GW1-2023-02610_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORI) ------
'Ihis fonu can be used rot single or multiple wells For Internll Use ONLY:
I.Well Contractor Information:
Mitchell Dean C4Q{C
.w
•.S? ES:a.c' :..:.:",.,::,+i :;4;.t3it;::.,:iic''.t•
Well CoulreclorNamc FROM TO (DFSCRIPTtON .�
2043 A 42 7-tL"/.28' rL '
NC We ontractor C -'
UC crtificarionNtnabcr 1,5(1U1'NRi(1p�71Yf4):f'`Cmtittick3 nC ( it 7 ;`• r;:•w''�fl.FY: 1ft.L)I` t^..`)c461i
Dennis Holland Well Drilling, Inc. FROM fL T0� ft. DIAMETER in, TFIffKNESS MATERIAL
Cumpany Narnc
} AI.Xf51{"xtJgIIVG' =-:v
`FROM TO DIAMETER THICKNESS „ MATERIAL 2..Well Construction Permit#: 40 7 )Z _ ft. ft, ---�— ----
List all applicable well permlrs(i.e.Cotrmy,State, Variance,Injection,etc.) _ - _
ft. lL
^—
3.Well Ilse(check well use): fr.
REV
Water Supply Wcll: FROM TO DIAMETER SLOTSIT.F, V*THICKNESS MATERIAL
ClAgricultural GlMunicipaUPublic ft. fr. in.
Doeothermal(Heating/Cooling Supply) esidcntial Water Supply(single) ft. Trt. " ' in.
❑Industrial/Commercial i1'8 r:::<
C]Residential Water Supply(shared) ,.:z�'.>:f:=��:;.� ;:?;`r<.>,,,:€_?^; ;;>>,Y,_.:..r<:�;:;�::•,::•�
FROM❑[rri anon TO_~ _ MATERIAL. F,MPI,ACF,MF,-NTMFTNO &AMOUNT
•----- -•- •-..-. .—
Nou-WaterSupply Well:
OMonitoring C311ecovery tr• fr.
!on Well: ft. ft.
0Aquif ? Ge rOrounlwater Reniediation ,a •A A
❑Aquifer Storage and Recovery I]Sal pity Barrier FROM TO -
MATTERIAL - T.. EMPLACEAWNTME'I7fOD
ft. ft.
❑Aquif.r TesI ft.
Drainage -
OFxperimentul Technole ft. _ft.
gY []Subsidence Control
00cothermal(Closed Loop) 1=1'I'rRCef y2Q;3llRft(6.IN( attach(5ddiffonel:sfi'ecYB"iftn"ce9§ei ,`a; <..s=. : ,.::;;'=_
FROM UE•SCRWTR)N eolorLhardoe soll/rock I gain wa etc.
OGeothermal Heatin Coolin Return f.'10ther explain imderN21 Remarks) fr. �L
4.Date Well(s)Completed: 49z -!Well ID# ,_--
So.Well Location:
Fscility�/O vt nor Narnc Facility IDH(ifapplicable) — ---
wft. - ~ft.
Physical Address,City,
snd'hiP
i,2�l:iltENlAlIK�h•..._,..�L'.:r.'..:_...?!��`t,...:.....'`_>,`1.....� -•�,�•,rf.,.,•��;...,
Cotmty Parcel Identification No.(PfN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
3 56 o-7 N a / w -�a-
Signature ofCertificd Well Contractor Date
6.Is(are)the well(s): Wermauent or n7'empor•aly
By signing this form,/hereby rectify that the we11(s)was(wrrcJ constructed In ncrurdnncr.
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.OP.00 Well Construction Standards and(hot a
7.Is this a repair to an existing well: Dyes or 05,0 copy oj'dtis record has been provided to the hell owner,.
lfthis Is a repair,fill out!mown well construction information and explain the nature of the.
repair under#21 remarks section at-on the backgfthisform. 23,Site diagran)or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You cony also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wish the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 2 (ft,) 24a, F r Ali Wells: Submit this fbnn within 10 days of completion of well
Formulriple.,Pelts list all depths ifdlfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: __ , ____- Division of Water Resources,Information Processiag Unit,
Ifwater•level Is above casing,use."r" 1617 Mail Service Center,Raleigh,NC 27699•-1617
11.13orehole diameter: 6"
,_ (111.) 24b, Fly lniec jq. Wells ONLY: In addition to sending the form to the address in
.Will construction method:
Rotary 24a above, also submit a copy of this fonn within 30 days of completion of well
(i.e.sugar,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(Pam)_ Q_. _ Method of test: Air lift 24c.For Water Su fl c&Injection Wells:
Also submit one copy of this form within 30 days ofcompletionof
13b:Disinfection type: H & H Amount:_12 oz. well construction to the county health department of the county where
constructed.
i
Foray GW-I North Carolina Departtncra of linviroumcnt au°I Nantral Resources-Division of Water Resolu:ws Revised August 2011
I

.Q'Cot 4 ee
Macon County NEW WELL CONSTRUCTION
0o r.,m Public Health CONSTRUCTION AUTHORIZATION
4,d . a' PRIVATE DRINMNG WATER WELL
Barry Copeland • 072122-P •
023622-5
' Single-Family Well Residential 6583532816 92
• ' • Lowery Lane
First left on Lowery Lane From 441 South (Georgia Rd .Behind Faststop gas station.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 100ft from all septic system components.
Diagram (Not to Scale)
Property Line
Tiny home RV
IT
60' Ex. ,z
S/T
}
9' Existing septic drain field
�A 114' o
r--------------------------------� 'LS
co
Septic ; r
' Repair Area
'---------------------------------'
Gravel Drive
Well 2I,
IP
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: 9/27/2022 Jonathan Fouts, REHS 1979 A r Authorized State Agent