GW1-2021-00038_Well Construction - GW1_20210327

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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# GW1-2021-00038
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 DRLG
OF SYLVA, INC
2.Well Construction Permit#:
2020-19798-9-10354
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
12/18/2020 1 PINT
(gallons per minute)"
5.Well Location
Facility/Owner Name* AMERICA'S HOME PLACE

Facility ID# OPHELIA VALLS JOB
(If applicable)
County* Parcel Identification No. (PIN)
Jackson 7529-13-2506
Physical Address* Street Address
1991 HEMLOCK FALLS DR
Address Line 2
City State/Province/Region
SYLVA NC
Postal/Zip Code Country
28779 US
Latitude* Longitude
35.305000 -83.288000
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.)
980
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?
31
in feet
10.Static water level below top of casing:(ft.)
500
If water level is abo\/e casing,use
11. Borehole diameter: 6.125
ininches
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)
1 PINT 13a. Method of test:
*If applicable AIR

13b. Disinfection type:* 13b.Amount:*
GRANULAR HTH 21.60 OZ
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
To From Diameter Thickness Material
0 31 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 31 NONE
in feet in feet
31 980 GRANITE
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload 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
RA MATPU
Signature of Certified Well Contractor
Submittal Date 3/27/2021