GW1--06506_Well Construction - GW1_20231013

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1'S'.rIaI.,CONSTRUC'T'ION RECORDThis form con be used for single or multiple wells For lutern;11 Use ONLY: �_ -_� "
I.Well Contractor Information:
Mitchell Dean Cook �T ----- ---_-____-
4:�1 Al F.R<'• ')17ES} _ - :.:...;::i,'
welt contractor Nnmc -_. - FROM _ .o --DE)scatrr7 rg cz{M___ t5'�,:. ...... ..._-_.:11:.
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N Well CounnclnrConifrealinn Number 6. __ t _-_
IS pIjTN_REG S7N(`: or urul'ii cb': �- ;'F`;r...� _-_
Holland .'�.. {{;; . ��i weile`:t� .ui k.TII�IfF+ files r.�:-':::::�.,,,,�,....,..._.
Dennis H t Well Drilling;-Inc. �FROA; - - n���;.. .•:::' :..
T n(i TO _ DIAMP.TER, -TtIICKNES4 "MATERIAL 7.
CompanyNamc -''.. -ft�� ' •iu,
3 __ IN%:}t*'TI.00.i. _,:'dot)i'griiia°iagiI`o.ap):.:aiaf?!%Z; --
2.Well Construction Permit II: C3. r .:FROM _ ro DIA`nIETER ` • ti:A :: :::"=;;:`^"-=_
��1 � QQ THICKNESS MATERIAL _
List all applicable wellf-• -.______.•_--_-^-_- it. fl. ^6'1.1_:__'''
,. in.
pp permits(i.e,(:army.Stare, vm fnnrr../njertion,ek:.J �__� S�} _ --
3.Well Use(check well use): f • fr. ft. //o ;�,"_ _.Y�'?Z` f'G'G ✓
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14aterSuppLyWc11: .-._____ --.-_a____----- ;i1!1nWRF}FN': ?fir --.,, ,,�_. �'
FROM_ -TO IAM ,... ,..:...: ,}rr.';i:"s';t;:.S . i ATERIA-
ClAgriculhtral. OIAM ETkIt ,r+ SLOT SIZE (11ICKNESS FtA rF:R1A L- _I
f_7MunicipaVPublie ft•_ ft. in.i'
OGeothermal(Heating/fooling Supply) CDResi ential Water Supply �I
❑Industritll/C, pl Y(single). ft_T ft. in.'
ommercial .
4hResidc;ntial'Water Supply :>18 ( O. >f-; Y',-�'•, --;,.r
(shored .C. IJ ;::: +, ;t,;:, :.z.::.-:•r,.a:-;; ,;,,-_.-
[Irrigation __ ) FROM ,.:;'.t;:> � � .::,,:r• :.:,,.. -:
- TO MATERAAI.• - EMPLACEMF.NTMETHOD&AMOUNT-
Non-Water SIIPPLY Well: --""'•"..____�.._._...._..._._. _.• fl, D. . __._......_..�.._.__
faMonitoring -----f( rr __ _ _. �_�_._.�
(:3-- Reeovery
Injection Weii ectiol -`_- _.- _.__..___..-__-__-..-.____-.____-__.___ - ••__
fr, ft.
f.7AgOiler Recharge
0Ciroundwater Rrmrdiation i.:iSA U_C11Aii.0-._.A. 10,0� P44b.e
` '•• ; : - ;,.:..: !J_`.
:• 3AquiiarStorageandRec Recovery y OSulbtity 13arricr MATERIAL EMPLACEMENTMEri9n
ft. flOAquiferTesl
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C']Stortuwatcr Drainage -- _.
f_'IEixperimental'I'c¢hnol(Igy C]Subsirlence Control •
ft. ft. ;;_' - ---_-__ - __�_ __..
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Lllneothennal(Closed Loo z0 ]).KIY Nw[ T ---; n ;
P) (..Tl rncu FROM N'T(i<Y(v. dtfatSiGitilil ori'altsti ee�'iftiiece4sui)'',• ,:: ;:: ia:'- --
)Esf_atpT_!ON[colo i_bantne- IVrock Inre,main size,elC,�
f7Geolherntal iHeating/Cooliug Retun) (7Uther(explain underti21 Remarks) ft. �_.._. ft. _ I'
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4,Date Well(s)Completed:/0_ � -3-Welt inn ►,6.��L.._ .-_-_ ft.
rt.
