GW1--05789_Well Construction - GW1_20230901

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WELL,CONSTRUCTION RECr(:Rll -- •—�----_ -
This
This form can be used for single or multiple.wells for lno:nrgl Use ONLY:
I.Well Contractor Informatiou:
..-..-..._. __.._
Mitchell D? ,DF:SC_RII''I 70N%t'- :c,,..
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4`wA "rT Wia ' -; - -- ;.-
'Well Contractor Name
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• 2043 A - /./.,� ____/.el b 1 rt__-_.__L f
rt. ft.
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NC.Well Contractor Certification Number r•••Y` �`
)1,Sn ,RK)E(:A8 Cyy foidtiihi Ir' �tvctls 3') ! ;.,•^:..-=
U 111 "(;[._ ^c et1�. �' lal(�C �if?Y1�Li'i9ti)e);.x'-:::_ ;.
PROM J To [DIAh1ETF:R THICKNESS 'MATERIAL -
Dannis Holland . �. ---•---- _.__.-•__--
_� w- and Well Drilling Inc.Ln(: ft. n.
1:6- Company NamefTNN )l.(•ANI,.t.✓3K> li3(JyC `'eot)i'ecinulcl''ed oo" "``.-` r-
FROAI _ 1'0 _ DIAMETER '171ICKNESS ' MATERIAL
2.Well Construction Permit#: -) 9 7 w !r. --II.
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List ul/npplfrable well pennirs(l.c.(:atntry, State. vrn•innre.;/njerrion,err..) --a. -•�.....�.�.-."._._• --1 __1___�2 ::' -- ._kZ.4'5 _ -
-ft. ft. r mi.3.Well Ilse(check well use): —`s � a_ c , .f ,
17'fi(RFrk , •
Watei Supply WCII: _ __._..T-._-.-.._..—_____-�__..-_.... '-'-"�'• „FROM __�O_�.. r,•DIAAMFThR�=,tiL(Y 51rs .�,•Y111(,KNESS •MATFRtAI~Li
.ClAgricultural (:.7MunicipaVl'ubhc fI. ' ft. ini:
CJCicothennal(licating/(oolulg Supply) 4>f side P i Y(single)ntial Water Su )I ft. ft.-~ - in�
1 Id SI rI I/Can u•citI
CResidential'Wauer supply
=18-,-_C-R--.-_h-.
x _... . -:=.`� = '�r. _:a...�
Sir npuan FROM _JO MATRlR FMPLACFMF,NTMEn
toi)&AfNO J.
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Non-Water Supply Well,; --_------._- - _ __ --• 6_ _ft __ _• _;! 7f'=i&,i - _11, .,P- ;k2� _
[Monitoring : ecvery 4) -.,, = rt• L•Y)"hire,.. ''_"Gu T✓p_/
Injection Well: . • --`_--_- - .�__._,_-_.__--_-_ it. , -r. y• .;_ __._
1.7A(uifer Recharge :r=: _ •
l is
w r• .A.D.•I�AVF A'•`K�'if f:7Groun(1 attar R.me(liation 9�4.N .LC3. 1.tP. G e"�ca.)ij�%-
_FROM _ TO- _ MATERIAL_ -,EM~PLACEMENT111ET1�D____
L7Aquifer Storage and Recovery i:JSalutily 13arricr -fr. .•_..-•R.-� --�•-�•• •-•�
CJAquifer Test fiStonuwatcr Dlainagc ---_-- _ ___ 11.
____ �___.____.__.______.___�.__. -
ft. ft.
C7F..xperimentul'lechnologY (1Subsid(:nec Control ...`...... ;,:,. --
r20 I)R❑wl.lN(:3R(•)T.(s)_'iatu�clit one_lf.iOt"s:•ftoic':iiiiik:p'f ^. -'�_,
C1(icutltefmal(Closed Loop) [:.)'fI lee( FROM,_ - TO _11- U&tiCR ;:-501 colps5antae solUrock 1 ,,afain.ura ele.`
17Geo0heri nal (Heating/Cooling Return) GlOther(explain tinder b21 Remarks) ft. ft. Ty - ` -_ .r.. .- _ ' �
• ft,, ft. I' �' • i
4.Date Wells Com leted: Well iDlr_-_,�/,
Sa.Well Location: --•----t'- ___, .• fi_ - _ _ _
1 4-G-f� zd� Y...d1; _.__._...__L(f I- ___...__ ft. rr. In frt,a inn r�r.:c g.;M `i .
