GW1--01942_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
:14.
Mitchell Dean.Cook M/.5 l�
ATER'LUINES' . DESCRIPTION
Well Contractor Name / ft. f + ft• ••
2043 A 02 ?`r ft.
NC Well Contractor Certification Number .'151OUTER CASING(for multi-cased'ivells)OR.LINERSif ap licable)
FROM TO DIAMETER . THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 6 ' it + ft. 8;". in. ,524-,-...z i /)vc
Company Name . .16:INNERCASING'OIRTUBING:(geothernrafelosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: E.) 7/(,,rX-3-/t' ft. ft. in.
List all applicable well pannits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use.(check well use): 17.SCREEN . it '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
�� � ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) [9YCesidential Water Supply(single) _
❑Industrial/Commercial DResidcntial Water Supply(shared) 18:GROUT
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑Irrigation $fr. ft- / �✓
❑Monitoring URecovery 3' / ii�,�G�c�
Non-Water Supply Well: `3 . //QH,!
ft. ft.
/7t4.,..J`_.,,;/6-r' I._-v e'' z'£/ /?-ry
Injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation •'19.SAND/GRAVEL PACK -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ' ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control .20.DRILLING LOG(attach additional-sheets iinecessar').
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft.
•
ft. ft.
4.Date Well(s)Completed:p,3-/92 Well ID# _t_ 12,2 --S ft. ft.
5a.Well Location: ft. ft. "-'w •,_
tT `/ �'�r lit 0//-0-'i /Y,%. ft. ft. _ _ 6 •
� LP C. , v �,�,s F_�..__
Facility/Owner Name Facility ID11(ifapplicable) ft. ft.
IYIA %s ^ 1
1 5 f /1: 2A-A9/2/ JC/4 /1 441, ft. ft.
Physical Address,City,and Zip ..21:REMARKS . 'Ittav" 4`71 '-,I...,:'.'5: : '1 Irli
M muss 7,5- 3 i -5 2
LwiC,if u'?(y J
•County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
33' z)6 35-`+ N -. - t•" .3' ., w .� �� - L __ '-/7-,2"/-42
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Pill4manent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with l5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ro o this record has been provided to the well owner.
7.Is this a repair to an existing well: L7Yes or OP' py•f
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or well
repair under 1121 remarks section or on the hark of this form, additional
You may use theback this page to details:a additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCI'IONS
submit one form. �_._
9.Total well depth below land surface: ,2..55' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdifferent(example-3@200'and 2@I00') construction to the following: ,
casing, �e ` (ft.) Division of Water Resources,Information Processing Unit,
If water
Static waterlevel bgow top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
/jsvatet level is aabove cnsi ,use"+"
11.Borehole diameter: 6" (in.), 24b.For Injection Wells ONLY: In addition to sending the form to the address in
' 24a above, also submit a copy'of this form within 30 days of completion of well
12.Well construction method: Rotary 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 WELLS ONLY:
/ Air lift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)_ (vG7 '` T Method of test:_� — Also submit one copy of,this!form within 30 days of completion of
well construction to the county health department of the county where
13b.Disinfection type: M&_H.______._ Amount:. 2 Qz___ ..-_._- constructed.
Form OW-I North Carolina Department of Environment and Natural Resources--Division of Water Resources
Revised August 2013

QsOLe�r D 2.../
I �A �m Macon County NEW WELL CONSTRUCTION
;� ,m Public Health CONSTRUCTION AUTHORIZATION
'tl , a� PRIVATE DRINKING WATER WELL
APPLICANT/OWNER John and Pamela Walker LOG# 071623-P OSWUVA 113122-S
INTENDED USE Single-Family Well, Residential PID # 7502033257 ACREAGE' 7.41
LOCATION TBD East Hickory Knoll Rd
DIRECTIONS Georgia Rd,to Riverside Rd,to Hickory Knolls to East Hickory Knoll.Rd,The last R before gate at end of East Hickory Knoll Rd
Permit Conditions 3i2,tl
Well shall be constructed in compliance with all NCAC 2C Rules. l�Maintain minimum setbacks as applicable. ,J I" -- .2
Diagram (Not to Scale)
/ • —__ .
•
i
i
P/4 /
i.,-"- /
/ \
/ //
// ��`,/Str, 66'
/ tir)
Nose slope 10' 1/6'
Qa 73'
—
45'; l- '-�1 '• Proposed 2 10'
•JS 8 BDRM Ld
o home
Ex.Gravel road ---
roy rd,'S.tr. r __, 10 '),.
I 30' Proposed
well area
1
1
nif 60' I• Repair 65' S0' 65' IN'
I (30x60')
I
Ip I 3cr _ .
f"
21'
19' 10' 13' A
\
104'
146, 153' ~ N
160'
Pit "'
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: 7/31/2023 Jeremy Pless, REHSI 3157 z�.-'�--` Authorized State Agent