_ _ I - f '`t F ` ?^�
Sa.Well Location: i r
V W/.e�_ IV 1' :max— -..___-rt. __.�_.�t _____ _ _{� -�2
eTG� Jt_ I OGt l 9'2-7'_,tee fr. - - • r _ ! --
Facility/OwncrNamc s ,; 1
Facility ID!!(if applicable) .__ __^__._.....,_..-..---..! 7r. ..•, r*:.
vr�I--�_ �1/ ��' tY�" .-____._.-._._.__--._.__..._.-_.—,:._-._._.._�:._.___.._.--.—.__--._.:�.__-_•s_� ----
Physical Address,.(:ily,and 7.ip ft. ft I-
-_—_--____.
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<y Gam_ ... .--.—. 7.'4./iQC3 &3�_ __ /-_,,5 .. L/
County - I'^ '
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Parcel Identification No.(PIN) /� ___...___
Sb.Latitude and Longitude to degrees/minutes/seconds or decimal degrees: __ -�'�� `-v �- - "--' '-`"'
Orwell field,one Iat/long is suflicicnt) 22.Certification:
51` 1— _ .NI'.�:2 '`'_/fir'. 1."._ -- _W %atrd -rat: z
_���-- Signr nare of Certified Well Contractor Date
F.Is(arc)the well(s): trrl'crmatient or_ I.TL'emporary . _-_
' • By-slyning this Joan,I hereby rertify-that the well(s)was(were)constructed in accordance- _-_
with I.SA NCAC 02C.0I00 or 1.1A NCAC 02C.0200 Well Construction Saint/m•r/s and that a
7.Is this a repair to xn existing well: [_]Yes or ril.FP`>"o cop;of this record lens been provided to the well owner.
If this is a repair,Jill out ktnowtr well construction information and explain the nature of the
repair under II2l remarks.section or on the back o/-thi.sfonn. 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 ____________ amshuctiun details. You may also attach additional pages if necessary.
For multiple injection or non-wmer.supply wells ONLY with the same construction,you can
submit one form.
SUBMITTAL INSTUC•I'IUNS �'
9.Total well depth below land surface: s ' r (ft,) 2.4a. Ir'or,_All Wells: Submit this Rtrm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') -' construction to the following: I'
, ,�' �_ (fI.) Division of Water Resources,Information Processing Unit,
10.Static writer level below top of casing:
I/+r•merlevel is above casing,,use"•t',.. -�'� 1617 Mail Service Conte�,Raleigh,NC 27699-1617,
11.Borehole diameter: .err�___ - (in.) 24b, nor Injection Wells ONLY: In addition to sending the fonts to the address in__. ROtal 24a alfove, also submit ;n'chpy of this 'rum within 30 clays of completion of well '
12.Well construction method: _ y _-- .__._-__.__ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
_ _^-��-_ 1636 Mail Service Center)Raleigh,NC 27699-1636
FOR WATER SUPPLY WELL:S ONLY:
13n.Yield(gpm)_2C•_,.-_ _ Method of test:•
Air lift 24c.For Water SuPlI &Igjectiou Wells.
•_..-._-----.....----- Also submit one copy of this form witltiri 30 days of completion of
13b.Disinfection type:_H (4t H Amount: 12 OZ. well construction.to the: county health dlepartment of the county where
-- --- - ._.._..____.____-�_.___. _ - constructed. l:
Form CiW•I North Caralinn Dennn Imam of liavirnommtlr and Natural Rnsnun•ot._Ili v:s,nn nr wo,,,,Roe,,:,,,�c Rwreod Amulet 9a17

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m Macon County NEW WELL CONSTRUCTION
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.: 0 1 Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER VW Investm•ents—John Wood LOG# 051623-P _ OSWWA 053923-S 1
INTENDED USE Shared Well, Residential PID # 7419008332 ACREAGE 0.34
LOCATION• Dryman Ridge— Lot 18 — J
DIRECTIONS Dillard Rd to Hale Ridge, R onto Daman Ridge; lot on right at top of hill,just across road from #170 1
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
• A denial was issued for this Log on 7/18/23; after a change to site layout,well construction shall be approved.
Diagram (Not to Scale)
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Drip Repair Area `N
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oad Be — '�
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7-77 ��,
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A \ ,Cj� 'ell Area
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`\ 63, 52°PIE ~
owe Box
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 INSPEL I ION AFTER PUMP INSTALLATION. QUESTIONS? [phone]
Issue Date: 7/28/2023 Jeremy Pless, REHSI 3157 v r"—'.____— Authorized State Agent