GW1--06505_Well Construction - GW1_20231013

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W._____LL,CONSTRUE,___Q RrCORll
This form can be used for single or multiple,wells For lntem;ll Use ONLY: _ - -
I.Well Contractor Information:
Mitchell Dean Cook -1---orit.i<'!arffir- .__.- -" =—�-,-,,...., ,'�_.� _-.— —_
Well Contractor Name --•-• FROM �'� ;L '_ DF'SCRIP770N.,1., 11'r t '= „1]'x;;:;
2043 A _•.tia____ 1_! '_�(__
3_60NC Well Contractor Certification Number '''
;G-A$1r54i faX)sii'iilti 29's�ASi etls' Ct1N };situ' .:. r-vs
-Dennis Holland-Well Drillingo^i ____ _ �_' r riMAT ' :_._.
IncLnc - .._
^^ RT RILL F.S.S MATERIA
r fl. ft.
Company Name
—..._.._.__.._-....__-_..._____..___...__.._.__. /ry tin. _
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a.___- SfN:.r Uli'T[1I1�'.�G;;(pieoi�o�rmul.Zrgicd reap):)_ rx.
2,Well Construction Permit II: FROM '10 DIAMETER THICKNESS MATERIAL
List a/I applicable well parlors(i.c.County,,State, Vrn•ioucr,I jer•.tion,alc,J-__.'__..,_.,__.__ __.___ ft. ft. , ,o•
-
3.Well Use(check well use): rt. -It.
- - i. - "_`.___ --- -....
)I- _ __•- M - __ ___..._-_ �'17_'S.(RFigN� „ ;),_,- '-�'Pk, __ --
_ :f�.,
-Water SItPI Y Wdl. _—____.. _ .._._�.=:_i_____��.;;.;;''.','mot.._ .�.�`s'iT'�:.;;.'.�?;:1�
FROM_ TO •DIAM F_fEit; ITS GOT�S1l E�i '11fICKNESS_ atAyERIAL.�•
I::iAgricultural h7MunicipaVl'ublir, ft. ft.-_, in.'? . "
°Geothermal(Heating/Cooling Supply) ft.
6 � pP Y) C)Rcsidcntial Water Supply(single) , ...____..-.
❑led s al/C , ft• ft. in.� -'-"'
tri onunerci;tl ���
(rr<sidentisl'Water Supply -:1$%;ORO.l1.T�'": :'�' - -
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glrrl atio 1 FROM �•TO _ .flI &
6 _ •.inaTF,NIAI. �EMPLALFMENTMFTII(�R&AMOUNT
Nnu-Water Supply Wells —_.-.__..__,_- ��. ft. �_ ff. _
faMo utoring (:)Recovery r ft' ft.
Injection Well:-" --_.____ _ __._-_ --- =�4 -___ =a. ,a _L-_ ��"' _..�...t,( kt�_
f.7Aquifer Recharge ft ft. .
C)Groundwater Remcdiation 1�9 SA'•NP/.CI;A )':x;iP 101C�if+ii"`Ui?"'a"i°t' — 'r.
• C7Aquifer Storage and Recovery CJSalulityl3arrier _FROM_ TO_.._._ MATERIAL. EMPLACEMENT
rJAquifer'fest ft. ft.
ft. i; _.._
C1Stormwatcr Drainage -•- • — _ w,
cif3xperin)ental Technologyft• ft.
ControlII
°Geothermal(Closed Loop) a'I'rnc;r •20 1 131:f.o.i(y(1 at.iien taiitiliiiiv iteet f Ytiec.c4sery)';S '^ ;..:=::... .,:; :FROM T O DESCRIPTION,jcolorlanloehnegreektzpigrain,tuz_cic
, _09cothernal klis tin Cooling Return) °Other explain under/I21 Remarks) ft. ft.
ft. ft. r
I Date Wells j _
O Completed: ) '�.5_Well 1DH _�1:r� _�.__. ._-. - _ ._-_.. _ ____ - - �f ..3,_;�-,�-�_..
