GW1-2021-00134_Well Construction - GW1_20210615

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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 1-2021-00134
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
4536 A W.DALTON SNODGRASS AAA GREENE BROS.WELL DRLG.
2.Well Construction Permit#:
2019-13609-9-7630
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
6/4/2021 2 GPM
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
ROLAND TANNER Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Jackson 7614-09-2846
Physical Address* Street Address
403 Boot Hill Road
Address Line 2
City State/Province/Region
Whittier NC
Postal/ZZp Code Country
28789-7169 US
Latitude* 35.4583000000 Longitude*83.3326000000
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.) 9a.What is the depth of the casing from ground
350 surface?
For multiple wells Iistall depths if different 140
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
140 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)
2 GPM 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
160 165
in feet in feet
290 295
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 140.00 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 POURED/8 BAGS
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.)
0.00 140.00 CLAY/SAND
in feet in feet
140.00 160.00 GRANITE
in feet in feet
160.00 165.00 CAVITY
in feet in feet
165.00 290.00 GRANITE
in feet in feet
290.00 295.00 CAVITY
in feet in feet
295.00 350.00 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*
/V. bALTDA! SAVg Off
Signature of Certified Well Contractor
Submittal Date 6/15/2021