GW1--01260_Well Construction - GW1_20240229

WELL,CONSTRUCTION RECORD For Interim)tlsr.ONLY: _- j—^ —
This Corm can be used for single or multiple wells " i
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1.Well Contractor Information: _ •
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Mark E. Holland 14,WATER ZONES_-_.__._.__.. _ . _
..--....- FROM _~MTO DESCRIPTION
Wall Contractor N intc �- 76fL 3 76 ft.
779 1-7q
NC Wc11 Contractor Certification Niunber .15.OUTER CASING(fotI multi-cased wells).(.>R-LINE:R jif applicable.),•__..__ :-.._._.
• NROM Ti DIAMETER TIIICKN ESS MATERIAL,
Dennis Holland Well Drilling, Inc, ft. ft. 4M 1in..
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
0/J I �] �� FROM TO DIAMETER -THICKNESS '' MATERIAL
• 2.Well(:onstructioo 1:Permit- aft. /yO ft, rr i io. G-_-.-
List ail applicable well permits 0.e.County.State, Variance..Injection.etc.) ----_._---_.-_-._..._-_..._,.__V._..._...___-..,._._——_________._ ____- __--7-----
/40 ft, 15c ft. C,f ,in. LC�
3,Well Use(check well use): - __-•---__.—_.__...:__-_ -_--------:---..__.__._.___._._ -L---....__._..__
____ 17.SCREEN __ _ 4_._____ _ _ _ _.__-._.__...__....
Water Supply Well:, -�� -----__-_,... _FROM---_T(1 ..-_---.-DIAMtinR •_SLOT SIZE THICKNESS MATERIALy____
❑Agricultural • ❑Municipal/Public R. R. in.
t]Geothennal(Heating/Cooling Supply).• esidential Water Supply(single) ft. fi--- 'a' I I
(!Industrial/Comtnt:rcial 17Residi isual Water Supply(shared) 18..GROUT I•
mom To MATE:RIAU EMPLACEMENT METE OD.c AMOUNT
❑hrigation_ R. rt.
Non-Water Stipply Well: _ _.__.--._.__-.____.___-._.__ -_----__:_.._.__.-•_•-_-•
ft. ft.
L�Monitarinw ORecovery -____- _. __:_ ._.._.__._.___.__-.._____._-__=---...-...
I_________..,l__ -...-___._-.--..______— ____ ft. ft.
Injection ell: '
OAquifer Recharge DOroundwater Rentediation 19,.SAND/GRAVELPA(K(if applicable,_
•_FROM '1_0_ MATERIAL r EMPLACVM ENT METIiOD
OAquifer Storage alit!Recovery C1Salinity Barrierft• ft,
DAquifer Test OStorm water Drainage ._--..--______..___.-:_._.______..:.._______-.._.___..-______.._.._._.._._..._.__-__-__---..
ft. fL
❑Experimental Technology . OSubsidencc Control _. _ __ _-.____...____...._____.
••220,DRILLING LOG attach additional'sheets if necessar
f-7Geothermal(Closed Loop) Li tracer FROM __ TO _ DESCRIPTION(color,hardness,scgrock type,grain sin,ere.) _
I:]Geothernlal(Heating/Coolinp Return) OOther(explain under#21 Remarks) rt- ft.
r._-___.._ -______ f �..__ _______.__.__.__.___.__.___li
ft. ft. I
Q�(J i LL -.-- A._.__._.__.-_._ _.___...____..._..._....__._...
4.Date.Well(s)Completed: Well IDN ft. ft. ' --.r �
r- _.,.
Sa,Well Locatio : .._ft________-ft_______ ..__;__._._. .�.p+. ...•.... t6_- .___,
La
•
R1Ar tl ft. ft.
t FEB z�24_
Facility/Owner Name _ Facility IDU(if applicable)
ft. ft,
ft. ft. <ti
Physical Address,City,and Zip .__.__.-__ -
55 oqq•(5 .3 ;21 REMARKS
County Parcel Identification No.(PiN). j
5h.latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: _I ,
(if well field,one hat/long is sufficient)
:,,,S5L1 ilq'630 N ---S 407 l'FO
12/41..- et;'•*---f.X._. _.2- '
Si6 moue of Cetitfiedy /7JIQ
ntractor t Datc
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' 6.Is(are.)the.well(s): 121Permanent or ETI•cmpurary
By signing this Joan,l hereby certify that the well(s) was(were)constructed in accordance
.with I SA NCAC 02C.0/00 or l SA NCAC 02C.0200 We/i Construction Standards and that n
7.Is this a repair to an existing well: DYes or ' LOONo - copy of this record has been provided to the well owner.
If this is a repair,fill our known well construction it formation and explain the nature of the
repair under 112/remarks section or on the back of this form. 2:3.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
8.Number of wells'coast!meted: 1 _ construction details. You may also attach additional pages if necessary.
Far multiple injection or nor-water.supply wells ONLY with the same construction,'you can
submit one fennel. , SUBMITTAL INSTUC_TIONS I
9.Total well depth below land surface:, • __ - U D __(ft.) 24a. For All Wells: Submit this form within 30 clays of completion of well
For multiple welds iisi all depths if different(example-3(r0}00'and).rJ100') construction to the following: i
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Division of Water ResouI•ces,.lnformation Processing Unit,
10.Staticwater level below top of casing: I O (fL) 1617 Mail Service Center,Raleigh,NC 2'7699-1617
/f waterr ilevvel is above casing,use"�"
1
l I.13orehole.diameter:_____•_ (in,).
•24b. For Injection Wells ONLY: In addition to sending the font to the address in
Rotary • 24aabovr„ also submit a copy of this form (within 30 days of completion of well
12.Well construction method: ry -constriction to the folhiwntg:
_ t
(i.e.auger,rotary,cable,direct push,etc.) I `
Division of Water Resources,Underground injection Control Program,
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FOR WATER SUPPLY WELLS ONLY: - T� - 16:36 Mail Service Cer ter',Raleigh,NC 27699-1636
Z. Air lift 24c.For Water Su>prll&Injection Wtills_
13a.Yield(gpm).-__ -_ Method of test -.---...-.----_-. •
- Also submit one copy of this torn I within 30 days of completion of •
13h.Disinfection type:H_& H Amount:_� OT, well construction to the county health department of the county where
-_-•-----•-_-• ---._.....r._-• constructed. 1 •
Fors O t W•I - North Carolina Department ofEnviromnent and Natural Resources--Division of Water Resources Revised August 201.1

Qtoteve • -
a:� m Macon= County
a ra Public Health
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NEW WELL CONSTRUCTION
• CONSTRUCTION AUTHORIZATION
4 ,f_ 3 (000 PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Paul and Hazel Wooten LOG# 041123-P OSWWA 044123-S
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INTENDED USE Single-Family Well, Residential PID # 7530996583 ACREAGE 2.76
'LOCATION TBD Oak Hill Drive
DIRECTIONS Patton Rd to'Oak Hill Dr,to top of hill take#273 and take gravel split to the Left(at top of hill)
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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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Property Line
r--
28'
r 4 16-
r--------Repair Area ---',
Type IIIf
(100'x25' _ ' /.?,?,
Prof • _ _ - ----- •
"erty Line -_-- 90''
IP •
60' 35
70' 26'
81' 1.00' 50' 13 Large Oak
Si
6' Witness Tree
3
Permitted i Proposed 15'Min 11 (Do not Cut)
-Bedroom f----►
Well Area
(20'x10') 107'
7, 5'
yor
Property Line 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: 10/17/2023 Chaz Allen, REHS 3258, C'r' /V L_ Authorized State Agent