GW1-2023-01071_Well Construction - GW1_20230125

1
WELL LL CONSTRUCTION RECORD ror Interval Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Mitchell Dean Cook .FROM TO DESCRSCR
FROM D'770N _
Well Contractor Name s'ft• ft
2043 A ft _�fit f
tt_DNRt( ' Y.7V1.G'yNC Well Contractor CcrtificationNumber SOram--
foXtmriltreasetl?,wells 'UI;.GI:El�f(fi" ` tcfilc"s::�'
FROM TO DIAMETER THICHNESS MATERIAL
Dennis Holland Well Drilling, Inc. ^ > rt. /ft. T In.
Company Name !16,5NN1 R}CASIN[r U1ZTI7$ING "e'of ieriria fcli>st 1il[i3'f'=r f A.
- - FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#:_. ft. �ft. in.
List all applicable well permits(i.a.County,State, Variance,Injection,etc) ft --- ft - in
3.Well Use(cbeck well use): CRFik)N'
Water Supply Well: FROM TO I DIAMETER SLOT.SIZE v}THICKNESS I MATERIAL
ft. ft.
ClAgricultural r_7MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) Caeidential Water Supply(single) tr; fit. i°; i
Oindustrial/Commercial ClResidential Water Supply(shured) 'e.•. RZj.U.ma,:,_. "~ '.•'.° r,::ii.. c1-'<'t=ri:.
FROM TO MATERIAL EMPLACF,MENTMEnIOD&AMOUNT
DIrri ation CJ fc. 7 ft. emu-
Nou-WaterSupply Well: `Ia •��� rr. r �•.
0monitch URecovery
Injection Well: fir. ft.
[..]Aquifer Recharge 00roundwater Reniediation 14. fiANn/bkAYFIaPACKI tf a Ilan.' j :: :,, , ;
FROM TO MATERIAL LMPLACEMENTMErHOD
' OAquifer Storage and Recovery 08Rlbtity Barrier ft. fir.
OAquifer Test r]Stormwater Drainage
It.
DExperimental Tectuiology [iSubsidence Control Y.
20 I)RTI IjlNfrsI h(r'atfachfhdOgg l?sh—ig gewy1 r "
OCreothermal(Closed Loop) O'I'mcer FROM TO DESCRIPTION color.bardne soil/rock lyin,grain s ze etc.
OGeothermal Hearin Coolin Return) C7Other ex plain under#21 Remarks) fit. fit.
ft. ft.
4.Date Well(s)Completed: + y�Well IDN �` `�
1 L/r ✓ t r — rt.T ft,
� r Z r
t i M t a' Ad L r
Sa.Well Location: l I _ ft. ft. s
jAlq
'/ ft ft.
Facility/Owner Name Facility IDit(iflicable)
- app
- ------ -----
ft ft v
Physical Address,City,and Zip IAA j
County Parcel Identification No.(PIN)
5b,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification;
(if well field,one ladlong is sufficient)
3S" 4 �r N ti�.'��� •rj•.J _LW [-:- LGG f1re- -1'
_ T Signatwe.ufConified Well Contractor', Uete
6,Is(are)the well(s): [Flys:rmanent of [..]Temporary By signing this fonn,I hereby rectify that the well(s)was(were)constructed in accordance
- with 15A NCAC 02C.0100 or15A NCAC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or hlq-o- copy of this record has been provided to the well owner.
If dds is a repair,fill out known well construction information and explain the nature.of the
23.Site diagram of additional well details:
repair under#21 remarks suction or on the back of thisform.
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with fire same construction,you can SUBMITTAL,INSTUCTIONS
submit one form. -----
9,Total well depth below land surface: 24a. Itor AIL Wells: Submit this fimn within 30 days of completion of well
For multiple wells list all depths if thffermu(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: __ _,(ft.) Division of Water Reis ter,Raleigh,ources,information Processing Unit,
ifs+'nret•level is above rasing,use."t'• 1617 Mail Service Cen INC 2799-1617
II 6
- --_6" -24b,For In'cc i 1 Wells ONLY:'Iif addition to sending the form to the address iri
11.Borehole diameter: (in•)
_ 24a abrrve, also submit a copy of this form within 30 clays of completion of well
12.Well constructiau method: Rotary construction to the following:
(i.e.nuga;rotary,cattle,direct push,etc.) Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WEI,iS ONLY: T 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift
24c.For Wntcr Su 1 &In'ection Wells:
13a.Yield(gpm)_.__. Method of test:__-___._____._.._ __ Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: H H T. Amount:. 2 oz. _ well construction to the county health department of the county where
constructed. l
Form QW-1 Noith Carolina I)cpartmcin of Environment and Natural Resources••Division of Wm Ir Kcsoruccs Revised August 2013
i

D
ote � Macon County NEW WELL CONSTRUCTION' Public Health CONSTRUCTION AUTHORIZATION
v , a PRIVATE DRINKING WATER WELL
Victor M &Lisa M Smith — ^ — • 091822-P _ • 121808
' ' Single-Family Well, Residential 7514172741 1.29 __
— — ------- --- ._.._...._........ —
• • 64 Ed Crisp Lane
' ' Hi hlands Rd., L onto Sugarfork Rd., L onto Arnold Branch Rd., I_onto Ed Crisp Ln.,to second driveway on L.
am►it Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. a
Must maintain 100'setback from onsite waste water due to Saprolite.
No Saprolite in neighboring OSWW; maintain 50'setback
Diagram (Not to Scale)
50'min to Neighboring OSWW
3�B
4�
Power Pole
do
PL
�► 85'
' 10' -'h
Permitted Well 551
Area 15'x 10'
100'min
�a
��c
a
N
is 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
umstance 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
lic 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
ranteed at any site by MCPH.
NELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
RVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS' iat—Authorized State Agent
?' [phone]
Issue Date: 10/31/2022 Jacob Elliott, 3081 _4_