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Home My WebLink AboutGW1--02636_Well Construction - GW1_20240501 , . . . . , . . • . • . . . . . . . . . . . . WELL CONSTRUCTION RECORD - , .........._ ... ____. . _ _ This form con be used for single or multiple wells —7 , For Intent&Use ONLY: • • • ' . ' . • • .. . . ' 1.Well Contractor Information: • . • . • ., . • —. ' , _ _. Mitchell Dean Cook . . •lel:WATER-ZONES' . ` . I. - -. - • ''. ' -• -' TO - okscturnON— --- .„,,,, . FROM —... . Well Contractor-Name ' - .,.. 11. 3.e././ 'It. ' ,• 1. ., . . ... . 2043 A ..'. . , . , - ••. ft I ft. • i - • . .. • . !. .. 'NC Well Contractor Certification Number,'' •15.OUTER'CASINGlfor•multi-eaked.wellsio:rilvANER if.applicable) ' • . . - . . „,FROM ....... TO • • DIANETERI: : . IIC .NESS„- 1'MATERIAC----- • . Dennis'Holland Well Drilling, Inc: : . .. .6 , ff. ...,2,..24.,--rt. ..6..',., ,'..•., • ir wil.•P Company Nabs '1 G ORTULitslf4futijherniittelcisedloon):.: ,-- • •' . ' „, . •2;Well Construction Permit II: FROM TO DIAMETER. THICKNESS MATERIAL ' : • e.)_:..eaE.,?:,..2 *'•/?:'.... ' ' mitt,ll applicable well permits(i.e.County,.State, Variance,hijection.('tc) . ----, -- - "- — , ....—:..... ,s = . ft. ' • ft. , ' ;in, .. • • :3.Well Use(check well use): . • — 17.SCREEN • " : It_4 .• . . • , • . - .• . _ Water Supply Well: --; .FROM- TO DIAMETER %SLOT SIZE TIIICKNESS I MATERIAL, . - , , - , ' • - . DAgrieultural - .. DMunicipal/Publ ie. . ft. R. in. . 121Cleothermal(Heating/Cooling-Supply)_',-.pt‘ide.ntial Water Supply(single) - ft. ft.: in. 1:, • • I . °Indust rial/Cominereial OResidential Wisner Supply(shar ed) -- - __18..5.3_R...2Y.I __..___._... _________I Ellrri:t1IIOD FROM TO 1 MATERIAL', EMPLACEMENT mEmoD&AMOUNT .. • . . ,.. _7_, ., ft. ;LC, . 6/. /*--) Non-Water Supply Well: . ... ft. • DMonitoring . t• -- l2.112.e.00very . - -- _ ,____„;_________ • In • -- .-' • •jection Well: — , ft. ft. DAquifer R.echarge • , ' 00roundwater R.emediation - . .19.SAND/GRAVEVPACK'OlAphyeable):. - •• . - •., ' , DAquifer Storage and Recovery DSalin , . FROM TO MATERIAL. EMPLACENIENT METHODity Barrier , .. - °Aquifer Te ft. '' st , OStormwater Drainage . ' ' ft. ' . . ft . • . °Experimental Technology 1138tibsidenec Control -- , . . , : IAZ:LOGiartrclailititionat'sbeets it necesl_R ;- ta _:: - • . LIGeothermal(Closed Loop) • ' O 20 DRIC Tracer ' .,. . FROM -7.-- TO DESCRIPTIOncolor,hardness,soilkock Vise,grain size,OSA:7 , . .. . . • . .. flicieothermal(Heating/(ooling Return) , CJOther(explain'under 821 Remarks) '. ' It . , ft. _.,_. . - -4' Date Well(s)Completed. i-Q9..._..c.,f, iV• ell D# /v /. t. —,•---t.------ —1-. Sa.Well L ._... ocation: ' ., , . . „' , -- . -- . .',.' . " ft: , ••ft. i: %.771?.(-f.k.- X -4-e-41.Qr.A.4.V.k,,..' , •' --I ..ALIIHL.. . • It. . ft. ' M AY - 1 Facility/Owner Name .,- ' Facility ID//(if applicable) ft. -. ' ft. - •,'Ir$-----,,. • • •.. , ,.t„,,...,47...,no. Pqr.‘c..":14r•-w:pi-,,..,3-' -1.,:•'•,..-u-''''--- -.- . • ___.4..s.L .1.-____3- 40..0_,',:_:4;e:_ji-o-te:;,$. 7. ' . , ft. ,, ft. ','- -1::t CYLtoG ' -— Physical Address,City,anal Zip - . ....„ • ------ — • • -- . • 21.-REMARKS ' , . .. , - ,444Le,y, . . .• • -. ....2-..ezie _is1Q 1.:_ ._ • . . . . _., •_. ._,_ . . . --- .--'•-•,- • County : . : ••.. Parcel Identification No.(PIN) — — . .-. '. . - ,• .Sb.Latiiuddand Longitude in degrees/minutes/seconds or decimal degrees: . '22.CertifIcation:• .. . , . (if well,field,Miie lat/long Is sufcient) - ' I' ' . .. . . 30 " : -, 9,2, // , /' ' . '17 :11_czyl,-/ k- _, 4: •':e_t __ . . Signature of Certi6ed Well-Confractor...,I. ' Date . , - , 6.Is(are)the well(a): li1P-efiiianent , or EITemporary • .. Fly signing this Jima 1 hereby certifr that':the well(s)was(were)constructed its accordance ' . • . with/SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: Oyes. 