GW1--02633_Well Construction - GW1_20240501

WELL CONSTRUCTION RECORD For Iutemgl Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook ,14.,WATER'ONES•,:-: •I .r . ' .
FROM TO DESCRIPTION
Well Contractor Name _ ft. ft.
2043 A ft. ft. i
NC Well Contractor Certification Number '.15.OUTER CASING.(for.multi cased wclls)'OR•L1NER'(if applicable)
' FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. A, • ft 50 -•ft. in. 50""/ P v`
Company Name .'16:INNER'CASING ORTUBING'(ge'othermal closed loop)....
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Id.6,5.2.,,,) -_ ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN, '
Water Supply Well: _ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. in:
❑Geothermal(Heating/Cooling Supply) idential Water Supply ft. ft. in:,
( f;/ B� PPY) � PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL; EMPLACEMENT METHOD&AMOUNT
❑irrigation , ft. .• ft. p
Non-Water Supply Well: •.-. 0 --? ���4U2if�/ / 'A.: e,62
j
❑Monitoring ❑Recovery ft. e � i ft. G,,. • ' h J• - / ' . / d
Injection Well: ft. rt. '� 7
❑Aquifer Recharge ❑Groundwater Remediation •.19.SAND/GRAYEI;PACK(if'applicable).. ..
• FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery • ❑Salinity Barrier • ft. ft.
❑Aquifer Test DStornwatcr Drainage ft. ft --1
❑Experimental Technology ❑Subsidence Control
20;DRILLING LOG.(attach'additionarsheetaif necessary). •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
❑Geothermal(Heatine/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. i
' ft. ft.
4.Date Well(s)Completed: 0TI'••y}S.• Well ID# A.A ft. ft.
Sa.Well Location: ft. ft.
A 1 fi'9:4 t.D..e in--IA A45,6O N// ft. ft. I:._'6 , -4 c.Y ''. i
Facility/Owner Name Facility IDt!(if applicable) —•_-. __ �_�_-_...- ,__ y +s_r . ,
ft. ft.
•
,50-S 064s// J-/Iv(� / S, ft. ft. M14Y V 1 2624
Physical Address,City,and Zip
21:REMARKS ., _ 7
,l/1c�Gc3i� � 'S88 ��2 r3J3'.Ly J �r',d
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) i ,
..35'1>5l 'T 6rY N gr .0 37 J 2 7 W A/I- A/% ,,Ci _aA ' tie. vY ^ D..S 20.).
Signature of Certified Well Contractor . ' Date
6.Is(are)the well(s): pc moment or ClTemporary • By signing this form,1 hereby cert(,that the we//(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or W17.- copy of this record has been provided Jo the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the hack of this form. 23.Site diagram or additional well details:
• You may use the hack of this page to provide additional well site details or well
8.Number of wells constructed: 1 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. SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface: J(2()S (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:
10.Static water level below top of casing: " (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Err 24b. For Injection 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 well
12.Well construction method:_Rotary _ construction to the following: I, ;
(i.e.auger,rotary,cable,direct push,etc.) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp ) Air lift 24e.For Water Supply&Injection Wells:
13a.Yield m __ _ __Method of test:________ _._
Also submit one copy of this form within 30 clays of completion of
13b.Disinfection type:-H_&4i�' _ Amount:. � •__ ,_^___•_- well construction to the county hiealth department of the county where
constructed. •
-Form OW-1 North Carolina Department of Environment and Natural Resources-Division of WateriRrsources Revised August 2013

Qtot`�ce
� .m Macon County
r Public Health
� �
NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
r PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Alfred and Deborah Rasso LOG#. 120523-P OSWW# 103423-S
INTENDED USE Single-Family Well, Residential PID # 6580328929 ACREAGE 4.2
LOCATION 505 Quail Haven Rd
DIRECTIONS Take 441 S to Right onto Coweta Lab Rd to R onto Quail Haven Rd
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Diagram (Not to Scale)
c,7
a
Ir �.
a
oy y
oQ o
Ex. ... ® Large
Well Tree
45' ter'
Property Line .__.�����-„•„�
45
:"1! Quail Haven Rd
A
•
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: 12/6/2023 Chaz Allen, REHS 3258, ✓IWr— Mlti— Authorized State Agent