GW1--01259_Well Construction - GW1_20240229

i
WELL CONSTRUCTION RECORD - For Internal Use ONLY: , . -
'fhis form can be used for single or multiple wells
1.Well Contractor Information:
l'4.•WATER=%ONES..'. ,-t:: -
Mitchell Dean Cook FROM TO DESCRIPTION
ft. ft. I 1
Well Contractor Name
2043 A . . ft. ft.
• •
IS OUTER•CASING:(for..multi cased:wells)'OR`LINER.iftapRicalile)r
NC Well Contractor Certification Number FROM 1 TO DIAMETER THICKNESS - MATERIAL.
I
in.Dennis Holland Well Drilling, Inc. ft. tt.
^16'INNERCASING OR'TUBINGIkeothernitd:elesed;lbrip).._
Company Name• FROM TO DIAMETER• THICKNESS . MATERIAL
2.Well Construction Permit#: .i tt),/ J.22= • • _ . 0 ' it > . ft. r;�.,_; in. .Slaj4-.. .% 5.9 •,
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) _ in.
3.Well Use(check well use): 17 SCREEN;-.` v
FROM TO DIAMETER) ,SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft in.
❑Agricultural • , ❑Mtmicipal/Public f It ft. to
OGeothermal(Heating/Cooling Supply) D.Residential Water Supply(single) ROUT..
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. 's_ : ft. .., rim.+,�' ....1.1-- r�:,��,j��.,/
C]Irtigation /.r j
Non-Water Supply Well: It. ft. yG- /._fj�c� )?, ;;-,>
❑Recovery4-7 • l •' ` /
OMonitoring ft. to
Injection Well: •
[7Groundwater Remediation ..19.,SAND/GRAVEL;PACKVIapplicable).., . ,.
❑Aquifer Recharge •FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ' ft.
❑Aquifer Test ❑Stormwater Drainage g, R.
❑Experimental Technglo(;y. ❑Subsidence Control -!.2k DRILLING LOG(attach'additional'sheets:if necessary)' ',-
OGeothermal(Closed Loop) • ❑Tracer - FROM TO DESCRIPTION(color,hardness,soiWrock type,grain size,etc.)
tt. ft. .
' DGeothermal(Heating/Cooling Return) ` DOther(explain under#21 Remarks) i,
• j ft. ft.
•
4.Date Well(s)Completed:(): lJ,_/ !lWell ID# i�✓�) ft. ft ""-.. r• -r-^
• ft
Sa.Well Location: ft. 1 °
'
- ft. ft. FEB 2 & 2n7n.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
(' R1 vL r4�.
. Physic 1 Address,City,and Zip 75 ) f% 3 Jt>' 21:REMARKS
Th'—* . C) /4 3 fe ez e;,r%J Az,.>)�`,-,
AA'rr�.ry>,
Cowry . Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.'CertificatioD:
_ .(if well field,one lat/long is sufficient) • ,o �J�,
w %✓7 [-ram% / .;" '.�' l7 4,,.. -2 -.ram.-ra.•!%.
"}�l7 t' /)f • TJ �� N �.}}�1, ,}.,��� t� Date
Signature of Certified Well Contractd j •
- 6.is(are)the well(s): l[-IPermanent or (_)Temporary - By signing this form,1 hereby cerl fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
7.Is this a repair to an existing well: DYes or. f�tNo' - "'
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under 421 remarks or on the heck of this form. - You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed:
For multiple infection or non-water,supply wells ONLY with the same construction,you ran' SUBMITTAL INSTLiCTIONS .
submit one form. I
(ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
9.Total well depth below land surface:_ �i�-�i � construction to the following: ; ,
Formultiple wells list all depths ifd Brent(example-.4Q200'and 2 too')
(ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: of!firmer level is above casing,use"+" I 1617 Mail Service Center,Raleigh,NC.27699-1617 •
6"
- .. 24b.For Iniection'Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: (in.) 24a above, also submit a copy Of this form within 30 days of completion of wel
Rotary
12.Well canslruetion.method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) - •- . • ' - Division of Water Resourecs,Underground Injection Control Program,
• 1636 Mail Servic`e!Center,Raleigh,NC 27699-1636
'FOR WATER SUPPLY WELLS ONLY:
Air lift 24c.For Water Su 1 &Injection Wells:
13a.Yield(gpm)_
' )----_ _______Method of test: Also submit one copy of this form within 30 days of completion of
well construction to the count health department of the county where
• 13b.Disinfection type:-H M _�___
Amount:,�2 OZ - constructed.
Form GW-1 Noah Carolina department of Environment and Natural Resources•-Division of Water Resources
Revised August 2013
II ,

e`o`e`,� h1Ak \ 1\al0 IS. -
`0 ml Macon County
k,c; ,: Public Health 0 _ '`G\' _ VfZI
NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT!OWNER Charles Nichols LOG# 102123-P OSWW# 120416-S
INTENDED USE Single-Family Well, Residential PID # 7521493374 ACREAGE 3.14
LOCATION Corner of Gold Mine Road and Gantes Gulch Road. '
DIRECTIONS Highlands Rd on 64E to R on Gold Mine Rd.,to R on Gantes Gulch Rd.,to property.on idnmediate right.
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules. .
Maintain minimum setbacks as applicable.
Well shall only be used for one residential connection
Diagram (Not to Scale)
Cullasaja River _
•
•
N75' .
36"White Pine
i25/
eduction rePair area; /�
r A; t - -f 0 a Proposed House S� '*
P ti ®Maple 58' 0o~As
66' o�
50'Min 75 �. Gib
e\\ ;ea'�o ''3. ®40" A ��e(
- P
�1le
White Oak 29'to road edge 100' •
O V
• Gold Mine Road
IP
Gantes Gulch
Road .
A
N
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]
• Issue Date: 10/31/2023 Chaz Allen, REHS 3258, AZ / Authorized State Agent