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Home My WebLink AboutGW1--05937_Well Construction - GW1_20241009 • WELL CONSTRUCTION RECORD �. .. - ---- Tins form cantle used for single or multiple wells For InteneJ Use ONLY:T 1,Well Contractor Information: • - , Mitchell Dean CC)Ok 14.WAT:ERZONES• .i,. • . • FROM TO DESCRIPTION Well Contractor Name • i ft. �"--�-- 2043 A `IL- om-- I ft. ft. NC Well Contractor Certification Number 15.OUTER 6:ASING(for,multi,cased;wells"OR LINE' -If:ap lcable�__-. Dennis Holland Well Drilling FROM TT DIAMETERI THICKNESS MATERIA L, Inc. . ft." O, SS ft, •,, in. Company Name "' ••16:INNER'CASING OR:TU:I'(.'(geothermal..eltis :oo '••- FROM To DIAMETERMATERIAL 2,Well Construction Permit IP_ _!„'�_ ,4, ,.?.'t� M / _ It. t in, � List all applicable well permits(i.e.County,State, Variance,Injection,etc.) _ -•;, • ___..__ — n - ft. ft. -in. 3.Well-Use(check well use): 17.SC[tF;FN'-.--"7.- -- -1�'- Wafer Supply Well: __________ FROM TO-- DIAMETER f SLOT SIZE TRICKNESS MATERIAL,^, • °A ricultural ft., ft in,' 0 L7Mtmicipal/Public -__ faoeothertnal(I•leating/Cooling Supply) 7 esidential Water Supply(single) ft. ft. +_ in.' ---_ _ , Olndustrial/C:ommerci_it • C1Residential Water Supply(shared) l8.GRUUT" �'T FROM __..TO MATERIAL, ENIPLACEMENT METHOD&AMOUNT 0 IrTl.atiOli - , ft. i ft. _ Non-Water Supply Well: - - f_, ft-- �' fr. �//• Ta. /� • °Monitoring URecovery _ �.,v /4,i 'r - Injection Well: —'` -" R, ft. °Aquifer Recharge {Groundwater Remt.diation •.1.9.SAND/GRAVEL PACK`SApplicatile)_' - ' OAquifer Storage and Recovery f:]Saliniry Barrier r . FROM TO MATERIAL.' EMPLACEMENT METHOD ft. ft. ❑Aquifer Test DStonnwater Drainage - • --- ft. ft. ' {Experimental Technology I:Subsidence Control • UGeothennal(Closed Loop) '20:DRILLING LOG.('attacli nditiiionahsheets if necessg� - p) l 1Tracet FROM TO DF.SCRIPTION�e�lor,hordors>aoWrack type,grain size,eieA.- °C'reothermal(Heating/Cooling Return) •00ther(explain under N21 Remarks) ft. ft. T- ft. ft. Date Well(s)Completed:C? j.. gZy(yell IDH__/VI:h�� i _ ft. ft. 5a Well Location: -/ _ -- Pgoee lecaclOLd/.5 ft. ft. ,' r ... l...,k.. . i ii... - ' - 4 Ti.4y V „ram.. L C,,.. .,1a.. _ ft. ft. C q _..-.-.-.--......._..__.�__._ ____...._..._._..__.__ n GI_:.0_.9.._ ____.-- Faccilliity/Ow�neer Name Facility/1DN(if applicable) ft h: • • .J J t .,st-k'f .f^�Y *�' r✓. ...._......—..f6... .-._�....ft. --•- ----.�1•r-�';r;n�i:- . �•r',;^ T.:.Fs t Physical Address,City,and Zip - - ""0..r """.s.l43 1`'`_- fi ` �iy _21,REMARKS -- ...._ County areal Identification No.(PIN) Sb.Latitude and Longit de in degrees/minutes/seconds or decimal degrees: 22,Certification: I ^ Orwell field,one tat/long is sufficient) J 2 • ?D° t 1 I 0 3 " .w_�..g3 b 'u ' aS"W , 'r- .L4,,,,,./z_ �_- G .42 o--.2 Signature of(:crtt5ed`Well Contractor r Date • 6.Is(are.)the well(s): pefrnanent or f_"ITcmporary By signing this form,I hereby certify that the well(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: DYes or PlIctir copy of this record has been provided to the well.owner. If this is a repair,fill out known well construction it jbrmarion and tccplain the nature of the 0 • repair under 1121 remarks section or on the back 