GW1--06507_Well Construction - GW1_20231013

W.rIaIa CONSTRUCTION RECORD
(his fonu cen be used for single or multiple wells Pot Intent jl Use ONLY:
1,Well Contractor Information: ,
. Mitchell Dean Ca6k - -,.� .�,. _
Well PROM is:,.. >^ b:i.:i::; r...'ci.. i.;;. . '}, r'
I Contractor Name
- T� _D85CRn'770Nw r:': Ui`
2043 A _ lq8.ft: 1`�.<°,f4 I I — - .
Ni.Well Contractor Certif - 2.J.5'f t' .2 34'ft' 1
tcation Number ^.,.
Dennis Holland Well DrillingFRDM1f .If. FBwcllsZ()fitf ' (tr.' ti;bl ; --t<,.:,-'-_.
To DIAMETER
Inc.
l n c .� . •1-FIICKNES,S
ft. � MATERIAL
Company Name - - --- ' ft. ` in.
r 1d;iNr4 )t C'A,S1N(i O12' t OIN.(s`(geo'fh iiiin'al;elo',ledllo8g".e,. !
FROM TO s_,. _
-2.Well Construction Permit#: OSDDIAMETER' THICKNESS MATERIAL
7 3^P • ft. rt. ' �'w
List all applicable well permits(i.e.Coin S'tatc, Vam•iance,Injection.etc:. -- -T / .1 in. / '-"".
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3.Well Use(check well use): 6j.' fI. 2,0_, ft. �.. i9• =��
Water Supply Well: _ ..._ > ,.z...,.a t: ,y...,.' . :�
_FROM TO DIAMETER 'SLOT SIZE THICKNESS TM
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MATERIAL.
C1Agriculhtrnl I:.JMunicipaVPublic ft. ft. in.i
°Geothermal(Heating/Cooling Supply) `-,
�' pp y) sidential Water Supply(single) ft. �ft. ID,'i
❑In S I dll,Ir Ifl
Ulm met ctal
C.l Resident ahWater Supply(shared) $......_.:...��0hIT� ,.. ... .r._.,: �,r.:
i Y ..,.- ft:; z:;'� ::,? ..�, ,.,,,.;� ..; .
ClIrri uticn FROM " ` '
^ TO. .a ;i+'t_::''-::5.. ::;'......_=.._r';.:..-_i:.:.i.....�"%«;;�:i9'.r:'�`i�s>:i.:,:'r,::..c::;".....:....'yt;'��
MATERIAL EMPLACEM ENT METOB&AMOUNT-
Non-Water Supply Welh T" D /�
D's ft-.-..��r ft. /�1)Y�'JGe,J �� �.,�e__!_:p!L'f7�C_e'''
C:1Monitoring' °Recovery - - i fr. i tr.
Injection ell: - �P_ .bah _. i _ .r:.e.R 427Z._
(.]Aquifer Recharge --
ft. ft.
• °Groundwater Remediation 19rONIi%6iti.iFT 711kOl i ifea'"Ili'' a :W �:t.r-
C7Aquifor Storage and Recovor _{ PL. z;°rr:rt;: r,,,:•..ri ' _
FROM TO MATERIAL• �Y C7Salblityl3arricr ..-. ErhehncEnlENr`nsE•nlonl'�'
[JAquifer Te-st ft. ft.
CIStormwater Drainage = _ _ • I
°Experimental Technology C)Subsidence Control.
3051)RiLIN ?(afreeff+G dtine191iedi1ftugt9ieiy UGcotherinal(Closed Loop) f-) refer
FROM_ TO UEsear TiON_(color bantams,soil/rock type grain sae etc.)__
, °Geothermal(Heating/Cooling Return) °Other(explain imderk21 Remarks) ft.. .,__ R, •I
4.Date Well(s)Completed: _y It. ft. !;
dQ O9-well IDn _-& .A___ _ , �_� ___ �_T___. ^____
ft. ft.
