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Home My WebLink AboutGW1--05785_Well Construction - GW1_20230901 W'r-- �m(.._4_ RUCTION ItEC()RI) i This form can htihsed fors le or multiple.wells For futernt(1 Use ONLY:-~-----7.-- I 1.Well Contractor Information: I • i Mitchell Dean Cook I� Nell<' •--_-. : L`: .is i:;Fy s.li„.,�i��; :b,CY;.ti,•_,. .,,"..'p,'...._ ontractnr Namc "•,FROM _ _To DESCRIPTION 3 _. N:Well Coutractnr(cnifice tion Number ,__.., �..-. a ;A;fi�IVCa%{rirmuEii ca's`'dxfNe►lg c) ;1nINR1'j ifFa' icablc;:.vt'.' z:% ' , ``°Dennis Holland Well Drilling „ETA, - ------ Drilling, Inc;._ , ft I ICK rD ia. DIAMF rF �'� - ''" -Tit NESS _ MATERIAL • (;urnpany Nasue --------_...—______....�..._.�._..__ Cl J _ ,,.`_•I:6 aI1"k_4ASfNI1:Ul2Tl.6-11yG. Aollioninas �' :,r;�:C: 2.Well(:) (&' wedztdop),,:_:..,: t:::.;1` s,: Construction Pel'Dut#: C7'�_ 7 T ....FMB_ ....T9DIAMETER IIIICKNESS MATERIAL - List all applicable well permits(i.e.County. o � _' ___'-'-_...___.-.---_- -• ft. .. _'�'• __ __..._... ._ Stare. Ym•inere:/r je(nial,err..) __...._. ___ it' ia.- 3.Well Use(check well use): - ft. fr._._.._-_ Water:Stl )j_" _ ""_" _,. __� __ :76,-e1Fci.)iVs ;i).' 75:r Ft- PI Y Well: —___.___-_. ==•.:•A_ ._� —_f 1:•' ?4s;-_a;: ? T:._;'..^ }^— ^:I _.. `FTtUM_ ^'OT'-_'� .;i:•.- �:,;.` ....:;.:r`r.! ._„i�•.�::<�.: • I lABriculhtral _ mowETF_R_,..SLOT SIZE,_ 131ICKNESS MATERIAL • f_7MuniaipaVPuhlic • ft._ i, in. ClGeothennal(licatinp/CoolingSupply) C�IR de.ntial Water Supply(singly) _ - ! __._. Olndustrial/Cmmne ft' ft. in. t rci(tl Cl e !t sidentiaP Water Supply :18��'i7C1?l? ' ra:- . - �,,,--- - I I Y(share(I l.11rrl lllln - •n'.'`� 'i�%i,„.;.1.` �(rir> Ez_.._I1 _ „LRAM TO_ Y MATERAAI �t::c:..:..cr_, :::>`s;,:,_ ,,, �..�__-,F.MPhACRM6NPMFTIfOR&AfNOUKr• Nou-Water Supply Well: ---_•_ ._"..-,._._-_._- _ _- ft. ft. CiMonitoring [:JRt:covery - • .� ft: _ ft. Itiet:iion We.11 -7 — .�....._."___-•---.._-_._...__- c�a_ ag _ `� � - f.7Aquifer Rechar'c R: ft. . 6 UGroundwater Rentediation 1:.9. SNND/Bit•OF1 illAgfq(iI4 ". _ L7AquiferStoragcand Recoveryl . ii' d ble A a:. if •" :ra LISal inky Harrier --nM----~T(t_.,....._ MA'rRR1AIT Y•,�EMPI,ACFAIEKIMF,'rFl�ll��"_' f7Agtlifer reSl ft. rt. — .:1Stonmwatc:rDrainage -•_- __ __..._ _,.._ C'16xperimentul'1'echnology C1Subsidenec Control ft. ft.DGeot • hcrmal(Closed Loop) 't 2p?Dftfk Isllvi'ft;EY(rr eitaelfti ildititY4il7yhiec _ (7'i nicer �_... _ ,.� IH'I�igPCP9aal,'j').. F1IOM_ _ ; _DFSf:R.T'ION.c.1"-t hanfoes,.,sot Urock It:e�g,•ain„u,err _. !7G_eothennal(Hcad Cooling Return) [70ther rxplainunderti2I Remarks it --" ft. --I 4.pate Wills d ft. ft. �___._._._..--__-• O Completed: e9?-G,7.)'",�:)Well IDH •••.__._.-__--._._..-___-- __-_--.._"-:_.h..__.___.____. • Sa.Well Location: _ �. a e Facility/Owneramc '� ` - - Facility ID/I(if applicable) _ _....__...._.._ ' ..:_.._---.__ . ..._ _:.._.__...----.^_.__..___...,._._�.___.. _.__.. . 'II. ft. l tr ra:±Cff Pr: c x .arr4 sty I ly-s,enl Address City,and Zip ft. _ � C'�1.L`✓ +3 • Con-roy 7bit�. _ z��!_ X�._ . _.. Parcel Identification No.(PM) 1 Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: (if well field,one ladlong is su11i icnQ 22.Certification: , i :.1.5".__,,,,-."