GW1--04981_Well Construction - GW1_20230807

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W• .I_f,LLL CONSTRUCTION RFCORI) •-- -'------ -�--
'(his loan can he used(or single or multiple.wells For tntvnrt(I Use ONLY: i
I '
1.Well Contractor Information:
Mitchell '9:WATER�t:..:N&§' •:r i;> .,,:,: 7:..ii* "-"::,-:r
.�_... _ Dean Cook �.,.�.�....�..._ � s .:<; _ :�:r�: .. _..,,<rr<.;»;' ._..._.___.
Web Contractor -' "' - _ _FROM TO DESCRIPTION - — -^
Name 'ft. �, r ft.
2043 A ..g..74 -_ �_ — _
NC Well Contractor Certification Number S O.U!IIKR.�"A e`•' ft:-
ft. - `"
l:.,..:_,._._.(,_•;SIN r�(fgY.inul'fiac9'swilS,wol1B'E)ftc[aIN�E�!•iti fckble ' 7'-,% .,,:.,
Dennis Holland Well Drilling, Inc. PROM TO DIAMF,TER'. TRICKNESS MATERIAL TT
Company Name .16 fNNF;R'CASSIN( URl'1t)9TNt3 e'olheeinal dosed l'oiio);;,':;?';i :Iggi. ,, _
FROM TO _ DIAMFTER TF iCKN SS MATERIAL ^•-
2.Well Construction Permit N: 3 ft. ft. „ tn. ,r�-
List all applicable well permits(i.e,Ca+rn yr lance,GJertlar,arc.) +-^-^ ��
3,Well Use(check well "�. ' ft. , t. 6 m inn. , s xa J i©
use): 'r ,3 V-
Water Supply Well: __FROM TO DIAM F:TER ,..SLOT SI7.F, _nt ICKN ESS MATE RIA I.
f_iAgliculhtrnl lJMunic.ipaVPublic rt. ft. in.,
fJ Cieothennal(Heating/Cooling Supply) L71kLs cntial Water Supply(single) __ _ _
It. ft. in.
❑Ind t¢ ..,.,.. .,-...�.,...,.,,.----------...,.
t,trial/C cnnmercial I:lResidentiat Water Supply(shared) ;18 RgUT ,,.. t, ;�. `> .::
FROM TO MATERIAL EMPIACEMFN'r METHOD-_.&AMOIIN'P
L7hriWulio11 - .__.� ft. t._._
Non-Water Supply Well: ---- ________-_.. -._
❑Monitorin ft. .,fl.
NRecovery _ ...___�_- _..___ ._ __�
Injection Well: - -__ - --------- ft. ft. -- - _ _____.._
°Aquifer Recharge t ri-;<: ar;. r;,:
T�Groundwater Rrmcdiation :1,9's:SANPlCv1;A�YFZ��!AGK,rf+a ll�``n" ,..
• ❑Aquifer Storage and Recover FROM TO -�L MATERIAL EM PLACEMENT INEntOD
y ClSalfully Barrier ft ft.
[JAquifer"Test C]Storntwatcr Drainage --•
ft. ft.CllxperimentalIechnolngY L ubsidencc Control ,
QO1)RILPINttIO(} atfneti 'di_na l to iiiiike:9sarY , i
[Geothermal(Closed Loop) f.Trracer FROM -TO ._DESCRIPTION(color bard aes_h sonVrock inn,grain size,c1.0._ .
_[7Geot henna l(HeatineCooling_Return) ClOther(explain under 121 Remarks) ft. ft.
4,Date Well(s)Completed:C3 J 2/•2-y Well MN _Ai',/11 __.__. _ .---`fL^ - ft, -'-- - _ 1--.� .. ; ._._
Sa.Well Location: - ft. rt. AUG 0 7 ZOZ3 -_1
7h.../..:t. e.//7 . ._ ,'e-V.1i J✓• rt. — ft.
Feeility/Owner Name Facility IDb(if applicable) ---•---- ---_,.-._.-.,._-.___.--_.__- r,)Rk;iV•a!^;..ter",;-.T3+s;'' LIZlit.__.__.
. ft. ft. 1-.A11 its' '
� _._��2.X___tell' ft. - ft .______
Physical Address,City,and lip �:.2I 1tFIVIAli1Er -....,, :..- y .• ^a
•_ /to e CO, 25. &4-.Li._' _ /ls' . _.1.: s as____. -.±.1 ife __..__
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:.--
:er tification;' _ _ _ -- __ __ ---
(irwcll field,one lat/leng is sufficient) '
3 S` -/, r 9'4' N r '_.26 ",9 9.+. _._._W .e:1,./..h• .c' _ed.j _ 0 7-2r 1-,..r i-2),Ss
Signature of Certified Well Contractor . Date
6.Is(are)the well(s): °mauent or DTcmporaty
By signing this form, I hereby rrrrifil that the well(s)was(were)constructed in ac•rw•dau:r.
with/.SA NCAC 02C.0100 or/.SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: L7Yes or eilli copy alibis record has been provided to the well owner.
If this is n repair,fill out known well construction information and explain the nature of the -
repair tinder Oil remarks section or on that hack q/this•loon. 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 tiny also attach additional pages if necessary.
For nudliple injection or iron-water supply wells ONLY with the saute cotstraction,you Cali
submit one farm. SUBMIT I•AL INS'I•UCTIONS
9.Total well depth below land surface: .f(, _ ft. 24a. For All Weill: Submit this form 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:E;4f ' (ft.) Division of Water Resources,Information Processing Unit,
Ifwatet level is above casing,use"-I-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole.diameter:6 (in.) 24b. For InjectionWells ONLY: In 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: f1 --- constructions to the following:
(i.e.sugar,rotaty,cable,direct push,etc.)
_ _ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS•ONf.,Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift Also submit one copy this form Iwithi
__. __.,.—_ _._—. Method of test:._.__.._...----_.. -__.
24c.For Water Supply&In actionWills:
13a.Yield(gpm)_-
py thin 30 days of completion of
13b. Disinfection type: H & •_�_.._. Amount:.�2 0 •_.-___-�,.__ well construction to the county health department of the county where
._ __-__ =- constructed.
Revised August 2013
Form OW•I North Cnrohna Depatlment of'Environment and Resources
Nahaal •-Division of Water Resources

Q,p2e,r
Q. `A •m Macon County
E a Public Health
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"� . . .NEW WELL CONSTRUCTION.
• -' , crI • CONSTRUCTION AUTHORIZATION
'.,j ,. :2 a Sid°'% �U,J9 1-f-q— (,H� PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Mitchell Stein U 6 I LOG# • 021123-P OSWW.A N/A
• INTENDED USE Single-Family Well Only(setbacks), Residential PID # 7524405571 ACREAGE 1.16
LOCATION 103 Fox Valley Lane
DIgECTIONS Take Highlands Rd to L on Walnut Creek Rd to L onto Ledford Rd to L onto Hidden Trail,to R onto Fox Valley
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. •
Maintain minimum setbacks as applicable.
Well may only be used for one Residential Connection
Diagram (Not to Scale)
-- - --Well-Area-#1— — ---
PP Property Line(155')
/ -6 1g,
15L, 3t •
�ePtea V II�33' 80� •Va%y Fox o
t� \ Lane ai o
N\ SIT
QR
Spring Sre co
.
..,.17`.!f'0
Stream
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,46
Ldi/
Pi, Se l"'
1-1'<ipe N
Nis,'
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: 5/19/2023 Chaz Allen, REHSI 3258 (A17'— r Authorized State Agent