GW1-2021-01743_Well Construction - GW1_20210916

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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 1-2021-01743
Are you submitting a printed form?* r Yes
C 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#:
MCM-248W
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r 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
7/27/2021 60
(gallons per minute)"

5.Well Location
Facility/Owner Name* Facility ID#
AMERICA'S HOME PLACE SCOTT COOK JOB
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Haywood 866-29-6632
Physical Address* Street Address
15550 Cruso Road
Address Line 2
City State/Province/Region
Canton NC
Postal/ZZp Code Country
28716-5471 US
Latitude* 35.2355000000 Longitude*82.4847000000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* G 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
275 surface?
Formultiplewells listall depths if different 80
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
60 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)
60 13a. Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH GRANULAR 9 OZ
14.WATER BEARING/FRACTURE ZONES

From To Description
255 265
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 80.00 6.00 .188 WALL STEEL
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(BAG HOLE PLUG)
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 80.00 TOP SOIL
in feet in feet
80.00 255.00 GRANITE
in feet in feet
255.00 265.00 CAVITY
in feet in feet
265.00 275.00 GRANITE
in feet in feet
21.Remarks
SELF CERTIFIED EXCAVTOR AND BEAM I BAG HOLE PLUG AND 8 BAGS CONCRETE
USED DRIVE SHOE
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
...................................................................................................................................................
*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*
�/ b&TQk SA - '�A.SI
Signature of Certified Well Contractor
Submittal Date 9/16/2021