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Home My WebLink AboutGW1-2022-09870_Well Construction - GW1_20221028 r WELL CONSTRUCTION RECORD This form can be used for single or multiple wells For Internal Use ONLY: 1.Well Contractor Information: Mitchell Dean Cook sa°. a+eERzol�tEs FROM TO DESCRIPTION Well Contractor Name °�� ft. i,�•• ft. 2043 A ft. V ft NC Well Contractor Certification Number s;t5 QUm•L+R: A51NG?for miltr cb�eifl�Y¢lls OftaalNEltt tf." cable :r FROM TO I DIAMF,TER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. • iL fr. in. z, P� Company Name ;16i11�N1 R}CASILVG ORT(1BING``eot(ioratel'clwed`loo FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: 0.5'J.5 +-5 1 tr ft, in. List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) ft it. in. 3.Well Use(check well use): Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL ` ❑Agricultural ❑MunicipaUPublic ft. ft. in. ❑Geothermal(Heating/Cooling Supply) ChCesidential Water Supply(single) fr. ft. ❑Industrial/Commercial ❑Residential Water Supply(shared) 1g•',CvRbUm Y FROM TO MATERIAL^� EMPI.ACEMENTMETHOD&AMOUNT F Supply Well:g ❑Recoverytt ell: f, ft. char e g ❑Groundwater Remediation ><19i:S•'iVD/,W`YEL?PACX tfia lii?abie r. ,quertorage and Recovery ❑Salinity Barrier FROM TO AfATERIAI, EMPLACEMENTMETHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control ft. M ❑Geothermal(Closed Loop) ❑T'racer 20:.bR 'LINf31 hfs atfachiiiddttroaslfn&cts'iftn"'na'a FROM TO D&SCRIPTION color,hardness,soiUrock rain size etc.) ' ❑Geothermal Heatin Coolin Return) ❑Other(explain under#21 Remarks) ft• fr q fr. ft. 4.Date Well(s)Completed: �& O7-�r'��J�/W�ell ID# �,� ¢4? 2-f� �I VII"A �v1A`-v' fr. fa Sa.Well Location: ft. fr. !"•�" ; �.� .�p , 2_5 3L/,C tr. tr Facility/Owner Name Facility lD#(if applicable) ft, ft. T n LL LQ f ik G-L e.,`i k-a4E- i ft. rr in;crn:« �� =r,^c: •i: i n:( Physical Address,City,and Zip 21r.'REIVIARF{;, rr ,t CtXCi a /14a i.GG, County Parcel Identification No.(PIN) 5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient) S°U g .11<'.4 N l �1�`�� w Signature ofCertified.Well Contractor Date 6,Is(are)the well(s): tilf—ermanent or ❑Temporary By signing this form,!hereby certh,that the well(s)was(were)constructed in accordance with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a 7,Is this a repair to an existing well: ❑Yes or gNo copy ofihis record has been provided to the well owner. If this is a repair,fill out known well construction information and explain the nature of the repair tender#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 g.Number wells constructed: construction details. You may also attach additional pages ifnecessary. For multiple innjection or non-water supply wells ONLY with the same construction,you can submit one form. SUBMITTAL INSTUCTIONS 9,Total well depth below land surface: `IOJr r (ft•) 24a, For Ali Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdtfferenr(example-3@200'and 2@100') construction to the following: 10.Static water level below top of casing: Soo ' (ft.) 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" (in.) 24b.For Iniection 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.auger,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 13.9.Yield(gpm). 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 8 H Amount: 12 oz. well construction to the county health department of the county where constructed. Forst GW-1 North Carolina Department of Euvironment and Natural Resources-Division of Water Resourcos Revised August 2013 i' Q��ceer Macon County IMPROVEMENT PERMIT and CONSTRUCTION AUTHORIZATION r Public Health ON-SITE WASTEWATER ffFrom L051�72-S 050822-Pot:18,Glennbrooke Ln7533482057. 3.49 Highlands Rd: L onto Walnut Creek, R onto Glennview R onto Fallbrooke, L onto Glennbrooke; property is across from #355 80 Gallons Per Day 4 Bedroom - Residential • = NewConstruction ot Specified Proposed Single Family Well/OnSite Valid fr 60 Months - ec_.--------- -rop-_e_.._Single-Family--- ---- ----------- --- ----( -.._.._..__.._..- -- - -.... Pern7if Conditions Comply with all applicable NC .1950 setbacks Divert water lines and other drainage away from drainfleld areas, including existing culvert beneath lower-drive Have licensed septic installer facilitate installation of system, level and on contour Do not cut, grade, or,fill designated septic areas Refer to MCHD for any questions or concerns Diagram (Not to Scale) YOV e p Q °vs •YOB ��v..,.--'"�.�-- \� e1110ve or Seal Culvert !� j; �.., •�� ::' Supply Pipe Onfv� � -Repair System , - --�_ (Drip) N j KOM= Laryc Diameter Pipe 10"(LUP10)-Gravity; Drip Dispersal-Pressure Dispersal; NSF-40 i ----- -- --�---- ---- .. ..... --._ .—.Dispe----- -�--- ------ ..... - T e fl[f Soil Depth: a in sloe al °o L'rAR:0.5 Sa rolite: es Type Vc Area:2400 ft= L.TAR:0.25 l Sa rolite: es I yP P O p.: -� P v YI O I F V I • . . wilily • ' 390' 4 6 on center 18 low side 12-14 inches Serial Feed 1000 gallon Not Required the issuance of this permit by ACPH in no way guarantees the issuance of other permits. The permit holder is responsible for checkinq with appropriate governing bodies in meeting their requirements. This permit is subject to revocation if the site plan, plat,site or intended use changes. This permit is subject to compliance with the provisions of the NC laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit. Construction and installation Rules NCAC.1950,..1952,.1954,.1955, .1956, .1957,.1958 and.1959 are incorporated by reference into this permit and shall be mcL. Questigns?_ 28 349_2490 Issue Date: 8/1.1/2072 Jonathan Fouts, RFHS 1979 -.-- Authorized.5tateA�enf /,,/