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Home My WebLink AboutGW1--04980_Well Construction - GW1_20230807 1 • WELL CONSTRUCTION RECORD - • This form can be used for single or multiple wells • ForImtenrgi Use ONLY: 1:Well Contractor-Information: Mitchell Dean Cook =�q4W,��ivag4- ". _ -;< :,:i ..;; ;. : ..;.;,'.. ... .. :.. . .7,- w FROM TOT DESCRIPTION Well Contractor Namc r ft. r ft. 2043 A - 1�. � 5 rtf 96.-Pt, • NC Wellc ,•;::,,.. Contractor ti Y r`" - ctnrCcrification Nwmber S`QI)�,[IK•RfL,�S�j!{.(5r(fQ m �S 1"¢]g'tO irI �i•pji'�j Cbbl "��•� ':^:�« .... A •zl..�. >:.�_vt'1 )�'fir N.k��l ft i,:: e);,:��-::.,:•.ii�:::� HollandOM R in. THICKNESS MATERIAL DennisWell Drilling, t, . TO DIAMETER TH ' Inc.i n c. ft. r �'• Company Name _" _ "-- }.... , ;f•. t,:,<• d,.. ;. -•::,..`}'j;i::1N1YE`1t:C•A [iV(,0ili1II`1G..(ga-oi)BtiiteY2l'obed-lb ' x'. c...:`?G';•;.,,,:.;�:°r.:.. - �I 1� FROM TO DIAMETER THICKNESS MATERIAL _ 2.Well Construction Permit#:e• ` / OC 3' r —_ _ ___ _ ft, ft. r. in. r - List all applicable well penults(i.e,County,Slate, Variance,Injection,elr..) -a 6''..—_. 0,i 5Q �D ft. ft. /�� in, ,+ i s 3.Well Use(check well use); Ln.�� f�. e _/ ° __ i'i Water Supply Well: - - --'�-- FROM TO DIAMETER' 4SLOT SIZE, 'TIHCKNESS MATb AL� !Agricultural ft. ft. in. P f_7MunicipaVl'ublic °Geothermal(Heating/Cooling Supply) dcntial Water Supply(single) ft' _ rt. la.� ItdllStflal C •'t�. nercial -) IP�i. Si.. .,<e?[�'s;:,.., :u:.,..-:; i.: ;. f:lResidential WateraterSuPPly(shuretl) U: ��'!' .... `:: r'".x :.-,..,.1,•r.� =� :C�`.:...��•fs.<.:..:•.,,..,,>...........:..:..:....,.• FROM TO� MATERIAL EMPLACEMENT METHOD&AMOUNT Oki_titian 4 -ft. J Non-Water Supply Well: -.- _ , ft. _ • t�. .. OMonitoring °Recove r rt. r rt, - Tr Injection Well; ft, ' ft. 7A uifer Recharge JGroundwater Rentediation � ANnOknvFp K epp'LLoe ea<61e ;' v =ve t _l; ` l .,.. °Aquifer Storage and Recovery (°Salinity harrier FROM TO MATERIAL EMPLACEMENT METHOD _ ft, ft, °Aquifer Test • . LiStormwater Drainage — -- - LiE xperinlental Technologyft. ft. C1Subsidenec Control _,._,_- . L1Geotlter iaWhitti?,I:INO;i(_Y(?(aiiaetiibddtiton"sll hect'e;iflnecedi1aiy) i' 5- :W:;:-j; . mal(Closed Loop) I..l'I'mcer FROM TO DESCRIPTION(color hardocas,soil/rock type,jrain size,etc.)_ OGeothermal(Heating/Coolinn Return) LlOthertexplain wtder421 Remarks) ft. ft. ft. ft. _ 4.Date Well(s)Completed:i�j� TWell ID# A-/4.. __ — •• • --- r—' F 7—",T'.1 i t Se,Well Location: ___ —ft. ft. _ , SACt/J1 hi � 24' O•?/ sa2.3 -�-� ft. ' r ft. - - _ Facility/Owner Name Facility IDE(if applicable) -- ��•-•_--f�. -----— � 1�zf?:- �:,;:,�Lt: - • 1ftWrFZ^i�; - �I!/ei- � ft fa _ft ___ Physical Address,City,and Zip ;,yi.'iti.. AitKJ`74 ^" . .. .' ''_,2..�.y,,,- .....-•, ,..,.::.>......,,-... :i /�Ar 'y t5 t5;1, _......•.�.._:...... _... ... . . �T:� -..'.a i.y, .�, ..,....w.,,.... ..a'a:? : ?tea: cf Cell) ,;1 44 - i e. ' County Parcel identification No,(PIN) �' e,. ®2� 1 e . — 56,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification: Orwell field,one let/long is sufficient) • S O /�!� 35° ()7 r S `° N 4) i 7 �. ,� ev 41 w �r2 4,.d s,[02 ,� _ 7:::,2a _n ul.es0,]� Signature ofCertifl Well Contractor Datef. 