GW1-2021-00001_Well Construction - GW1_20210204

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WELL CONSTRUCTION RECORD
NORTH CAROLINA
en.lronmenmf Quurlry
• Construction Electronic
North • Department of • - , Quality
Di\Asion of • •
September2020
CONTACT INFORMATION
......................................................................................................................................................................................................................................................................................................................................................................................
Contact Name* Tim Mathis
Email Address* [e-mail]
This will be used to email you a copyof the submitted form.
WELL CONSTRUCTION INFORMATION
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1.Who is installing these wells?*
C Owner r Well Contractor
1.Well Contractor Information:
Well Contractor Name NC Well Contractor Certification# Company Name
TIM MATHIS 2598-A AAA GREENE BROS.WELL DRLG.
2.Well Construction Permit#:
2020-18235-9-10456
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* f Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
12/29/2020 15
(gallons per minute)"
5.Well Location
Facility/Owner Name* AMERICA HOME PLACE
Facility ID# NICHOLAS CONNER JOB
(If applicable)
County* Parcel Identification No. (PIN)
Jackson 7640-38-8988

Physical Address* Street Address
43 HIDDEN CONNER HOLLOW
Address Line 2
City State/Pro)Ance/Region
SYLVA NC
Postal/Zp Code Country
28779 JACKSON
Latitude* Longitude
83.213000 35.350000
Decimal degrees Decimal degrees
.............................................................................
6. Is(are)the well(s):* (-- Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)Plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.)
540
For multiple wells list all depths if different(example-3@200'and 2@100�
9a.What is the depth of the casing from ground
surface?
in feet
10.Static water level below top of casing:(ft.)
100
If water level is above casing,use
11. Borehole diameter: 6.125
in inches
12.Well construction method:
• Auger Air Rotary
• Cable Tool C Direct Push
• Mud Rotary C Rotosonic
• Other
14.WATER BEARING/FRACTURE ZONES
From To Description
485 490
in feet in feet
525 530
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)

To From Diameter Thickness Material
0 114 6 SDR 21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0 20 CEMENT POURED
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0 114 CLAY
in feet in feet
114 485 GRANITE
in feet in feet
485 490 CAVITY
in feet in feet
490 525 GRANITE
in feet in feet
525 530 CAVITY
in feet in feet
530 540 GRANITE
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification
O5
Signature of Certified Well Contractor

Submittal Date 2/4/2021