GW1-2023-02867_Well Construction - GW1_20230418

WELL CONSTRUCTION RECO.RI)
This form can be used for single or maniple wells For luteni tl Use ONLY:
1.Well Contractor Information: I
Mitchell Dean Cook • 4 K6 Rt .1VEs'k�:; :t :- '•s .. ,, ' 11
,e•� :t.:� ._'ice:.;.5..:'�(•,Y.�5:�/': f� ' ), S'�• ••(r'l':
FROM TO , ,:.�if''liiti't,l%i.,..?iy'...Y::3''.Ft� ;1:13�.`.;�
Well Contractor Name // DESCRIPTION
/4S'ft. • ft
2043 A •
445' ft. 264'ft.
•
NC Well Contractor Certification Number S'n,'TKkt,Z '(f. - t,•'=c.�`�"'`a Cl e i` F'' 3 •r;s;
-
�;(� 5 ti��1Y.� gi;imii7 (�. )r 1i.frla.>AlZ:4{(f.'�I4�Ifck�f)i:<,:;:;..:wt}?S ;.
FROM MTO DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. ft. ft. in. -�-
Company Name
z'2'.ti:illliIt}Y•t1SI1>frri()IZ llJ$ �Cy' 'o(be mul'c!W l <e`Ur'r ' ' ;
2.Well Construction Permit#: Q3 FROM TOT (t e ' edzlo3p)'t `: :ATER A;s l;r :;;
p DIAMETER THICKNESS MATERIAL_
List all applh:able well permits(i.e.County,State, Variance,Injection,mc.) �~ ..._.._._.� _ _ _ f9 Sd�-Z ) �('�f P[/l • ,
3.Well User fr. r ft. r� in• ' 8 f-HO
(check well use): /00 0.4 .'
Water Supply Well: - _FROM To ▪ :-,..;,:r.,.;: ,',,..•..r`: >, ..,, t;:,::.,,:.:a:;,, ,; ,,: '• .
DIAMETER .SLOT SIZE THICKNESS MATERIAL .
[Agricultural DMunicipal/Publir•, ft. ft. in.
OGeothennal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. io. __'
❑industrial/Comm ercial
piresidentiel iI"tlt�jt;4,U?I'�' _. :;:f.>;.<:, ,_:1,,.,y. �n.t(_ •n.,:::.::;�
Water Supply(shared) >: ........ s:`;;':�%<s�:..� ,�:. - ';;: ;t..,.��r.:e?" i' ..i..
FROM TOy i:7::;•>:.;:d � ...... f:rvs:.....:..�......f
lJlrriititiotl ,•MATERIAL,y ^-;•FMPI,ACEMF.NTMFTHOI),&AMOr1NT,.
-Nan-Water Supply Well: , d_' ft.
. ft. Po,--t-1 '__,7-hg,, r iusys Pe4
OMonitoring 3' ft. rt.
Injection Well: •L"JRecover
y _.rp?2�..-. zv e 1��'"5 'yam p i
ft. ft.
°Aquifer Recharge
C)Groundwater Remediation <9 d OVjk EI AGC(lf a ptaq�je� .^ " -0VS v 'W1•:,-::
4f:i:w.':'
FROM TO MATERIAL EMPLACEMENT OAquifer Storage and Recovery °Saliity 13arrier ..
OAquifer Test ft. ft.
fa Stonnwater Drainage _
ClExperimental'Ieelutolo ft. ft.
Technology °Subsidence Control
OGeothermal(Closed Lon i20 DR11,qNr 1;.0(s(at(nch"i�diitl oriellitiects•!Ifii gces5er:;'(;;;.;: ;;;r;?:°f;?i `; i, ;:..-
p) Il'I rRCer FROM TO DES CRIPI70N eotor,bardaaa sail/rock type,grain size,err.)
, °Geothermal(Healing/Cooling'Return) DOther_Srxi)lainunder#2I Remarks) ft. ft.
