GW1--06757_Well Construction - GW1_20241112

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WELL, CONSTRUCTION R1 ECO]RI) For iRtemal Use ONLY: I ---^•'-----'-- " s
This form can be used for single or multiple wells '
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iI.Well Contractor information:
__./141-1--C-h.e i i De-Ccn C�D 14.WATER ZONES I i -
I FROM TO DESCRIPTION
Well Contractor Name //-} 'ft. 3a... ft.
NC Well Contractor Certification Number 15.OUTER CASING(for awlti-cased wells)OR LINER if a 'abiit
• FROM TO DIAMETER _ TIIICIWESS MATERIAL
..1).k11 n( S kio..)i and VVe1 I. D ri is I f. 3t-1c.. -. - - r ft. m . ft.- , in. �5 l -
d D6 � ,��- pdi.G' -
Company Name 16,INNER CASING OR TUBING'(xeotherrial clwedaoop). ,
• FROM .TO. DIAMETER THICKNESS MATERIAL
:I,,'IWell Construction Permit t`l:. tAJ q 0-�..•Z _ i ft. ft. in.
List all applicable well permits(i.e.county,State, Variance,Injection,etc.) -
ft. ft. in.
3.Well'Use(check well use): J 17.SCREEN M�
Waiter Supply Well: _ — FROM _TO DIAMETER DIAMETER SLOT SIZE
..� THICKNESS MATERIAL.
ClAgriculti ral OMunicipal/Public ft• A. i in. .
—
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) rt. ft. I iti. ~'
Ci
UIndustrial/Commercial esidential Water Supply(shared) 1 .GROUT ,1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
l_)11TI lion _ , ft. ff.
...._.. 'Iza 4 Z rr jr rl " .- s.:,4/°91l'
;Jou-Water Supply Well: �-' Y
J1v1onitoring ORecovery - ' It. ,2.4 r fL �C7i� 4- ; .d 5 . 4 i'-,
Injection Well: ^ �' r�' - ft, ft.
_]Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACKAopplicahle)
0Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. rt.
UAquifer Test OStormwater Drainage . ft ft �—
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attncli additional 41003 if awruawry)
[]Geothermal(Closed Loop) OTracer FROM TO i DESCRIPTION(catty,hardness,soiVrock type,,rain size etc.
C)Geothermal(Heating oolin Retut7 OOther(explain under#21 Remarks) ft. ft. _ '
CUrrieta:' jalk55,ra<1 u -r It, ' II.• •
.,I,bate Wells Completed: /- a 0 Well iDll 1 r ---
Sa.Well Location:l ,t' / ft it, t I 1/
�./.'A Q�'/_e J�r li e� i/ !_v�// _�_ ft. _-- fL� ' _ ._____t7ig.y -6`Ai 204 Z _. ......
Facility/Owner Name Facility lDll(if applicable) -- ------;---.7:----
./1_ ,Dy7,g,L1 f I R• -_.e- .[.._.__ _________T_ ft. ft. 4•' _:i:L.3 -
Physical Address,City,end Zip 21.REMARKS
/Vt aGOh l,57.,2 ! 6S __
County Parcel Identification No.(PIN) •
'Ili.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: I
(II'well field,sue let/long is sufficient)
r.
(f Signature of Certified Well Contractor Date
ti,is(are)the well(s): {b 'ianent or OTemporary
By.signing this form, 1 hereby cery fy that the well(s)was(were)constructed in accordance
• with i5A NCAC 02C.',0100 or iSA NCAC 02C.0200 Well Construction Standards and Mai a
7,Is this a repair to an existing well: OYes or CNo"'" copy of this record has been provided to the well owner.
if fins is a repair,fill out known well construction information and explain the nature of the
repair under II21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
O.Number of wells constructed:__•_ i _ •„ _ construction details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS.
9.Total well d'e.pth below land surface:,•-_ / C1,5 . �_(ft.) 24a, For All Wf1Is: Submilt this form within 30 days of completion of well
For multiple,yens list all depths if different(example-3@200'and 2@i00') construction to the following: I
.Ii),Static water level below top of casing: - ..2. 40
. - (ft.) Division of Water Resources;Information Processing Unit,
If miter level is above casing,use' I-" .__ , 1617 Mail Seryiee Center,Raleigh,NC 27699-1617
It Borehole diameter: ld " (in.) 24b. For Injection Wells ONLY: in addition to sending the form to the address in
24a above,'also submit a copy;of:this:foray within,-30.days of-completion of well
12.Well construction method: Le i fkil:X.' '' conslntction to the following:
11.e.auger,rotary,cable,direct push,etc.) �� 1 '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636-Mail Service-Center,Raleigh,NC 27699-16.36
13a.Yield I (-- • 24c.For Water Supply&Injection Wells:
(gpm)u I ivtethod of test: I r 1.! L Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type:1-LiH, Amount: . )el-OZ. __ well construction to the county health department of the county where
.._.....-_.___ �.� .—.. __�_ constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2011
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t�bi'� (J_P / ,t-, -, u CLr1C_19Cz..�
`01 •m Macon County
o ,a Public Health j j --(r`7 I �l
d NEW WELL CONSTRUCTION
CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
PP[ICANTJOWNER : Michael Scofield ' •
, LOG#:` 090224-1 OSWW4 101720=S
-INTENDED USE Shared Well, Residential `PID6#; 6572446582 ACREAGE ' 2,49
,:,LOCATION'` 115 Jonquil Ridge East •
;,DIRECTI .7 -S' 115 Jonquil Ridge East .
Permit Conditions o
Well shall be constructed in compliance with all NCAC 2C Rules. t
Maintain minimum setbacks as applicable. �-�•c2 C cc
Contact MCPH when well is completed and ready for inspection and water sample.
Diagram (Not to Scale)
• . 95' /' I. . ..-...
efil Gne i P
marked.wet'Ones along Pro, -
341
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o 122' c, o
5 ' 51 122' o_
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201-• 0, Oak N1eU
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10'� .
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Tiny 99' 5
Home
PL gcceSS Rd
PL
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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: 9/52024 Chaz Allen, REHS 3258 l / ' Authorized State Agent