GW1--07339_Well Construction - GW1_20231113

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WELL CONSTRUCTION RECORD
This form can be used for single Cr multiple wells Per intermit Use ONLY: •
1.Well Contractor Information: ,
Mitchell Dean Cook a4wA ✓Rt rEs;;� ,
, >.,;<a;. �>:, . .:.r.?aar:a:,.5z F_:,:.:.. :r'..
...
FROM TO DESCRIPTION i
Well Contractor Name .n, eft
2043 A _.!_9Q rt. 1 2L eft " I.ez&, 2 /
NC Well Contractor Certification Number 1$Wt'ItER:(;fY,S);l�r(y`•(torimtiltiiick'sct11; 1]s)i)nrGINERi[(p' '1461e '."-'" =-:i .:'7
• FROM TO DIAMETER , :THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. -_ _ ----�nc— o ft. �O ft. si in.
Company Name _-^ i n n S,D/? d � �
11.6rIW4fli.R'C g eoi 4`iN•:[':r::!`i'�'Sii•:'>i.:.. :.
_ eXSIN'r:�lt'�I1$IIYG..(R haRuu+1,cl"o'3ed'^:IGfip')"s�;r:4:•,;:i�i::,:i<:,.,<::s.,;;.,+:_:;.:;�_;
FROM -TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 100 $'.,23-P U. ft. . in.
List all applicable well permits(i.e.County,Stare, Variance.,Injection,etc.) __----- - —•__
3,Well Use.(checkwell use): fr. fr. in.
,-; _
�t1TiS.L11P;0[71'•' " .V, `,, ia4 xrPlit'. n.c.iWi'
Water Supply Well: ------ --�_.._._ :FROM : :..O ;:. nTHIC'•':.fNESS...::.a RIAL
TO ^• DIAMETER —"SLOT SIZE THICKNESS M1tATtiRIAI.
°Agricultural DMunicipaVPublic ft. ft. in. ,
OGeothermal(Heating/Cooling Supply) - C idential Water Supply(single) — rt. ft. In.
°Industrial/Con "3': _.r.° ,/ t, ,.mercial 't?t�'
(: a .0 .. .. ...,... >:�': ;;t�
]R sidential Water Supply(shored) _ '=_�" .�%`s':��' "����.•�:''��^•�
FROM TO_ .MATERIAL, ';EMPLACEMENTMETHOD,&AMOUNT
Dirri_ation --- /
Non-Water Supply Well: 0 ft t' 3 - ft. )9,,, 4, e- .:
[Monitoring °Recove 3 ' R, -20' ft. 4 b ve*-� , /D4."*" _ry
Injection Well: ' f•
t. ft.
°Aquifer Recharge OGrot ndw t r e •t a e R mediation t19%: ANIi%b`''AY ip�� `r{ ( r" :. tt?:«:
'r 1`'�F�,..:AV`1(!;1�.8�{1�G�aV�C�L.. ... ....^.Y.y� t{f.::}�!`i:: .. .
OAquifer Storage and Recovery i7SRlhrity Ilarrier FROM TO _MATF,RIAI, EMPLACEMENT METHOD
ft. _ft. j
°Aquifer Test DStormwatcr Drainage -- ----
[Experimental Technology [)Subsidence Control ft.
ft
(�.t M.ilWt,,l,I-..INr%[I:GO aKelitGliiitoniiifsfi'eofkith'eee.igiifi „•'n`'`' e; ;:r: +:-.
Ll a)therlllal(Closed Loop) (.l'I'racer FROM TO DESCRIPTION(coloahardocss,salLreck type,grain size,etc.)
+]Geothermal Hearin Coolie;Return) °Other explain tinder/21 Remarks) ft. ft. 1 .
ft. ft.
4.Date Well(s)Completed:/r?-5-23 Well ID/I 41....A.4 - -•• - - -- -
ft.• ft.
Se.Well Location: ----_---fL — ft. _ -
•
e .___Tt9�f �.,.. r. ,
(% 1V�A. fr. rt.
Facility/Owner Name Facility ION(if applicable) — --.,ft__ f`.._____ -- `1 2Q23 T _,
3 0/ G ti.a��l //iet_,(,�`., rt. rt. � _ —___ --
Physical Address,City,and Zip ?; :z.• w... __^
ii2'1::zitt AhK;;µ:::._�.+W`` .. ....}1 . .. -i•gi;^... ii ' .-,,...;32:gi. ":;`.;;.,,r
—AA 9 "7' K,5754I-3-2d'51 .
County Parcel identification No.(PiN) --
---
Sb,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: —
TT _ ' 1
(if well field,one lat/loug is sufficient) 22.Certification: i ,
N W •,,,,; �f'_. - ._,e ,�O'_o2J� .
•
Signature ofCertilied Well Contractor-. Date
6,Is(arc)the well(s): fill anent or °Temporary
By signing this fonu,1 hereby cent fy that the walks)was(were)constructed in accordance.
with ISA NCAC 02C.0100 or/IA NCAC 02C.0200 Well Construction Standards and that a
7 is this a repair to an existing well: °Yes or All-No copy of this record has been provided to the well owner.
If dds is a repair,fill out known well construction information and explain the nature of the. .
repair under 1121 remarks section.or our the back 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 may also attach additional pages if necessary. -
For multiple injection or non-water supply wells ONLY with the same construction,you can -
submit one form. S[nlMI'I"I'AI.rNS'1'UCTIONS
9.Total well depth below land surface: r ,
[ 5 __ (no 24a. For All Wells: Submit-this form within 30-days of'completion of,well
For multiple wells list all depths if different(example-3©2�and 2(n�/00') ( ) construction to the following: •
10.Static water level below top of casing: 70 ' _,(ft.) Division.of Water Resources,Information Processing Unit,
If water level is above casing,use"-t-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.lloreholediameter: 6" (in.) 24b. For Injection Wells ONLY: Ibt'addition to sending the form to the address in
• 24a above, also stibmit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary - constuction to the following: h
(i.e.auger,rotary,cable,direct push,etc.) ,
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
r
13n.Yield m __ Air lift 24c.For Water Supply&Injection Wells:
(gp ) a..O__�_._ Method of test:____________
"- Also submit ono copy of this fonu ;within 30 days of completion of
13b.Disinfection type: H & H Amount:-�2 OZ•_, __ ____ well construction to the county health department of,the county where
- .�. constructed.
Fount OW-l North Carolina Department of linvironment and Natural Resources.-Division of Water Resotvcos Revised August 2013
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i �e ,;,, Macon County .
��;5� Public Health NEW WELL-CONSTRUC110N
'd_a/ CONSTRUCTION A.UTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Jeff Boatwright LOG# 100823-P OSWW# N/A
INTENDED USE Single-Family Well, Residential PID # 6574932651 ACREAGE 1.02
LOCATION 301 Chapel View Dr
DIRECTIONS Mu Ihy Rci�L on Louisa Chapel Rd, R onto Chapel View Dr to 301•on R. . - -•
W
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. •
Diagram (Not to Scale) •
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% 24 Well Area '
Driver ray j 10 (10'x 10') .• .
10 -
Well#270 / • '
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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 NUR,
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: 10/12/2023 Trevor Justice, REHS 3294 /4^,-- Authorized State Agent