Sa,Well Location: ...__-_ _ --_._- _ _
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Facility/Owner Name
�r ��// .fin /�,Z,/ �Q�itncility ll)N(if applicable) •-..•-•-------- Titt:
-.__�...__,...: ._ ._ ••..�. _ __
J 7' �'rkGfX L{e /J_"'[7d G ',l ' �H l�t; 1r)* (L f4 . __ .
OCT �� 20�1
Physical Address,City,and Zip • 1� , t k,t
;21 f1lFMARK� ;:, -..ell.. `_` ''- `+k .v.
County Parcel identification No.(PIN) t / T".,.....- / z: _ _____ � -'-"_...
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: -' �`_
22:Certification:
(if well field,one lat/long is sufficient) •
r
.3. 6 O 9 ,.." N- 9. a2 2 '/O" _--W ,r-_ � ' — /D_-0.l-. mZ,3
Signatee of Certified.Wall Contractor i Uete
6.Is(arc)the well(s): manent or DTamporary .
a - By signing this form,??+ereby.rertify-that the well(s)was(were)constructed in accordance
spill:ISA NC'AC 02C.0100 or LSA NCAG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well; °Yes or OAK Copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nana•e of the .
repair under 112/remarks section or an 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; 1 ____ _ consruetion details. You may also attach.atiditional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. S1112M1 ---.-l.IN..----'(IONS
9.Total well depth below land surface: oZ LS'_
a✓- --,_.-••,_..(ft) 24a. For All Wells: Submit this form`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: 1
i
10.Static water level below top of casing; '.Q �._.(ft.) Division of Water Resources,Itifnrrriation Processing Unit,
• ?/wage,level is above casing,use 7.1." 1617 Mail Service.Center,r,Raleigh,NC 27699-1617
na
11.lltirehoI diameter; (in) 24b, For Infection Wells ONLY: In addition to sencling the form to the address in
Rota
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m 24a above, also submit a copy of this foi'n within 30 days of completion of well
12.Well construction ethod: ry ���^� construction to the following: .
. (i.c.auger,rotary,cable,direct push,etc.) 4
_ Division of Water Resources,IJudergritunil Injection Control Program, •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 •
13a.Yield )m _, Air lift 24c,For Water Su�ily&Injection Wells:! i
(g1 ) .3Q..;.A.___^, Method of test'----__•_
"'"`— Also ub smit one copy of this form within 30 days of completion of
13b.Disinfection type: H & T. Amount:, oz.
_H well construction to the.county health department of the county where
T _-�.T___.__..___ __ constructed. .
Ram OW-1 North Carolina Department of Environment and Natural Kesourccs•-Division of Water Resources I Revised Anoust 2013

7,°t'e cr
y iii)•m Macon County •
o Public Health NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
1 0-f_ ff 3 - SO 31, PRIVATE DRINKING WATER WELL
•:Af'FIUCANTIOWNER.i Lyle and Cheryl Roberts '`•LOG# : 050723-P OSWWW 052223-S
=I14TENDED USE Shared Well, Residential "PIS` # 6563473120 `ACREAGE
' OCATI.OM Property on Right just after 34 Maxwell Home Road
.D RECTION.t. Property on Right just after 34 Maxwell Home Road lean,concise directions here
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Permit Conditions
Well shall be constructed in with all NCAC 2C Rules.
Maintain minimum setbacks as applicable,including 100'from all septic components.
Proposed barn is for storage. No livestock. .
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. Diagram (Not to Scale)
I
s-----------\\.........„.........„,,,,,,,, ______________-s.
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xisi.Pit
•c.ek .�-
1' Creek -.'
25•minR11
e,
>50'Min § 50'
Permitted ( SO PAad
Proposed Orive p
roRosed
4 .......r-tso'•x•su7"i sa,...................
-N4Zierai: ,ve---or-------- .--t-0 ,
✓ '62 d : l
rya
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e r Qc Batt 9eif
fi D.O.T. e .
R.O.W. a
2° CM&IP
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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]
rA"' p�
Issue Date: 7/18f2023 Jonathan Fouts, REHS 1979 i'Vk "UU'�i '4;. Authorized State Agent