'or 7 WI.6 -.. - copy.of this record has been provided to than well owner. . 1 phis is a repair,fill out known well construction itilimmation and eiplain die;finials of the 23.Site diagram or additional well details: repair under P21 remarks section or on the back of this form. • 1 . . - • You may use the hack of this Page to provide additional well site details or well • . • • 8.Number of wells constructed: construction details. You may also attach additional pages if necessary. For multiple injection oiyson-wates•supply wells ONLY with the same eonStruetints,you COI? l' , Submit one form. SUBMITTAI INSTUCTIONS ,. • . . , . ' . , • • • . • ' 9.Total well depth below laud surface: 74,4'- . . •- •_(I ) 24a. For All Wens:. Submit this fonts Within'.30 days,Of completion of well For multiple wells list all depths if different(example.3®200'and 2®100) construction to the f011owing: . , . , . . .• 10 ,,, Stalk water level beloiv top of casing p (ft.), :,„ — ' Division of Water Resotres,'infatuation Processing Unit, : :' j_ ' '2,- L,. _ . _ . . . .limner level is above casing,use"4" " • ' . 1617 Mail Service Center,Raleigh,NC 27699-1617 , 11.Borehole diameter: ' ' 6" . _(in.j. • ,-.''''•:. •..- ' • • •.1,11). Fbr Initstion Wells ONLY: In laddition to sending the form to thesidd ress in 24a above, also submit a copy of this fonts within 30 days of completion,of well .. '- - • :12.Well construction method: . • ' Rotary " . constluction to the following:. • 1 ''..,..._ . • (i.c.auger,rotaiy,cable,direct Push,etc.) - • • ....... . 'I ,, ..._ - , , •- Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS'MIN:* • . • ., . _....„. , 1636 MailService Center,i Raleigh,NC 27699-1636, ' • • . . • I • • 24c.For Water,Suppir&Injection,Wells: . 13a.Yield(gpm)____ __,/ ________ Method-of test:_Air.l.ill• . . • Also submit one copy of this forriii within 30 daysof completion of - '13b.Disinfection type: H & H,,....,,_ . ____ Amount:.1 2 d i.-" well construction to the, county healtb department of the county where --- _ ',,,,, .constructed. ' I ' - . I . ' , •. . . Form GW-I Nos th Carolina Department'of Eiwironment and Natural Resources-Division of Water R6sources Revised August 2013 ' • I I • • (7.a fe �Gl U-' '" L- - / .Qotepr, • _ ',n Macon County •E � d Public Health � NEW WELL CONSTRUCTION cCONSTRUCTION AUTHORIZATION 'n , e - gilt- 911e-007 /_ PRIVATE DRINKING WATER WELL t._ nPPIICni;T10410 O #k ER Jeffrey Browne ,.--_ ,l ; LG ` 040522-P OSWW 041022-S INTENDED USE Single-Family Well,Residential •LOCATION PID # 7418451801 .ACREAGE ' 133 Lot 55,.Rocky Knob S/D ' DIRECTIONS Dillard Road to R on Hale Ridge Rd.,to L on Rocky Knob#1377 gate code to property on right across from Mountain View Drive Permit Conditions 0 Y . Well shall be constructed in compliance with all NCAC 2C Rules. • ;Maintain minimum setbacks as applicable. . • • • • __ Dia►ram Motto Scale ey, • Rocky Knob Road .q..q `°Oq i • 50' 50' . -0 °° ° >100' oil• isting®prang Box ,° aft�� 120 Poplar . 301 DIV ReP • r t tt et White Pine l: \i. 0 PL 4t.-' 60 60 -....- �� r PoSeaN°pse 2S,hrlq Pine. • 5 m >SO' .• Proposed Single • ' Family Well • • • • j PL . i , • 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 iri any fact or dreumstance 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. i A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED 03 THE WELL IS PLACED INTO • SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?.(828)349-24w • Issue Date: 9/20/2022 Charles Womack,REHS 1300 • u65orhed State Agent