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Home My WebLink AboutGW1--05790_Well Construction - GW1_20230901 , WELL CONSTRUCTION RECORD This form can be ils.ed for single or multiple wells For!menial Use ONLY: 1,Well Contractor Information; Mitchell Dean Cook • a4{. a do t Esf�` ._:: ,i:tom J'�l.f° .:}jJ'•.i•;• •: �1 �e. ;,_`r.•.. FROM TO .' ..:.,4;.:??6..,: �if: .a'-�5:.�fi°rii'aF..:...�;r�:p•,:.a�r:x,'•.'� ..:.... i DESCRIPTION Well Contractor Name ft. ft. I 2043 A -- - I rt. ft. , NC Well ContractorK=Certification Number �$M1PERt',(4TOI�( iiird&li?..agi,1 etle)1.0iVii NlwRgfett+jf• i iiii -''':'=':T...:':` DIAMETER THICKNESS MATERIAL Dennis Holland Well Drilling, Inc. ft. ft. in, Company Name 4 v }',l;i?1NIYlt.(�AgIN(y'':U hltli3 +' 4A..e,e :. • #C '{P,'ditiO iirl:¢lbiaf4.lafiii'):*iv:.�•!:`.•:>:€:xi':<t; :',iss-bg.:., ,� FROM TO DIAMETER THICKNESS MATERIAL 2,Well Construction Permit/4: VG0 � 62 3 _ , tc, �2"R- ,, . io, , List all applicable well ennosCounty,State, Variance,Injection,etc.) ______.- �J _ --.--. -- f/C -) 1 n (i.e.( - __ _� G3 P r3 7 3,Well Use(check well use): • ft' �,it, ft' 6— a in. / a.1' ' • �_ '.'1'1:r,5vREFRY'.: R;•, .''s.� �"�ti.;i';'t i; c�-s�--:,r. Water — DIAMETER �4:0TSI:;.:1.:r ......ia" .x41:r,`ATE .. Supply Well: .... ,,,..� <:::•..;�.::_ ,: T PI YFROM_ TO ��fiI.OTSIZR THICKNESS MATERIAL ❑Agricultural OMunicipaVPublic ft• ft.� in. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. • ❑Industrial/Commnercialis18t "t7: •.:.�''' '<<s, ;.t W x::... C]Residential Water SupplyR_ Slms�`` ._... ,•.t.: ,.�f-S: . , "`>'3;j�`° :•�,;�'::, .>�-:; :.:i:::.,; (shared) _ • � '}- '�,. � s= •'•..�^:.,....•.�:,;:=. 4..,..,.,,.. N. ❑Irri^tltiolt FROM TOT,^ . MATERIA[, �••F,MPhAL'F.MBNTMF,THOIT&AMnOUNT/� Non-Water Supply Well: - e) •R. 3 ' it- o,-7eLs .r -IjQ,s Ai"Al ❑Monitoring °Recovery , ft. as r f. �- __.2 l� i !fir s- u Injection Well; tr, ft. I.7Aquifer Recharge s. .j. ❑Groundwater Remcdiation MA'AM' •�e1Y1 `- '"` ; £'° .•4¢;«iy.'•v^-' ^;•dry,:n,k-� r StoragekiPACoICs(tttel9)S)1i1ri1i�e`j}:.`.�� :�r::;: :;: :r:zfi; . ;r ;'��v,.. • ❑Aquife and Recovery i75Alllllty Barrier FROM TO _._ MATERIAL: EMPLACEMENT METHOD^• ft. ft. IJAquifer Test DStormwater Drainage -- ' • C1Experimental'1'echnology °Subsidence Control - ft. ^ rt. L1Geothertnal(Closed Loop) ZQ M.ItI BIN(y3[i0(s' ffacH'ifi ldit nabshinte•iilntcivgsi Z;` - =s„>`:f...'' P) I_l1•racor rs�i e...)— : ^FROM TO DESCRIPTION,(color�6ardaeu,roiUrock lyae,train size,elc.)�' , ❑Geothermal Heatin' Cooling Return) ❑Other explain wider421 Remarks) ft. ^rt. I r� ft. ft. 4.Date Well(s)Completed: 51-r73Well IDII - -•- ^_ ft, ft. Sa,Well Location: --_ -- " ::7"'"fig<•t.� ..,I ft. ft. LP� �l '1.._L f — Facility/Owner Name Facility IDIP(ifapplicable) _— ft. ft, J 4-/a/Y/l 0 0 prVe_� ft __ft —_ __._..�_ CI� ft. f. Irhvrinalla t ter( Physical Address,City,and Zip _,, rv.. n.,•. ediA71'1'K. , ;,,,,,•:.- r?:>,. :'ir.+,r°� . u'. „�;S:S:,:r::.°i .>' c1 4 -25o 831776,4, County Parcel Identification No.(PiN) Sb,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: _~_____ Orwell field,one lat/loug is sufficient) 3 So /c9 r D 6 ' N 7.1 a 2/ ' 22�-" w ".g7..;._ _ � .�� _tom r- -�� Signature ofCertifedWelt Contractor _ _ Date 6.Is(are)the well(s): f3Pcrmaucnt or .❑Temporary By signing this form,1 hereby aert fy that the well(,)was(were)constructed in accordance. with 1 SA NCAC 02C.0100 or 1.54 NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: °Yes or EINo copy of this record has been provided so the well owner. If this is a repair,fill out known well construction Information and explaht the stature of the repair under 1121 remarks section or at 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 any also attach additional pages if necessary. For multiple infection or non-waier.supply wells ONLY with the same construction,you can submit one form. SUBMITTAL INS'FUCTIONS 9.Total well depth below land surface: • d .�' (ft,) 24a. For All Wells: Submit this form,within 30 days of completion of well Par multiple wells list all depths i/'different(example-3@200'and 2®100') construction to the following: 10.Static water level below top of casing: 5-D • (ft.) Division of Water Resources,Information Processing Unit, If water level isabove'casing,use"•t-' 1617 Mail Service Center;Raleigh,NC 27699-1617 1L Borehole diameter:k' (in.) 24b. For Injeetign Wells ONLY: In addition to sertcling 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: ry construction to the following: , (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,IJnderground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 I, , 13a.Yield(gPm)___.L ;_ ___. Method of test: A_______ir lift 24c.For Water Supply&Injection Wells: • Also submit one copy of this form within 30 days of completion of In.Disinfection type: H & H _ Amount: 2 OL• 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 Resources Revised August 2013 4 otecr. j ., ti a c.o n County NEW WELL CONSTRUCTION Q � eo. r Public Health CONSTRUCTION AUTHORIZATION a';. PRIVATE DRINKING WATER WELL • APPLICAiITIONER :Jack Boonstra LOG# 060323-P OSWW#..N/A INTENDED USE ;Single-Family Well, Residential PI D # 7508397766 ACREAGE 2,0 LOCATION 63 Alamo Dr • DIRECTIONS 63 Alamo Dr Permit Conditions Well shall be constructed in compliance with all NCAC 2C Rules. Maintain minimum setbacks as.applicable. Diagram (Not to Scale) • • _ - ..- - Pond _ - _ .. ' N 123' • 4) a• • e Septic Area f0 • `Fosca 31' i S— --41111111 108' • /34' 43' - • Property tine • Shared Spring 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?(828)349-2490 Issue Date: 6/9/2023 Jeremy Pless,REHSI 3157 !�"�L--..___`Authorized State Agent J .