GW1-2021-00457_Well Construction - GW1_20210727

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-00457
Are you submitting a printed form?* r Yes
F No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
TIM MATHIS [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F 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#:
2020-20246-9-10754
List all applicable well construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
C Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/25/2021 6
(gallons per minute)"

5.Well Location
Facility/Owner Name
MARK AND VICKI TODD Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Jackson 7630-74-2165
Physical Address* Street Address
2563 Webster Road
Address Line 2
City State/Province/Region
Sylva NC
Postal/ZZp Code Country
28779-6805 US
Latitude* 35.3366000000 Longitude*83.2351240000
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 explain 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
400 surface?
Formultiplewells listall depths if different 73
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
160 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)
6 13a. Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH GRANULAR 11.25
14.WATER BEARING/FRACTURE ZONES

From To Description
130 135
in feet in feet
350 355
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 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
0.00 20.00 CEMENT POURED/12 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 73.00
in feet in feet
73.00 130.00 GRANITE
in feet in feet
130.00 135.00 CAVITY
in feet in feet
135.00 350.00 GRANITE
in feet in feet
350.00 355.00 CAVITY
in feet in feet
355.00 400.00 GRANITE
in feet in feet
21.Remarks
USED DRIVE SHOE
22.Site diagram or additional well details:

You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
*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*
Signature of Certified Well Contractor
Submittal Date 7/27/2021