6.Is(are)the well(s):-I 'tl crmaucnt or ❑Temporary By signing this form,i hereby certifit that the walks)was(were)constructed in accordance. wit,,ISA NCAC OW.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well; °Yes or @it1Vo copy afrhis record has been provided to the well owner. If this is a repair,fill out known well construction information and explain the nature of the repair under 1121 remarks section or on the back 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.Injection or non-water supply wells ONLY with the same construction,you can submit one form. SUBMIII'AI,INS'I'UCTIONS 9.Total well depth below land surface: o�el,., _ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list ali depths if different(example-3(a;200'and 2@100') construction to the following: 10.Static water level below top of casing: _50 ' _.(ft.) Division of Water Resources,Information Processing Unit, if wore;level is above casing,use"•E" 1617 Mail Service Center,Raleigh,NC 27699-1617 • 11.Borehole diameter: 6" (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 fort within 30 days of completion of well 12.Well construction method; r 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 13a.Yield pm)___ _, i" Method of test: Air lift 24c.For Water Supply&Injection Wells: Also submit one copy of this form within 30 days of completion of 13b.Disinfection type:H& H Amount 12 oz,_ _________ well construction to the county health department of the county where -- __ constructed. Revised August 2013 Form GWI North Carolina Department of Environment and Nahtral Resources--Division of Water Resources ___ tecr, .4,,,i 3 Macon County r .2 Public Health .d • 9,0 NEW WELL CONSTRUCTION CONSTRUCTION AUTHORIZATION PRIVATE DRINKING WATER WELL APPLICANT/OWNER Shawn Marcie LOG# • 031223-P OSWW-A 052420-S INTENDED USE Single-Family Well, Residential PID # 7512873720 ACREAGE 1 Acre .LOCATION River Rd DIRECTIONS Highlands Rd,to R on Peeks Creek Rd,to 2nd Bridge,go across bridge and property is on immediate R. Permit Conditions be constructed in compliance with all NCAC 2C Rules.�f�„-, +wry i° kf tain minimum setbacks as applicable, including 50'from all septic system components. permit is for the construction of the proposed well site only. Please contact MCPH for any questions. Diagram (Not to Scale) e Ls; . Over 100'to neighbors well Q- • pr+ Con Road ose6 2. Rover QroQ aCea s2 • tO0 min �e ,.�y61 T �*�po . 35'-$Z — p only)-i 12' rof ed 0 <� 1. \4 ,-' da, . i P 'Se pl. ;- Septic Area k— ——- —` �►.as z5 . tie ro , 143' i .- ; —en^ tic Area 20' s� `�I •. \j, 50' 1'- - 60' .• . ,,V 30' .EALgitelV •... v , - �- C Peeks Creek/PL :y�: J 3 i r , fie.. t,,XY , a elin or Peeks Creek Road • • his 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 -ircu ii taci e'vpon which the permit is issued. Well location,installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County Pubhi610 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 yeran eed 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?(828)349-2490 Issue Date: 3/28/2023 Josh Wilson, REHSI3227 orized State Agent