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Facility/Owner NameFacility iDN(if applicable) ft. ft. '•
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-= . ,� o..4 C id -T _._ __r ____ _ _ ___._-. "(- ft.
[ _... _.'__.____.__-_____.__..__.__-_-- _ --____-
Physical Address,City,and Zip731, _ - -'`Y I i`12Fi1NA iS' -
ram,
Comuy Parcel Identification No.(PIN)
• Sb.Latitude and Longitude In degre.es/minutes/seconds or decimal degrees: _.__- _-__._.___. -•i
22.(....ertification:
.(if well field.one tat/long is sufficient)
35 :;iv
_____- NI•.__43`,.)._ 4. ' _,�._ _—___w ,; . N e-
fa v .j;L
_�_ Siguanue of Certified ell Contractor'. l Date .
6.Is(are)the we11(s): LA.Pi'C'inauent , or. [.7'Fcmporaty By signing!his-form,/hereby certify that the well(.r(was(were)constructed in accordance
with/.SA NCAC 02C.0/00 or 13A.NCAC 02C.0200 Well Consrrurtiun Standards and Olaf a
7.Is this a repair to an existing well: 0Yes or EJ.N copy of this record has been provided to the well owner.
If this is o repair,Jill ou,Anown well construction information and exploit:the rrann•e Of fill:
repair under I12/remarks section or on the hack(Obis 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: _____------
consnuclion details. You may also atiach additional pages if necessary.
For mltiple injection or non-water supply wells ONLY with the same construction,you can I '
submit one form. Slf11M11-i'AL tn1 11C1'IQNS
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9.Total well depth below lanil surface:.• -d j-___.._---___.,_____(ft•) 24n. f r,_Al.1 1Yells: Submit this'form within 30 days of completion of well
following:For multiple wells list all ddepthsijdijjarrnr(example•3@200'and 7.(rtll)0') construction to the follow• f 1 ,
Division of Water Resources,Information Processing Unit, - •
10.Static water level below top of casing.:_._^_r�`._ - ---•--.-•(ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
/(water level is above casing,use"-I-" I ;
e" 24b, FM-injection Wells ONLY: In addition to smiling the form to the addt'ess in
11.Borehole.diameter: P-_ —on.)-" _-• • - . 21a above, also subunit n copy:of thus form within 30 clays of completion of vital
12.Well construction metliodr Rotary , ._,____-_____ rxrnstniction to the following: 1' j
(i.e.Huger,mtaty,cable,direct push,etc.) •
_ Division of Water Resources,• Underground Injection Control Program,
FOR WATER S[IPI'I,Y WELLS ONLY:^ ^.-___ _ -_-- --- -� 1636 Mail Service Center,.Raleigh,NC 27699-1636
• Air lift 24c.For Water Supper&1nje.ctiou Wells:
13n.Yield(gpm) .
- . .__•___._. Method of test.-__,•_•,•„•..-.._ _.__........__.:_- Also submit one'copy of this form Iwithin 'CO days of completion o.
H well construrlioi),CO the county health department of-the county where
13b.Disinfection type: --•--••-_• Amount:. 2.C� :.._.-.__.___.___._ consuuctcd.
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Penn(OW I ��^�'_- Not III Caroline Department of linvirunment and Natural i&csourccs••Division of Wnlrr Rcst limes
Revised Auoust 2(111

Q<°tece
i MO
Macon County NEW WELL CONSTRUCTION
Public HealthCONSTRUCTION AUTHORIZATION
'mod '� PRIVATE DRINKING WATER WELL
APPLICANTIOWNER`; John H�McCurleyJr. ^_— 1OG# W
100822-P OSW# N/A �
INTENDED USE;
Single-Family Well, Residential ',PID '# 6569__604100 ACREAGE- 24 —r
-•.LOCATION 208 Judds Tr _ _ _ _ .
;DIRECTIONS B son Ci Rd�to Judds TRl-, drivewayjocated at intersection of Judds TRL and Whitlock Rd.
Permit Conditions u
Well shall be constructed in compliance with all NCAC 2CRules.
Maintain minimum setbacks as applicable, including LOOft minimum from all septic system componehts.
Diagram (Not to Scale)
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Well Area#2
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1,17 Whitlock Rd
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: .:• ve �` —,`1�/---1• Shed •
Gravel n
drive I tee,
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25,
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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: 10/6/2022 Jonathan Fouts, REHS 1979 Xi- Authorized State Agent