/ " N' 73°. ,i0 -'1c , r' Signnntre.ofCeitifed Well Contractor Date 6.Is(arc)the well(s): t ancnt or (:T emporaty -._ - - _By signing this forum_1 hereby cert05,that the well(,)was(were).constructer/in accordance with/SA NC"'AC 02C.0100 or I3A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: L'Yes or ELI/Nk r copy alibis record has been provided to the welt owner. If this is it repair,fill out known well construction information and explain the name of the - repair under 1121 remarks section or on the hack /'this fonts.- 23.Site diagram or additional well details. You may use the back of this page to pritvide additional well site details or well • 8.Number of wells constructed: ____ ___ conslnuaitm details. You may also attach;udditional pages if necessary. For multiple injection nr non-waler.rupply wells ONLY withthe same construction.you can submit one form. S(fllMl'1"l'Al,INS:!'l1C:TIONS_ I ' 9.Total Well depth below land surface: 4,J`� ,_ �(ft.) 24n •i1 ,,_All Wells: Submit this,foam twithin 30 days of completion of well Far multiple wells list all depths if different(example-3@200'and 2@l00')' _- construction to the following: 10.Static water level below top of casing: �'�� (ft.) Division of Water Resources,'Idformation Processing Unit, . 1/wrnerlevel is above casing,use"•t" ..__ 1617 Mail Service Center,Raleigh,NC 27699 1617 p I1.Borehole diameter:6 __"" _. __(in.) 241), For Injection Wells ONLY:" 1n addition to standing the Corm to thc address in Rotary 24riabove, also subiuit a copy of this form within 30 days of.completion of well • 12.Well construction method: __ _T_ _ ____ construction to the following: I. (i.e.uuga',rotary,cable,direct push,etc.) _ ___ Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: _._ "T T^ "-_ __ 1636 Mail Service Center,Raleigh,NC 27699-1636 . 13a.Yield Im _.,_-...r Air lift 24r,For Water Su pj &Injection Wells (gl ) .� .,._------• Method of test:.__._...._...: -- _ th H HAlso submit one copy of this form within 30 days of completion of 13b:Disinfection type:_� __ Amoitut:"12 0L. well construction'to the county health department of the county wh(:re F01n1 GW•1 Nnrt}r r'arn Gan Ilennn,n,.dt of u,,,,,,,,,,,,,,,,,, „d n,,, ,,I 1),,,......,,, n:,,:.:..,...rut....,1).,,,.......... u..,.:.•,.,t n:,,.:,�,)nlv • e--017.o� f _ " Macon County NEW WELL CONSTRUCTION 'o2 ) Pub s H al5 CONSTRUCTION AUTHORIZATION ' PRIVATE DRINKING WATER AVELi I G>'Yv':ri fe st . Nancy Buchanan , C1.@gam 1 080523-P to l'N"TA..: �vU LU us E�\. }Lal 561�9nL7 i I Single-Family Weil Only;(setbacks Residential _ i?L!J_ I 4 ,1� , 0,34)c Imo. _. _ ... 75Jb04972 f �iUC':t--03• 171 Carvli Rd - - - _____��?_'4�� i Syie'a Rd to Ria ecres!.Heights Rd, R onto Caryl' Rd; property at end on right ! Permit Conditions Well shalt be constructed in compliance with all NCAC 2C Rules. Maintain minimum setbacks as apollcabie. v Diagram(Not to Scale) P � I Canril Rd I•+ ii ii i\ \ ,:. u II 11. R i 1 I V) • / \ '.I. ii 1 T i I ' I A \\\ I • 71 Caryl!` i ii 11 `I ' f 1 \ • . II '.. .. ' ei • li •r 230 ``+ • ;l�I Ridgecrest Heights') • i / i It <\ i If (N./ / li I i{ II 1 li It li Ii • /i ; i ,l I I iII i LI ill ll ii s _ _ it Iriigs perm G.' uaiiki Mr a,,per ."d,of a ivie.Imam 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 iON MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO SERVICE. PLEASESCHEDULE A �ELL4EA�INSPECTION AFTER INSTALLATION. Q_�-�CHS' ��;9_^::::,4l9w i--7 Issue Date: ?i/11/2023 3eremy Pless, REHSI 3157 _—_' r_ --•-• E —�s______Autharized State Agent.