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Home My WebLink AboutGW1--04982_Well Construction - GW1_20230807 WELL CONSTRUCTION RECORD This form can be used for single or multiple wells For lmternyi Use ONLY: , I i. 1,Well Contractor Information: , l • Mitchell Dean ':A4•W`i11?ER?IOt.4ES ,n<z; -,,�",- :rr: ;r,;,; FROM TO D ij.. :. ;;w:i'y ,. ' F,SCRIPTION Well Contractor Name sft. >i��ft 2043 A i r 5 7 G��1 NC Well Contractor Certification Number ' • Vi�.'SiWW!P ai `' `L tad '�:77 catio ; TGA�SIIYs(fozimulti rksctlleljs).2)ft�?) IRIZI�ifPfcAb]'e`);is .i'.•'tf'j;rr:: ' FROM TO DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. ft. ft,, in, Company Name _ �_ 1:6 INN>kt1:C3AS a ? 'tiied,:totl 'r,M <<.,,.:n ..; INSz()12`Tll$yi`ICYIReo(herms.cl p)=." :`ra`.,.:::; :. ,.__,...,., FROM TO DIAMETER THICKNESS MATERIAL'*'~: 2.Well Construction Permit#:•; .24-2 ''_fig s ft, , ft. 6, . in, 1 '�oL List all applicable well permits(i.e.County,,State, Variance,Injection,eta) — _ a__ -_ v`" 1• 3.Well Use(check well use): '• er, /! 'fit. ,-,r 6 in. ) olgWater Supply Well: - _ . :.:. ,; t:: �` .z ';:.. :P,... r,:..,,:., •:......; •. ,..,, >: _FROM TO _... DIAMETER SLOTSIZE ThICKNESS MATERIAL, DAgricultural °MunicipaVPublic , ft. ft, in. , °Geothermal(Heating/Cooling Supply) sfdential Water Supply(single) ft. ft. in. ❑industrial/Comm t::•:r. <-ra•:==;,r,;:; .,. ercial "8:��"(: - f:IResidential WaterU .. �..,.. ,.. �;.: ,; :a., Supply(shared) FROM ..,5•,.:'.:,_:;.>.��;�'s:� ❑IrfLatlOn TO__•_ ,� '.MATERIAI,:; iEMPLACEMENT•METHOD&AMOUNT Non-Water Supply Weil: - — d ft. < fit.' ,i4.,%,, k,; _. " L,ee C1Monitoring UReeove fir, fir. 0/ Injection Well: ft. ft. • °Aquifer Recharge °Groundw • ,�.. ,":•t,� ;,�: ater Remediation a1,9SilIVl/b r;<<�` :Ej�:;;.,;; :�� ' ' FROM )iT`•FIiYuA'�YC?(t ap�li2a.blaY `�- ' �; ...._. �. ,•:L�.;;<.-;:i�r:;::,,:: ;Fs: DAquifer Storage and Recovery I7Salinity Barrier _ MATERIAL, EMPLACEMENT METHOD ft. fit. °Aquifer Test °Stormwater Drainage — -- Uiixperimental'Iechnolo ft. _ ft. Technology .°Subsidence Control °Geothennal Closed ' = tTi t . -. ecc airy} ,''r :: �,20`�.I)RIL�tNfy`F h'4�'atfacliififitU4ltiilfAfi'eof`ai,`ff[n 9'i. ;�'i' 'r;:y<'�,; ;';��'':;:,,'::: ( Loop) °1 racer, FROM TO DESCRIPTION colorhardoess solUreek type_grain size,etc) , °Geothermal Heatin•Coolinl Return) °Other ex lain tmder#21 Remarks) ft. ft. ----- fad R 9 1°i•.s"'� . 4.Date Well(s)Completed:d•1-;2-,23 Well ID# A --- fr. ft. A U G o f1 Sa.Well Location: - - .�l' . ft, ft, c'- t' .e., 1 _ Q � .� ft. ft. _ iftivi..,•.;5,:iv9r Psi•-..:-At.:1.: t,;rr„• , Facility/Owner nine ___ _w_._. _ _ __�__�_ rAsta,:cw:; Facilit• y ID//(if applicable) fit fit. A� _ —� --- ft.fit fit _ Physical Address,City,and Zip • ..._...._.,, ;,.,2�krtREiV1il�kt'Fts;�_ _... ..... ::y<>,. ,;y f,�-:::;:'�:%'r,.F„%�; :i:; �:;?;' �•• _......_ County ei/-w -4' �.1 45 ' ,��j a-t-- r: a ParcelidentificationNo.(PiN) � � / Sb:Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: cc �, (it-well field,one lat/long is sufficient) o 9 s. N r9J „2:c 1 . ",, w z_,,e,� ® '- 1 __"_`rdd' �' Signature of Certified Well Contractor Date 6.Is(are)the well(s): lmaucnt or OTempor•aty By signing this form, l hereby tern that the well(s)was(were)constructed in accordance. with ISA NCAC 02C.0/00 or 1.5A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: DYes or I11A4e-'--' copy of this 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#21 remarks 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 injection or ton-water supply wells ONLY with the same construction,you can submit one form. SLAIMI'I"I'AL,INS'I'UCTIONS 9.Total well depth below land surface: •i dS ' (fit,). 24a. For AU 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: ' .20 j (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+" - ' 1617 Mail Service Center,Raleigh,NC 27699-1617 • il.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 fonts within 30 clays of completion of well 12.Well construction method: Rotary 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 13n.Yield(gpm)___ Air lift 24c.For Water Supply&Injection Wells: 0_-__-_• Method of test:-____•_-•_ "-- 'Also submit one copy of this form within 30 days of completion of 13b.Disinfection type: H & H Amount._12 Qz• well construction to the county health department of the county where -"—; constructed. Form OW-1 North Carolina Department of Environment and Natural Resources.-Division of Water Resoitr•ces Revised August 2013 JIVI36-0Is° 11i"be-C . °!eta, M Q0/J % Macon County NEW WELL CONSTRUCTION o 43; Public.Health CONSTRUCTION AUTHORIZATION 44 , , PRIVATE DRINKING WATER WELL APPLICANT/OWNER -Jeffrey and Andrea Bosio LOG# 072622-PR OSWW# 072122-S INTENDED USE ;:•:Single-Family Well, Residential PI Co # '.6573894576 ` ACREAGE 5.843 LOCATION' :137 Valle View Rd DIRECTIONS 23 W,turn L onto Patton Rd, L onto Valley View Rd gravel driveway on the R 137 , L Permit Conditions 7 5 a 9 t `"TT`"'rl Well shall be constructed in compliance with all NCAC 2C Rules. `/� Maintain minimum setbacks as applicable. F Q -, 5 A, �`- Diagram (Not to Scale) i' C ? ;,, ; '%'' 70` i 70' 15' 1 C • . 9‘ >5 I � \ • Roposed Driveway ,� . a \1 %g. 6>. �•IP' i Permitted tf Well Ate, i 20' ZO,ry ,, 65/ lOS'to fence no • lr a•il, S> ' N DrirewaV _ { 1 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:insp"ected 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 containiriation. How 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?(828)349.-2490 Issue Date: 6/16/2023 Chaz Allen, REHSI 3258 jd'}4q,✓/� /,..., ..Authorized State Agent J