4.Date Well(s) ft. ft. ''"~ -
Completed:o6 03 a3 Well ID# N �� ._ _ -._� ,s-' ,': '"', ---
SFl,Well Location: .-....._._ _ ft. ft, "' -' 'W
3Q 4, ¢ giro,le r;6 h Ma., -.s ft. ft. - -
Facility/OwnerMune. FacilityID// if applicable) -------— = %'iw^ r ^.� L'r�:
Q Pf 4—df1y0 1 f• �l ft. ft.I!'e a /v .T..- _.. v.e Ll1 J•.:.= _
Physical Address,City,and Zip
+'21:KE s fi
:4 11'IAItIC��s' - �. .�{:,� ....'A% „r'�+--n>' . ... .:'.o•�ifia -r
__AAA00"7 6s7.2/ 599 /(© ' Pvc _ <i
'minty Parcel Identification No.(PiN) t / l
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: �'__ "
(if well field,one lat/long is sufficient) 22,Certification;
•
3S ° o7 ' a.8" N 83° ,2. 6 "3 `, " W _
• sig...ofCcrtificit Well Contractor Date
6,Is(are)the well(s):fillrermanent or °Tempor'aty -
Dy signing this form,/hereby cm*that the well(s)was(were)constructed in accordance.
with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7,Is this a repair to an existing well: °Yes or VINO- copy of this record has been provided to the well owner.
If this Is a repair,Jul out known well construction information and explain the nature of the
repair under 112/remarks section or on the back of this form. 23.Site diagram or additional welf details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: constriction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane construction,you can
submit one form. SUI3MIT'I'ALINS'f U CTIONS
9.Total well depth below land surface: 3.25'_ _ _(ft,) 24a. For 6.11 Wells: Submit this form within 30 days of completion of well
For'multiple wells list all depths ifdii different(example-3@200'and 2(I00')M construction to the following:
10.Stalk water level below top of casing: ..50 ' - (ft.) Division of Water Resources,Information Processing Unit,
/jwater level is above casing,use"')" '- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter; 6" (in.) 24b.For lnjectiQt n Wells ONLY: Its addition to sending the form 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; Rotary constriction 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
13a,Yield o2 ' Air lift 24c.For Water Simply&Injection Wells:
(P,pm)_. __ _-_. ___ Method of test:._•__._
-'— Also submit one copy of this form within,30 days of completion of
13b.Disinfection type: H & Amount: 2 OL. well construction to the county health department of the county where
-____. "-"�""v constructed.
Form OW-I North Carolina Department of Environment avid Natural Resources-Division of Water Rcsotueos Revised August 2013

• U.
v`ote�r •
' ! ' •m Macon County NEW WELL CONSTRUCTION
oV �a Public Health CONSTRUCTION AUTHORIZATION
�tl • a, PRIVATE DRINKING WATER WELL
APPLICANT/OWNER John and Jamie Gibson •
LOG# 100322-P OSWW•A 102822-S
•
INTENDED USE 'Shared Well, Residential j PID # 6572198599 ACREAGE 2.91
LOCATION Off Camp Ultima Blvd.
DIRECTIONS 441S to R on Belle Dowdle Road to R on North Skeenah Road to R on Camp Ultima Blvd,take first drive on left.
Permit Conditions, ,
Well shall be constructed in,compliance with all NCAC 2C Rules. -
Maintain minimum setbacks as applicable. ' ,
Diagram (Not to Scale) -
� PL
i
IP
'• •i ave Approved New
\ 17' Well Area 48 82'
`• 0 Existing Well
Existingg;n5 '
del " S —5sti05`. '` N150' I If the easement area Is
i `• 14 i surveyed with 20 feet
% t additional space from
18'oc % % 1 the current property line,then
I
Exlsdn 48' tt A I 100' the new additional lines
I t13q t� t may be longer
i io$t� 1 3
r pn t t
t 1
`•.. 1� °t1 i N I 8 PL
Id I N , 1
1 to ;® i3 4' 38 ramp
1 u! Ultima Blvd
r
110111
,,,`� t t /` ..
,..i.4,
'`. • r i . 1So .—85' .
r
\ �_ 9CC / Ae.° "FP •
°da �6 .;. RP9 Pd 4
\ . rij,e, ,i
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•�`� Pond 'IV%%• /40'
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%r — �n� a�r�i4 PL ► -- _
- - odd p%$4,.-A 980, '
, pib was 980. 1
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This permit is valid for a period of five years except that It may be reoked 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] •
i
Issue Date: 1/20/2023 Charles Womack, REHS 1300 uthorized State Agent