v ,rew V�
n .M�
a n AJ.n h, ft.
Facility/Owner Name Fncility1Dk(ifapplicable) ---- -- -r1--0-2022
• ft. ft.
i g>�,+'-lip
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Physical Address,City,and Zip +
Cowtty Parcel identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/loug is sufHeicnt)
,35aa 3 ,3&2 N o �' W
Signature ofCcrtified Well Contractor Date
6.Is(are)the well(s): frdFci manent or L7Tcmporary
By signing this form,1 hereby rert fy that the well(.c)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 at'15/1 NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: CIYes or 91,116— copy of this record has been provided to the well owner.
lfthis is a repair,fill art/known well construction information and explain the nature of the
repair under#21 remarks section or on 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: conshuction details. You cony also attach additional pages if necessary.
For multiple,injection or non-water supply wells ONLY with the some construction,you ram
submit one form. SUBMITTAL INSTUCTIONS
9.'fotai well depth below land surface:
_ ZEE ,(ft,) 24a, F'gr„All '1'ell;I: Submit this form within 30 days of completion of well
For multiple.wells list all depths ifrBfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b. Eor Iniecliqu Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,cUrect push,etc.)
Division of Water Resources,Underground Injection Control Program,
F'OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13it Yield(gpnl)._�Q Method of test: Air lift 24c.For Water Supply&In'ectioa 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.
Pomr GW-I North Carolina Department of Enviroumcnt and Natural Resources-Division of Water Resotrrcos Revised August 2013

QtOte�e
o� Macon County NEW WELL CONSTRUCTION
,d Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINIQNG WATER WELL
Jamie West McHan • 082222-P • N/A.
Single-Family Well Residential ' 6586794302 0.85
• • 80 Bennett Road
.28N to L onto Bennet Rd.,to first driveway on L.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
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�.Creek-'
a•
PL
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Pear
Tree_
Vlne >63'
® pca�n
IP
100 'Septic Tan ' 14'
ao
Permitted
Well
Driveway Area
5'x 5'x 5'
1 PL
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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.yleid)Is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED 0 THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 8/31/2022 Jacob Elliott,3084 OIT64Q& t 9 ' uthorizedStateAgent