GW1-2021-00109_Well Construction - GW1_20210525

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
NorthCarolina Department of •
Di\Asion
April 1,2021
Page 1
Submission ID#
GW 1-2021-00109
CONTACT INFORMATION
..................................................................................................................................... .......................................................................... ..........
Contact Name* Email Address*
TIM MATHIS [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2598 A TIMOTHY MATHIS AAA GREENE BROS.WELL DRILLING
2.Well Construction Permit#:
121920-s
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* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
3/29/2021 12
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
DAVID AND SANDRA HISEY Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Macon 6586-67-4074
Physical Address* Street Address
Sky View Drive
Address Line 2
(COUNTRY VIEW FARMS LOT 24 AND 25)
City State/Province/Region
Franklin NC
Postal/ZZp Code Country
28734 US
Latitude* 35.1359480000 Longitude*83.2358410000
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 F No
If this is a repair,fill out known well construction information and e)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 GWA is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
300 surface?
For multiple wells listall depths if different 73
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
100 6.125
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
12 13a. Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH GRANULAR 9 OZ

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
260 265
in feet in feet
273 278
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 73.00 SDR 21
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
0.00 20.00 CEMENT
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.)
0.00 73.00
in feet in feet
73.00 260.00 GRANITE
in feet in feet
260.00 265.00 CAVITY
in feet in feet
265.00 273.00 GRANITE
in feet in feet
273.00 278.00 CAVITY
in feet in feet
278.00 300.00 GRANITE
in feet in feet
21.Remarks

22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
*PF 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 5/25/2021