Se.Well h. fL . �,r k -r". `+ q 1
Location: ._____ _ .-_.-._.. __-
= ,,
i�' �� -� 1 Sys, �___- �_..� Q ..._.i!..2-Q23--__._.-_...--
Facility/OwnerNrmuc Malty IDN(if applicable)
Physical Address Cy,and 7.is it _ T��" ^-
'l012.FMiC• K f f .
----zL .f..-�-,,_,
it
County .. 77'i9 fie,,:_6 ._._ -----_—.•.._.—..._.__...._----_—... tc Parcel identification No.(PiN) i —-•--__ _ _.-_-_ ___...___
r
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: __ - ^�-��-i �� --'
(ifwcll field,one InUtong is sufficient) 22.Certification:
Signmrve of(:cnilled Well Contractor Dam
6,Is(are.)the well(s):••)alert of D.Tompova(y
- By signing this fore,, I hereby earth,that the.well(r)was_(were).constructer)in accordance. _ _
• with/.SA NCAC 02C.0100 or I.SA NCAC 02C.0200 Well Construction Standards and dial n -
7.Is this a repair to an existing well: °Yes or ((1Adtr copy of this record has been provided to the well owner.
If this is o repair,fill out known well construction information and explain the notrre of the •repair under Y2I remarks section or on the hack of dos torn, 23,Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: _____ __ __ eonsuucliun details. You may also attach additional pages if necessary.
For multiple injection ar non-water supply wells ONLY with the sane construction,you can
submit one form. SUBMITTAL1NS'1'tl(,:TIONS
9.Total well depth below laud surface.: fi, 24n. For_All Wells: Submit this limn .within :lit days of completion of well
For multiple wells(Cci all dopi/rs(different(example-3@200'and 2@100') construction to the following: II
l
10.Static water level below top of casing: _-- 'v ' _T (ft.)
Division of Water Rcsoui'ceis,Information Processing Unit,
//wafer level is above casing,use"•i" -� 1617 Mail Service Center„Ralei&h,NC 27699 1fi17
I1.Borehole.diameter.•6--___.—.--(itt,) 24b, For 1nieciiau Wells ONLY: In audition to sending the form to the address in
Rotary 24n above, also submit a copy of this Ifortn within 30 clays of completion of well
12.Well construction method: _ _•___ _. _. �____.-___...______ ronslntction to the following:
(i.e.uugeu,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
urn _•_- Airlift 24c.For Water Suppj&Injection Weller
13n.Yield
(gl ) f_,•.r-_._.._____...__. Method of lest: - ---- -- -
"'''''-- Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:_H& H Amount:•12 QL, well construction.to the county health department of the county where
.____.-__. .............—•-__-._
_�__ _..-..._.-._�___-_...___ Y _ constructed.
Form OW•I Ninth Caroline Deunrrment of linvironutent and Natural Resources.-Division of Witter Resources Rrvisrd Auousn 2111 l

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Q(otect
d .m Macon County NEW WELLCONSTRUCIION
o �' Public Health • CONSTRUCTION AUTHORIZATION
�d PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Joseph A. Dawson LOG# 010121-P OSWW 010321-S 1
INTENDED USE Shared Well, Residential _-- PID # 7418182369 ACREAGE 10.86 j
LOCATION Off Hale Ridge Road
DIRECTIONS 106(Dillard Rd.), to R on Hale Ridge Rd.,to R on drive towards#385. Take first dirve on L and follow across bridge up 1
to site. .1
Permit Conditions -
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. J 1
Any questions call MCPH.
Diagram (Not to Scale)
Si
32' t 50'
PL
-- Drip Repair.Area— - -- - - — —
74'
Oak 0 80'
OakLY 46
1...
S;
5'Min
Prop.
Prop. 2 BR
,. i. I ,, 2 BR
Ex. Driveway
S.
3
78'
48'I Well Area is,
PL
This permit is valid for a period of five years except that it may he 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]
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Issue Date: 2/11/2021 Tanner Stamey, REHS/2712 _a Authorized Slate Agent'