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 S.Number of wells constructed: ___ construction details. You may ttls• +attach additional pages if necessary. For multiple injection or non-water supply wells ONLY with the same construction,you can • submit one form. SUBMITTALNS lTLICTIONS 9.Total well depth below land surface: /'t .5 ' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(esatitple-3(0200'and 2 a®100') -construction to the following: ,,_ - 0 10.Static water level below top of easing 7D _ (ft.) 1)i'visian of Water Resoui ees,'Information Processing'(1nit; Owner level i.raboveeosing,use. "�" 1617 Mail Servicel(;enter,Raleigh,NC:27699-1617 6 11.Borehole diameter: (in.) 2lb. For lnjrction-Wells ONLY: ,In addition to sending the form to the address in Rotary 2,1a above, also submit a•-cOpy of this form within-30.days of•completion of.well 12.Well construction method:_ ry construction to the ti111owing: j (i.c.auger,rotary,cable,direct push,etc.) Division of Water Resources,;Underground Injection Control Program, 1636 Mail Service• 1Ccnter,Raleigh,NC 27699-1636 FOR WATER SUPPLY WELLS.ONLY: (gpnl) Air lift 24c.For Water Supjlly&Injection Wells: 13a.Yield ___ - Method of test:__._„_____•____•-, _._._ Also submit one copy of this Form within 30 days of completion of 13b.Disinfection type:,I-I &,.. Amount ,12 oz. well construction to the county'health department of the county where _... __ ._._. .._ constructed. Form OW-I Not th Carolina Department of Iinvironmetft and Natural Resources--Division of Water Resources Revised August 2013 (Tho ..• • Iii I 183.O.Lakeside Dr Macon Count - PubliHealth y Franklin;NC.28734 c (828)349-2490(Office) o • � ,'7'?? • (828)349—4136(Fax). • y � a WELL CONSTRUCTION AUTHORIZATION . - ty Owner -;Peaceful Meadows Tiny Village,LLC W L' ", 081624-1 ;' T8D `sLacation t.527 Saunders Rd ,SEP ,1;Drrechons,'Cat Creek Rd,R.onto Saunders Rd, Property on L. — .� -` PID,'a:, 7504393663 ;,ACREAGE 28.86 )l};,;pesign, . Shared Well =..Permit Type :New Construction--�_ -sExpiratiom: Valid for 60 Months . s' 9 . N . 44.0 . , . . S . Ex.Shared Well. rr.,. • P/L Fence 17' a • - Well Area ' • - (-------Th - - . 100'Min (30'X 15') 15'. :' Q81.624-1 Pad . , a . . ._ 30' ^10' _I . 0 • GC 've��d Pad Diagram not to scale Permit Conditions ' 1) Well shall be constructed in compliance with all 15A NCAC 2C rules. 2) Maintain all minimum setbacks,were applicable, 100'setback to all parts of septic systems. 3) When well and pump are completed, contact MCPH for inspection. The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking.with appropriate governing bodies In meeting their requirements.This permit is subject to revocation If the site plan,plat,site,or•intended use.changes..AII rules-In-15A NCAC.02C Well.Construction Standards are incorporated by reference into this document,including any subsequent amendments to those rules and shall be adhered°to:Please contact MCPH for inspection when well head and pump installation are'completed and you are ready to place.well into service. . Any.person abandoning a well.must submit to MCPH Form GW-30 upon completion.. ' ' C--� . .. ' . . ' September 9, 2024 Issue Date- Trevor Justice EMS(3294 _