GW1--04709_Well Construction - GW1_20230724

VVELL CONSTRUCTION RECORD •
This form can he used for single or multiple walls_ For hnerngl Use ONLY:
1,Well Contractor Information: 7�
Mitchell Dean Cook :�1a';jYAtl(E :715 = ! ');; �
- FROM�' _TO DESCRIPTION
Well Connector Name ft. _ ft.
•
2043 A _ ft. _-It
NC Well Contractor Certification Number 1_ � .'
:aggil. (�4STNCr(fat mulWeirs�d�S141,1a)0i111aINkW}i iTi 7fcable'.f r :,:;.:-'
FROM 1 TO
DIAMETER THICKNESS MATERIAL --------
Dennis Holland Well Drilling, Inc. rt. rt. ,o,
Company N —_•" --'
- -- gl6 iNSik).C%NSi OOIVIZORIY eolkViiii clW(d51o�' ...`.?F
•'�' :PLR-�____ FROM TO DIAMETER T' .•`:MATERIAL _
2.Well Construction Permit ff: r ft. �j 0 ft. 6'io'. in.
List all applicable well permits(i.e.County,Sinte. (rarianee,Injection,etc.) - -- - - --_ % - _ i '-2 w�
I. fr
S/1 ft. <i in.
3,Well Use(check well use): _- ✓ p -51ee ��
Water Supply Well: _....._ -�s.:_:�:`,� � 5',.•. r :rf ,;.•`.'.
I y FROM TO ti DIAM F,TbR SLOT.!An o-i1::ri ICKN ESS MA FERIA'.
ClAgricufntral 0MunicipaVPublic• ft. ft. in. •
_
°Geothermal(Heating/Cooling Supply) [1 cftsidcrrtial Water Supply(single) 1 It, -- ft. in,'
°lndustrial/Commercial .,... ,. ..,...r,v;i9.,.:.,,.•-,,.;....<<;x::.:a:;;;
'.'1g`r ri--;,-i["si ,,.,f. • 11
LJReSidetltlal'Watel'Supply .. -......., '.��'
(shored) ..._ ..;:' `,?�^;p, 3 �t. "�[
�FROM� .:�YTOT;. .�.,:.:::�•s.:'.�;•t .,.. `:Ydi+<E, „:<:'!c:•r:c• �'; t.+:. ?i '
°Lai ation _. _• MATERIAL:: �r:F,MPI,ACFMF,NTMFTHO D&AmouraMr/-••
Non-Water apply Well: '. T -_ `j ft. 2 , ft. k�! . , .3,. ©r`1T•-
__ � �' amiss-_
Monitoring [.JRecovery -f ft, ' n. ` �i
Injection Well: ---� _� Q _ ! � �—.
ft. ft.
(Aquifer Recharge °Groundlwater Rentcdiation '11,9if53('Nii/; AVF?;i+P''' :r" ,t!:>_ a:.:::;�t:::,::,: •" ",°.;_::::::
• k. � �ArK.()f„ep tLlld�ble�L:_.�_..0
RecoveryC3Aquifer Storage and FROM ,-TO._.__ _MATERIAL EMPLACEMENT METHOD
Mali/lily Barrier ft. tt•
D Aquifer'fest CiStornrwater Drainage ---- __ __
•
C1F..xperimental'leclmology °Subsidence Control ft. ft. w
--�
20 ftitlNr1(l _{aiiietildltnla1taheetsifnccessarY r7Geothennal(Closed Loop) [ Tracer
FROM TO DESCRIPTI(lN(ealori_herdocs oNrock tie,grain eiu,etc.),
, °Geothermal(Heating/Cooling Return) oOther(explain under/121 Remarks) ft. It.
�l rt. rt. _
4,Date Well(s)Completed:C1.6-3e)J•. ''Well IDH ___ ._:.- •---- -----••- _--_- _B i.q/
Sa,Well Location: ---- ------_--- - _ ------._
chaxl obi sr h w it N _ ______--
ft. n. _ JUL ?.-4---Z°Z1- .�.._
Facility/Owner Name Facility IDtf(if aplicable) -----••-------_..-._.............-_.-�.-----.v..._—.___.• ..-_
L ft. ft. StI�FYf�tyF1'trffF".. '���--•--•--
�t k['t/e. Re)G/i �� ft. ft: _-_--M"' '�' ------•-----•--__--_
Physical Address,
y dr ss,City,and Zi r .�.,��,__
142- g.9 (, o �_. 2e 2 .::j:.. .. ..-
Comtty Parcel Identification No.(PiN) __ a /p
Sb.Latitude anti Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lot/long is sufficient) i
35° vim. ' ,,r N 93 C._ _� � - __W0. _ _ • '
Signature of Certified Well Contractor . Date
6.Is(are)the well(s): OP rmauent or [.]Temporary
By signing this form, l hereby cart fy that the well(,) was(were)constructed in accordance.
• with/SA NCAC 02C.0/00 or LSA NCAC 02C.0200 Well Construction Standards and that a
7,Is this a repair to an existing well: CDYes or . o copy of this record has been provided to the well owner.
If this is it repair,fill out known welt construction information and explain the nature of the
repair under 1/2/remarks section or on the hack of this foray. 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: 1 ____ construction details. You may also attach additional pages if necessary.
For multiple injection or nor-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: - / Q, ______T(ft.) 24a. For All Wells: Submit this thrin within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:_ �� _(ft.)
(ft.) Division of Water Resou'r ces,Information Processing Unit,
1/wetter level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter:6 _�(in.) 24b, For Injection Wells ONLY: lit addition to sending the form to the address in
Rota 24a above, also submit a copy of this form whhin 30 days of completion of well
12.Well construction method: ry construction 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
i
13a,Yield(glint)y, ". Air lift �Y Wells:
24c.For Water Su I &Injection
_ ,.-._._._-• Method of test:-_.__..._.._,_--_. ___._.
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: H &H�.,____. Amount:,�2 04.1..____,___ ___ well construction to the county health department of the county where
----
Revised._ --_ constructed.
Form GW•1 North Carolina Department of linvirooumrt and Natural Resources••Division of Water Resources Revised August 2013

Q0°tect
v " .m Macon County NEW WELL CONSTRUCTION
e r Public Health CONSTRUCTION AUTHORIZATION
°mod , a� PRIVATE DRINKING WATER WELL
.APPLICANT/OWNER• Charlotte Schwirtz ' LOG# 102222-P-R OSWW# 103622-S
.INTENDED USE- Single-Family Well, Residential PID # 7429879609 ACREAGE 0.63
LOCATION 261 Garden Trail off Kettle Rock Road
DIRECTIONS Dillard Road from Highlands to R on Kettle Rock Rd.,take center road to Garden Trl.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. "
This is a revision to change the location slightly from the original permit issued.
Diagram (Not to Scale)
iP -
' -`--_55'
rNc
1 1
1 1,65' 13' -
Q 1
A p
l w ;� 144' 66' 1r . i 1p ,Rs , 1' a„
1 .'-, g 1 5'min 1 y
1: _ G 1 A Garden Trai
I 1
t Existing
� Driveway Structure
10 t— 6 ____
Sig/had "---- 92'
__ IP
- _ IP
i''/X. '_'----` -50
` - P:4New Well Location
A
N
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: 6/23/2023 Charles Womack, REHS 1300 DLL lit) Authorized State Agent