GW1--02634_Well Construction - GW1_20240501

WELL CONSTRIJCTLON I2ECUItI) - For Intern yl Use ONLY: j
This form can be used for single or muh :w ipleells _.._._._
1,Well Contractor Information: — _ i,, . _ -.•_
• Mitchell Dean Cook . ::14,WATERIONES•_-- T 1. . ..
' 1 FROM 'TO _DESCRIPTION ,_,,,_,_,__
Well Contractor'Name ^— _ _ :�J ftft.— Lice....j ft.
2043 A it. ft. 1 I . —
NC Well Contractor Crrtificaiion Number d5.OUTER'CASING.(for:multi casedwells)''ORLINER iit:applicabte�__�l,•_
- FROM ` TO DIAMETER THICKNESS I.MATERIAL.
Dennis Holland Well Drilling', Ind.
. p•• ft. r`ft. 1 1. in. i ,
• Company Name ••16:INNER'CASING OR:TUBIZNV(„Sgeothe_rtnahclosed-loop):.. ,•.• ____
FROM TO DIAMETER 'THICKNESS .MATERIAL �
'2,Well Construction Permit if: '• ::_,J' a- c .3.—e._. _ _. ft. ft. • li in. .
list all applicable well permits(i.e.County,Store, Variance,Injection,etc.) -• f6 ft.~-T i; ' in.
;3.Well Use(check well.use): ' .. SCREEN--N T_._:-._-_-•--•_ s` •
•
•
Water Supply Well: ' FROM �•-TO DIAMETER SLOT SIZE THICKNESS MATERIAL. '
io.
°A(3rictilhtral • {7Mtmicipal/Public •
it ft. __ _ --.- - •--
ClGeotherntal-(1•IcatinWcooling Supply) 7 esidential Water Supply(single) ft' ft.7 .
^in•
Uhtdustrial/Commercial • L)Residential Water Supply(shared) 18,CROU.7^ �T
- FROM •,'f0 ['MAfE.RIAIT.--. .EMPLACEMENT METHOD&AMOUNT-
Cllni
4 ft. _.,7, ft. 6,.� a, . / •-Gci ud-d+/'`'Pc"/
Non-Water Supply Well: '
• fL r fL tip-, • _ ?y 4•_'._f't �rf
L7Monitrn'ing l]Recovery __ G �, ! Fn '-
Injection Well: ft. ft.
•
°Aquifer Recharge °Groundwater R.enu;diation ..1.9,SAND/GItA.VELi PACT(if;eppiicable) . •
_ FROM ' TO MATERIAL EMPLACEMENT METHOD M—•_]
°Aquifer Storage and Recovery 17Salinity Barrier _
ft.. ft.
°Aquifer'fest L]Stormwater Drainage, fL^ ft. ,
°Experimental Technology °Subsidence Control 20:DR1l.I,ING LO C• attach'ailfinoaelxheets if necesse
_ °Geothermal(Closed Loop) - ❑Tracer ' FROM TO DFSCRH'TION—(color,hardaessooillrock type,grain eizeygts.L•V•
°Geothermal(Heating/Cooling Return) °Other(explain under 421 Remarks) ft.— ft. II'�^�_ `� ___- -
,,
___ _ _ ...,..._. ,
4,Date Well(s)Completed: e c:tt 17,, f)A/ell IDfI__/V � ft, ft. ,' -^
Sa.Well Location: . ' ft. - ft: I' tl._r Nd�' �� J j
A G 'w � �G�ra� � , � _a_ -14 _ -—_ MAY _ -
Facility/owner Name Facility Ott(if applicable) - -
.'.J el.. :-fra,;i•�, ./7 at.Gi+a:vJ ft. 'bat n11 yt r
• Physical Address,City,antl'Lip 21• .REMARKS __ _ — --•
• %.e".. 3___ •- 6.,rz.,e-a r2. iiiv'&ll 3 i %' __•. .
County • Parcel identification No.(PIN)
. Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: , 22,Certification:
(if well field,one Iat/lmng is sufficient) I' 1'
35` 11
©5"i.5%..2. ;0 �,9 �r. / ! O L 1 Z
.
, Sit taetre of Certified Well Contractn'r.1 Date
6.Is(are.)the well(s): peficiane.nt or °Temporary lty signing this forth,I hereby certt&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards turd that a
7.Is this a repair to an existing well: -°Yes or gJ'N • copy of this record has been provided to the well owner.
If this is a repair,fill oat known well construction it fbrmation and explain the nature of the 23 Site diagram or well details:
repair under IL?I remmka.rertiar or on the hack of this form.
You may use Im,back additionalof tis pogo to tails:provi 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 sante construction,you cari SUI3MITTAI,,INS"CLICTIONI
subnrir one form. ..._ ____..__�
9.Total well depth below land surface: gU3 ' _(ft.) 24a. For All Wells: Stibmit1(his.form within 30 days of completion of well
- For multiple wells list all depths if different(example-3@200'anti 2 at l00') construction to the following:. I:
•Divi
sion of Water Resource's,Information Processing Unit,
10.Static water tolevel
ca below top of casing:_� -- - a ICcntcr,Raleigh,NC 27699-1617 ,
!(water level is above ca ing,use";"
11.Borehole.diameter: 6' (in.)• 24b. For Injection Wells ONLY: In addition to sending the form to the address in
2.4a above, also submit a copy,of this form within 30 days of completion of well
12.Well construction method: Rotary _.-_._-______ construction to the ii>Ilowing: •
(i.e.super,rotary,cable,direct push,err..)s _ - I
Division of Water Resource s,Underground Injection Control Program,
1636 Mail Service.Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
• Air lift 24c.For Water Supply&loll coon Wells: .
13a.Yield(gpm)._,__ /_ _.____.._._ 1\'lethod:of test:__•__. ._.___._..._.._.._ Also submit one copy of this form within 30 days of completion of
13b.Disinfection ty
1_1
i l Z well construction to the couritylhealth department of the county where
12
e:._..._._................._.. •
Amtlttttt: �._.._.___._...
p — — constructed.
'
Form OW-1 North Carolina Department of Guvironment and Natural Resources-Division of Water Resources
Revised August 201;1
i

Q<Ote�r
o ` l m Macon County •
•
E a Public Health
NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANT/OWNER Alfred and Deborah Rasso LOG# 120523-PA 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)
/414114 Ex.Septic uoDrain field o/• Septic Repair \%
f Area
Oo�4mQ�i
i i
t, 17': ZA ✓ / 69,
Ex.Dry Min / % \Power
Well r �J \Pole
2s'
Pn' •.• .
�ryt
ate ®Large Permitted Well
• Tree Location ►��4
Ex.Dry (120523-PB)
Well � ,
Property Line 6a a
Quail Haven Kd
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: 4/5/2024 Jonathan Fouts, REHS 1979, klUUM1` f ► Authorized State Agent