GW1--04707_Well Construction - GW1_20230724

•
WELL CONSTRUCTION RECORD -------
. . This form can be adfor single or multiple wells For Intern id Use ONLY.
1.Well Contractor Information:
Mitchell Dean Cook :aA'w•s1tFRaiiNEsz•` aw,i'
— FROM TO DESCRIPTION
Well Contractor Name / 'ft. / 6, ft. -
'5
2043 A ft.� _ ft. _-__-
NC Well Contractor Certification Number •47,6.. T• v' ' -' Y'r`" `:' `"'
1. )N�i3:4 $1N4`fgr;mtilti=cog':"?, t �' •;
cai.s;�;¢1�"s�;Ofi hi1NlAI�(�t�ii ''�i'cA61i;; :;:cg i<:•.,
FROM TO t( DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. , Ii. � ,ft. — r. n. ��
Company Name 95 in, 0.1*r2 I f'V'
• i-4j;s INS.IF Rr'(sA5IN( 3it•'•ruf*. aoi a bia't ci cd 3a . 0.i.-.A ,>'r=?'.FROM _
TO DIAMETER THICKNESS MATERIAL �T'
2.Well Construction Permit#: LD3 a ----//Q ft. rn ft. .. in,
List all applicable well permits(i.e.County,.S'iatc, Varlan�/njection,arc.) -- _-�- _ _
ft. ft.^ in.
3.Well Use(cheek well use):
'
Water Supply Well: - . i:"< `:::_i%is ..i i'( 3t: : :
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
IJAgricultural DMumieipal/Public ft. It. in.
[Geothermal(Heating/Cooling Supply) talltesudentiai Water Supply(single) ___ ft' ft. in. —
[Industrial/Commercials<lk 1 °tr::;.; .+ "*:: ,+. _:.: °,:;.;V-
stdenhal WaterSupply(shared) .�sI;D:�Ii::�; ,+;"�>s��� ;�:; .1::�.,::.;i,,,
Cllrri.at1011 FROM TO MATERIAh F:MPLACEMRNTMRTHOD&AMOt1NT
d . ft. 3 , fr.• Dv- if - 6a5S/6u is,P['j-
Nan-Water Supply Well: "'" ft
[Monitoring CJRecovery 3,ft. ., . rt.
Injection Well; _ ft, • ft.
[.7Ac uifer Recharge e C7Grottadwater Remediation ';1R NNVI I4V 'Ilf CGl0 ie`"itc`' "4"'`t''` i `,:.%%i-zn
[Aquifer Storage and Recovery [Snluuity Barrier 4 ,�... t pp A e ° :,':EMPLACEMENT
: E•. - OD
' FROM _ TO MATER1Al. EMPLACEAIF,'NTME'CIIOD.M�
ft. _._. ft.
•
[Aquifer Test DStormwatcrDrainage •
• • - _�
TechnologyCI}sxperimentalft. ft.
[Subsidence Control _
ClGeothermal Cl( osed Leo 01)111 I Ifv:3?I ti:U;'(ar<ac 'eaaitiii al.s&e fe;i}Y ecessei(y:
FROM TO UESCRIPITONAcolorybardoesa soiWroektype,grain eize,etc.)
, [Geothermal Heating/Cooling Return) C'lOther(explain under121 Remarks) ft. t.. -
4,Date Well(s)Completed: 07_/2-23 Well ID# LV•./• ---•-..•- -.•------_.-.-_____ _ ,ft. �ft,
5a.Well Location; ---_• ----- _ __ __..__
ft, ^ft.
ri,7"s.A''u,r•.,.te Jtl�r7
/C 1,aiI �I/56d5 . ft. .__.
(�LC _._fL T-7T'LLtzY �F `,L
)
Facility/Owner Name Facility 1DN(if applicable)
.7O es illte - a!d . AA a bp,i v le�-1 ft, ft. �U
• Physical Address,City,and Zip „�_
%2'1.'�IeEiVIA'RFK,��`f'`:`�'�'' �>;. i:.i,�L-•4f)Ti'fuS»`�;T-;�:n,�;e�s+`:'...-r
5;5.2 1 7 5 9/S
County Parcel Identification No.(PiN) _ ---- .._—�_-_ —
- ___
Sb.Latitude and Longitude l.n degrees/minutes/seconds or decimal degrees: --�-�
(if well field,one lat/leng is sufficient) 22.(':el'tification:
3.5a 437 ' ao 1, N g3' g ' /6'/ W , ..-- � ... ..z 4.____ .2J.=1. .- a..a-.c2.'
Signature.ofCertificd Well Contractor Date
6,Is(are)the well(s); lAfcrmaucnt or [Temporary
By signing this fonts,/hereby cen fy that the well(s)was(were)constructed in accordance
with/.SA NCA(--'02C.0/00 or l.SA NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Yes or Win' copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and exploits the nature of the
repair under Y21 retnssrks section or on the hack of this form, 23.Site diagram or additional well details:
You 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 infection or non-water supply wells ONLY with the lame construction,you can
submit one form. SUIIMTITAL INSTU(:T•IONS
9.Total well depth below land surface:• SaS•
_ _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hornmhiple wells list all depths ifdlffe.rcnt(example-3@,200'and 2®100') construction to the following:
10.Static water level below top of casing: 70' ,. (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•F" � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.13orehole diameter:6a _ (in.) 24b, For Injection Wells ONLY: In addition to sending the form to the address in
Rota • 24a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: ry - construction to the following:
(i.c.sager,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 3 Air lift 24e.For Water Supply&Injection Wells:
(gpm)_..__-•-- ,-•---__-- Method of test:-_-.•__._-.__^._. _
' Also submit one copy of this fonts within 30 days of completion of
136,Disinfection type: H & H _ Amount:.17 OZ. well construction to the county health department of the county where
- ----- - �__._.. "._"'� , constructed.
Form OW-1 North Carolina Department of Environment aril Natural Resources-Division of Water Resources Revised August 2013

_.:,.
Q,otect a
;�
t Macon County
o , � '''Public Health rY
NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Richard Woods LOG# 040323-P - OSWW# Ex.
INTENDED USE Single-Family Well, Residential PID # 6552975915 ACREAGE
30 acres
LOCATION 2085 West Old Murphy Rd
DIRECTIONS 64 W,to L on West Old Murphy Rd,about 2.5 miles on right
Permit Conditions
Storage Tank next to Well Area must be moved greater than 100'from Well Area before well is drilled.
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 100'from all septic system components.
.-- Diagram (Not to Scale) ._ _
\\\\ .\\
Storage Tank must be
am removed before well
is drilled.
`y
-Power Pole Power line
-- 4 15'min Soil road
r---1 ,.._____
-.......................--N:
,,,.:. ; ,_,::.;: , . . ..- r `- 5T -4______________ Proposed Well
Area
10'x10'
o°
Existing 3 vti
BDRt4 AC;
residence
-----.......'---.---....---*--------.-.".."......"..---------•--------•...........
So\\road.- _ _
........ A
_ _ ___1_ _ S/T q
Ex.Nitrification
I area . i N
L ,
This perrtiit: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
dreunistance`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 IA 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. UESTIONS [phone]
Issue Date: 5/11/2023 Josh Wilson, REHSI 3227 Authorized State Agent