GW1-2021-00025_Well Construction - GW1_20210316

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WELL CONSTRUCTION RECORD
NORTH CAROLINA
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• Construction Electronic
North • Department of • - , Quality
Di\Asion of • •
September2020
Submission ID# GW1-2021-00025
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
................................................................................................................................. .................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Well Contractor Name NC Well Contractor Certification# Company Name
TAD THOMPSON 4364-A AAA GREENE BROS WELL
DRILLING OF SYLVA, INC.
2.Well Construction Permit#:
2020-18250-9-9105
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well C Geothermal(Heating/Cooling Supply) C Industrial/Commercial
C Irrigation C Municipal/Public/Community
(-- Residential Water Supply(single) C Residential Water Supply(shared)
C Wells> 100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
8/17/2020 30
(gallons per minute)"
5.Well Location
Facility/Owner Name* ROBERT MOSS

Facility ID# (If applicable)
County* Parcel Identification No. (PIN)
Jacks( 7553-68-6846
Physical Address* Street Address
North Norton Road
Address Line 2
City State/Province/Region
CULLOWHEE NC
Postal/Zip Code Country
28723 US
Latitude* Longitude
35.158889 83.162222
Decimal degrees Decimal degrees
6. Is(are)the well(s):* (- Permanent C Temporary
7. Is this a repair to an existing well:* C Yes (-- 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:
9.Total well depth below land surface:(ft.)
590
For multiple wells list all depths if different(example-3 a200'and 2@100')
9a.What is the depth of the casing from ground surface?
21
in feet
10.Static water level below top of casing:(ft.)
300
If water level is above casing,use
11. Borehole diameter: 6.125
in inches
12.Well construction method:
C Auger r Air Rotary
r Cable Tool C Direct Push
r Mud Rotary C Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
13a. Method of test:
If applicable

13b. Disinfection type:* 13b.Amount:*
14.WATER BEARING/FRACTURE ZONES
From To Description
560 565
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
To From Diameter Thickness Material
SDR 21 PVC
in feet A in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
20 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 21 SAND
in feet in feet
21 560 GRANITE
in feet in feet
560 565 CAVITY
in feet in feet
565 590 GRANITE
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only

*r1 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
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Signature of Certified Well Contractor
Submittal Date 3/16/2021