GW1-2021-00036_Well Construction - GW1_20210323

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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# GW1-2021-00036
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
TIM MATHIS 2598-A AAA GREENE BROS WELL
DRILLING OF SYLVA, INC.
2.Well Construction Permit#:
MCM-199W
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
3/1/2021 2
(gallons per minute)"
5.Well Location
Facility/Owner Name* AMERICA'S HOME PLACE

Facility ID# JASON SMITH JOB
(If applicable)
County* Parcel Identification No. (PIN)
Haywood 8627-73-1667
Physical Address* Street Address
Woodlawn Circle
Address Line 2
City State/Pro\ince/Region
CANTON NC
Postal/Zip Code Country
28721 US
Latitude* Longitude
35.538200 -82.942600
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r 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.)
500
For multiple wells list all depths if different(e)(ample-3@200'and 2@100')
9a.What is the depth of the casing from ground surface?
66
in feet
10.Static water level below top of casing:(ft.)
100
If water level is abo\/e casing,use
11. Borehole diameter: 6.125
in inches
12.Well construction method:
f Auger r Air Rotary
f Cable Tool f Direct Push
f Mud Rotary f Rotosonic
f Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
2 13a. Method of test:
"If applicable AIR

13b. Disinfection type:* 13b.Amount:*
14.WATER BEARING/FRACTURE ZONES
From To Description
115 120
in feet in feet
-90 495
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
To From Diameter Thickness Material
0 66 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/8BAGS
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 66 CLAY
in feet in feet
66 115 GRANITE
in feet in feet
115 120 CAVITY
in feet in feet
120 490 GRANITE
in feet in feet
490 495 CAVITY
in feet in feet
495 500 GRANITE
in feet in feet
21. Remarks

22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
*W 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
TIP MATPU
Signature of Certified Well Contractor
Submittal Date 3/23/2021