GW1--04287_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells I For internal Use ONLY: I •
1.Well Contractor Information: ; I I
Mitchell Dean Cook - ;a.w R A= r fi.; i. ;py :; ::::{:::;.,.::: ,. ::-.:.,-
_PROM TO '•' ::a..,. '.;%t'`si* . .:>,:.,. .a°`i'?:v ;;f. r
Well Contractor Name .._ DESCRIPTION
2Q�3 A �65e a6•e ft. -- - --
ft. ft. I
NC Well Contractor Certification Number 3`.5::(1"U•`Iif4R� " f `�' -"'"'' :,•IP -•-_,--
...�::4P$21Yf3 tfo[Imulti:ck1J`Ct11,IYc 'C.Q1;2e,rl:.la ,fir� f"`ble"t=t�'':<,c ,:,,r,
FROM TO � ii':.^,�,,;:"'�,
Dennis Holland Well Drilling, Inc. '` .f` ETER TA[CiQVESS MATERIAL ^�
Company Name V , f6 in, DR- , VC.
•
p10.i.1`` R}:f3ASING t3)f711_ . (P(ge'ofti rifialtcl •' Iti. i•v W..
2.Well Construction Permit#: U�/ PR FROM TOP'}•`•a.eM�:TERIA y;; _ _:
DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State, variance,Injection,etc..) -__ __�._ ft. T ft. - m.• __
3.Well Use(check well use): ft. ft. in.
WfltP.t'SII Supply ��. '�Ir2l''S.CI.RF k7:77, fi:-. n .ih-':.• ;' YR:�=;.•.r:iFEZ ....
Pi y Well: • _PROM Tow _. ~' i':•;i ::-;: :..,,..::: <:i..
DIAMETER i-�SLOT SIZE 'THICKNESS -MATERIAL
f_lAgricultural DMuun�nicipaVPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) I'Plesidcntial Water Supply(single) ft' - R ft. in.
❑Industrial/Commercial CJRe ?lA;lGRY}: :ir:=
sidential Water Supply(shored) t1;T:�. ... �: ,` ;'>:;;'� ,:: :r,;,,as��xtaf' •:rt;,t;,.::n.,.;:..:�,.::,:,:
FROM_ To!r_ " ^'- =
[HuiI;allOtl •�MATERfAI,�=� �.EMPI,ACF,MF,N1'METHOR&AMOUNT
Non-Water Supply Well: e) 1ft• o ft. J .2`2
IMonitoring C.IRecovery �'' ft. 5.10
+ ft' -bhp = n�� J
Injection Well: ___ ft. • fr_B y
f.7Aquifer Recharge ;i
C1Grouadwater Remediation Yl S'' �.
�9i i{�T1n�0IiA�1.!'�)•';iJ'?161ft`(ffjdli(f11Cil.tiM:".•';.. ... :,x,. :st, :r^i}p:M`4.;?:�;
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL. EMPLACEM1SFIVTMaTstOD
DAquifer Test ft. ft.
Ca Stornlwater Drainage -
DOxperimental'fectulolo ft. rt.
gy °Subsidence Control
C1Geothermal(Closed 'ZQ?ll17f 11:fN �LQ atEac} a " r.-T} k ::,.r;f:1
o ed Loop) C.Tfraoer _._c :(" 1 CRIP listito'tolorn rdne.3 s;il/roc:,:=.-h: rain ';
FROM TO DESCRIPTION color,hardness,soil/rock iype rain size,ate.)
DGeothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) ft. ft,
ft. ft. T_.
4,Date Well(s)Completed:4C-/V„2S' Well IDH,_-___eZ2' - _____.. . _.-- <"�"a g" a y,q'" d
Sn,Well Location: .____. ._.T_,.
_ ft. ft. ? ?
1��; (123 __.__
M p/'J IyA/ e f 22(,I/'�®! 49.2 5.2.2-.S' rt. ft. _.__
Facility/Owner Name Facility IDtI(if applicable) !t
Physical Address, ity,and Zip ft ft.
•
A4 ata_el 7S%��7Gal6 �.1
County Pnrcol Identification No.(PiN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: _________ --_
(if well field,one lat/long is sufficient) •
p � 22,Certification:
V '.' N (53.30
4. a�f '© 2i' ti'►' /.r+c %'_ - --- -� #-- ©.2:s'
Signature ofCenified Well Contractor _ ^ , �Date
6.Is(are)the well(s): faKmanent or °Temporary
By signing this form,1 hereby certi6i that the well(s)was(were)constructed in accordance.
• with ISA NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or f.1X copy of this record has been provided to the well owner.
If this is a repair,fill out known wall construction information an explain the nature of the
repair under121 remarks coat/wi or on the hack of this form. 23.Site diagram or additional well details:
Yon may use the back of this page to provide additional well site details or well
8,Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUI3MITTALINSTUCTIONS
9.Total well depth below land surface: .0,.. s _(ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®/00') construction to the following:
10.Static water level below top of casing: ' (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.)or InjectLon Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method; _ constntction to the following:
(i.e.auger.rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEI,I S ONLY: I636 Mail Service Center,Raleigh,NC 27699-I636
13a,Yield m ____-,_ Air lift 24c.For Water Su u1i ,&Injection Wells:
(gP ) Ll __--__. Method of test:__•__.•__ -
H �{ !"-�- '- Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type: Amount:_�2 oz. well construction to the county health department of the county where
-�.-- —7--., constructed.
Revised August 2013
Form GW-I North Carolina Department of Environment auil Natural Resources-Division of Water Resources

Q,oteer
2 n�rn Macon County NEW WELL CONSTRUCTION
o °
S Public Health CONSTRUCTION AUTHORIZATION
. ' PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Marilyn Crawford LOG# 081422-PR OSWW-t 082522-S
INTENDED USE Single-Family Well,Residential PID # 7514476016 ACREAGE
27.24
LOCATION Ellijay Rd
DIRECTIONS Hwy 64 to L on Ellijay Rd to intersection with Battle Branch Rd.Site on the Left.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 100'from septic components and 25'from building perimeters.
Diagram (Not to Scale)
Jos n
IP
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- N
1.19
0.
o zo y
441111, 00'
25'min N e.
Proposed Well Location N
• . • 081422-PR ^
10ft2 Area 4'
,' `. /mod
Se yo GS fol`s`� '• y4a
06,0
s'
t.
ss
sir i � ss
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s
PA Flow Divider
Tee
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. 2—..--- -
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: 6/9/2023 Josh Wilson REHS 3227 4•9/P— Authorized State Agent
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