GW1-2023-01072_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD — I
This form can be used for single or multiple wells For luterniql Use ONLY:
L Well Contractor Information:
Mitchell an De CQQI( NES :? '7`S•'.:"'t`',":,',r;,'.>i:';ted­
Well Contr me FROM TO :DRSCRIPTfON !
actor Na
2043 A r.
-- — ft. ft.
NC Well Contractor Certification Number ^r.
IS p[J'DNR(° TN6 foi rtriiiltv.,eaWWW'o ( E i(f" --
Dennis Holland well Drilling, Inc. FROM TO D[AMFTF.R• THICKNESS MATERIAL
Company Name d ` ft ft /i in.
• `��11!11!1F:It C'ASllyfr()1Z ;UI3I1V(3`' e'oJ'eci$alicl5sed l08 °r:x+ �t _ ;,k•-:. '�
2.Well Construction Permit 0:��...,���''f �� FROM_ TO DLIMFTF;R THICKNESS MATERIAL
List all applirable well penults(i.e.County, tr�Variance,Injection,etc) �� '- _f t �ft• In.
3.Well Ilse(check well use); ft ft. in.
Water - ---- ]:7('wrtC4tFrF - t:;: ;•,..,-"---. ;;;.,
Suplily Wdl: " :>'a.!`s ; ,s t:•`:'du% :' :: : ;'::"
FROM TO 'DIAatF,TERI..n81-OTSIZE 'R1ICKNESS I1tATERIAI,
FIAgricultural 0MunicipaVPublic ft• rt. im
❑Geothermal(Heating/Cooling Supply) LOQidontial Water Supply(single) ft. ft.
❑industrial/Comm erctal G]Re st' .... .- -dennal Water Supply(shared)
❑Irrl ation - FROM T0 � MAfERIAI, r1MPLACFMF,NTME7110II&AMOIINT
IV in-Water Supply Well: ft. fr.
0monitoring IJRecovery ,ft ,
Injection Well: ft. ft.
(.]Aquifer Recharge OGroundwater Rem -r
cdiation :'19t`'NnIOkAYET;rYpG1Cr',f:'e'.gi111 0
„�.<;,:.::`;'y'.:i,a�rss:,:;'.2;;:—:::cap.>:'r:i;,;.;J•r ���f
❑Aquifer Storage and Recovery f�Sillltllty Barrier FROM TO MATERAAI. EMPLACEAIEKrMETHOD
❑Aquifer Test ft. tr.
08tormwaicr Drainage
CJExperiinental'reclulologY IJS ft. ft.
ubsidence Control '
c
❑Geothermal(Closed Loop) £'DLO )RM I1V(ath'(il atfucHitiildlhoae!?s&ects,f}h
p) [_1'1RSCer FROM TO DFSCRIPT'fON eolori6ardae aoiUrock t rrin size elc. %)
❑Geothermal(HeatitgCooling Return) GUther�xplain tmderh2l Remarks) ft• ft.
4.Date Well(s)Completed: Well 1DH IV,, � ft. ft' .'�, -1--,'I fi4;�,
Se.Well Location: ___
ft. ft. JAN 2 5 2023
rr, rt.
Facility/Owner Name Facility ID#(ifupplicable) ---- — DwQMOG
` ft. ft.
Physical Address,City,and Z,ip ^
g21tR1ZEMA]IICSri;•` "r
w .,.,.
Corurty, Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: _ -"-
(if well field,one latilong is sufficient) 22.Certification: l �.
eru Ord ll ..ontractor Date
6.Is(ere)the well(s): ftlPcrmaucnt or ❑1'cmporary Signal oC
!1y signing this fonn,I hereby cer fy that the well(T)was(were)constructed in accordance.
will,/SA NCAC 02C.0/00 or!SA NCAC-02C.02.00 Well Construction Standards and Moto
7.Is this a repair to an existing well: [-]Yes or ZINo--- copy of this record los been provided to the well owner.
!f this is a repair,fill our known well construction information and explain the nature of the
repair under921 remarks.rertionoron the back gfthisform. 23.Site diagran)or additional well details:
You may use the back of this page to provide additional well site details or well
F Number wells constructed; construction details. You may also attach additional pages if necessary.
For multiple innjection or nun-uarer.rrrpply wells ONLY whir the sane cortsrructorr,you can
submit oneform. SUIIMITTAI,INSTUCTIONS I'
I.
9,Total well depth below land surface;
Q_—_ (ft.) 24a. For All Wells: Submit this !limn within 30 days of completion of well
Formultple wells list all depths ifdiffere t(example-3 r@200'and 2@100') construction to the following:
10.Static water level below top of casing: ^ (ft.) Division of Water Resources,Information Processing Unit,f water level is.above rasing,use"•F" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:A" 24br hor In'ecti u Wells ONLY: Ili addition to sending the form t the address in
Rota 24a above, also submit a copy of this form within 30 trays of completion of well
12.Well construction method; Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resorrrces,•Uuderground Injection Control Program,..
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnl).___ �}� _T Methn(1 of test: Air lift 24c.For Water Su 1p1 &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.
I
Fomi GW-1 North Carolina Department of Environment and Natural Resotuces-Division of Water Resources Revised August 201.1
I

w `�•m Macon County NEW WELL CONSTRUCTION
of r ,d Public Health CONSTRUCTION AUTHORIZATION
✓ `PRIVATE DRINIQNG WATER WELL
VJ
Pemnit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. J rl
�{l��C�dA �1.� G.7` �C I�C�T' `�_U' t►,. (�nr� l e U Ems}f C C'
Diagram (Not to Scale)
BUJ t�G� CI
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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 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]
1
Issue Date: U-446•authorized State Agent