GW1--04983_Well Construction - GW1_20230807

WELL CONSTRUCTION RRCORll —
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'Ibis form can he used for single or multiple wolfs For lutemgl Use ONLY:
1.Well Contractor Information: _ 1 i
Mitchell Dean Cook • a°-.tv,•Afr"Fii�t tN —
FROM T R _rk'; 4 .
Well Contractor Name ... _,_TO ,_DESCRIPTION �- -
2043 A li0.rt. J�f0 ..ft. ��1
NC Well Contractor Certification ;.pt tP �'�" R '—,
J N•R' A•'_SINCr, fotimtil etllw.its ( r 'Y=: ' ;'.;:'
Number j<.�)1t�aINE�((ifp'°'jcklile .. .���.�,.
FROM TO DIAMETER THICKNESS MATERIAL• —
Dennis Holland Well Drilling, Inc. jj in.
— rt. l r, in.
Company Name f
16 I10/t1t CAS11Y( UR'P[1$I1t3:4 jReoitier miirC iii:d-lbt' '`"
2.Well Construction permit#:i//'• ,. µ FROM _ Tr-M P};t:'i';...:::.RIAL— ^
••yy ry DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.Gnome,.S'tate, Variance.Injection,etc.jit. �_
3.Well Use(check well use): h •fr. ,J qt. ,' i 1. 5� /T I`5(
jtIffI.SrS(RSFN 5-3 y f
Water Supply Well• FROM TO — DIAMETER SLOT SITE_ THICKNESS•'•`MATERIAL
°Agricultural DMunicipal/Public ft. ft. in. -
°Gcothermal(Heating/Cooling Supply) CJResidential Water Supply(single) R. ft. in. ""-' J.
❑Industrial/Commercial .' ':. ' '. "'"
srdcnpal Water .. ... "'f'^Supplyt
(shored))
l7lfrl tttion FROM ^ TO -MATERIAI. .'EMPLACEMENT METHOD&AMOUNT
Nnu-Water-Supply Well: - r rt* r fr. fL ,o 'I
°Monitorin ' ft' . rt. .6L�� :G2 - =5z!' ) z._er.s%�ad -}_.-
g (:JRecovcry _�G'J .�1= t� '� ./
Injection Well: ft. ,ft.
I.7Aquifer Recharge ❑Groundwater Remediation ____NVIEWk::.F A'' +.-` :rts:,'"'i,1 I . G1Ci(tta Itc�6t�'t;':;<� •: '•`;:;:;'is��e%;:�`.:...,:•...,::.,.:.:....,;., "'>�_'<
(JAquiferStorageandRecover FROM _ TO MATERIAL. EMPLACEMENT METHOD
Y °Salinity Barrier - -- - -----
ft. ft.
°JAquiferTest DStornrwater Drainage _ — ,_--. •
C°Experimental Technology °Subsidence Control ft. fr.
h20 i1)R11 i:INr i1;O(>>. 'a(aeh add f o''nl9&eo(a'•ifrof "an ia'4 :a:+:rt.e'""
CJGcotherinal(Closed Loop) H'I'rttcer a IFFIO _ _ _w_�. i .n. and a sol.,.roc :.aa:i e;`,)
FROA1 TO DE.S(;RLYTION eolor�hardacas soiVrock IYpe,groin sin,cic.)
, i7Geothermal(licating/Coolin Return) [:JOther(explain under 821 Remarks) ft. ft.
4:Date Well(s)Completed: �? ) •v2 Well 1DN _ --- ft.
�_ h^ ____ .„4---''r-;'t f'":,;f�' _ _ ._
.-'-- t t.
l/air _ _ ft. ft, � Z,.7.„�! •a Qf
So.Well Location: -_-_____rt ___.._.ft, q rj�023 �__ ._—.__:
� 1F 1 _._.I
, ;_-___L.(,�: /-a:1 ,'liy�i(•�?.3. L i t y ft. ft.
_w__ _ _..
Facility/Owner Name Facility 1DH(if applicable) s-)- -t
IL ft.
y e lit` 6l .ro
�yib. L s : ��� y''�i 1. 3.E�>/ - 1Ph'3, •_._---.__--_-___....
lw.� rt. ft.
Physical Address,City,and Zip _
_521 SRFMARK __ _'•':
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Connty Parcel identification No.(PiN) —_,-_
Sb.Latitude and Longitude In degrees/rninutes/secouds or decimal degrees: 22.Certification:- T - _`- �'_._-__. _.._._
(if well field,one lat/long is sufficient)3,_5 .
`'_) '____.N .. c 3 ra , ,. W . 12 :._-R �� a 2.1-te r=,2
Signature of Certified Well Contractor . Date
6.Is-(arc)-the well(s): iikPcrmauent or °Temporary
By signing this form, i hereby certify that the well(s) was(were)constructed in accordance.
with I.SA NC:AC 01C.0100 or I.sA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 1:1Yes or •(rINo 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 underii2/remarks section or on the hack o/'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; 1 ___ constntrlion dcutils. You rnny also attachadditional pages if necessary.
For multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one form. SlR1Mi'I"['AL•INSTl1C1'IONS
9.Total well depth below land surface: c �� (fl) 24a. For Wells: Submit this form within 30 days of completion of well
t•'o•multiple wells list all depths if different(example-3(a;200'and 2®100') construction to the following: 1
10.Static water level below top of casing: .J _ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"r•" 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 form within 30 clays of completion of well
12.Well construction method; ry runstntrtion to the following:
T
(i.e.Bagel•,rotary,cable,direct push,etc.)
_ Division of Water Resources,Underground Injection Control Program,
FUR WATER SUPPLY WELLS ONLY:-� — 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield 1m _._ Air lift 24c.For Water Sup.p &Injection Wells:
(gl ) 1 5__..._____. Method of test:___._._._..._
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H _ ___ Amount:_� �Z• ._�•__•._ • well construction to the county health department of the county where
-3_.___ "T _ .__ constructed.
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Form OWI Muth Carolina Department of Environment and Natural Resources•-Division of Willer Resources Revised August 2013

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vQtoteC So--- P ILKi b 32. Lzi (-52!
�A r•m Macon County , NEW WELL CONSTRUCTION
,,- g Public Health CONSTRUCTION AUTHORIZATION
'd , a' PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Joe W. Parham LOG# 111222-P.• OSWW•t 111722-S
INTENDED USE Shared Well,Residential PID # 6597359966 ACREAGE 2,74 •
LOCATION Off Lamar Lane,Alben Lane and Mason Branch Road.
DIRECTIONS Corner of Mason Branch Road and Alben Lane.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
• Maintain minimum setbacks as applicable. " i
The well may be drilled in any of the approved area shown provided that it is not in driveway.
Diagram (Not to Scale)
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Existing Residence
Pr 9101 Lamar In Res dense ExistingGt ,' ``�`
° e Line a1W Alben Ln So
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S •s`
—' 50Ailp `• `<
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A0i. : 53
4
fT ' ,v�62 58,
5:' 0 t
`' >100' s OS Trees N
Existing Well osy
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ds: Pc yob 'PG, ,
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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: 12/14/2022 Charles Womack, REHS 1300 itei bA/�_Authorized State Agent