GW1-2021-08177_Well Construction - GW1_20211231

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
GW1-2021-08177
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
TIM MATHIS [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4536 A' W. DALTON SNODGRASS AAA GREENE BROS.WELL DRILLING
2.Well Construction Permit#:
SAS 158W
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
11/26/2021 5
(gallons per minute)"

5.Well Location
Facility/Owner Name* Facility ID#
AMERICAS HOME PLACE JOSEPH MIELE JOB
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Haywood 8711-37-2043
Physical Address* Street Address
366 Caring Place Loop
Address Line 2
City State/Province/Region
Clyde NC
Postal/Zip Code Country
28721 us
Latitude* 35.3914000000 Longitude*82.5945000000
Decimal degrees Decimal degrees
................................................................................................................................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes 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
250 surface?
For multiple wells list all depths if different 69
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
80 6.125
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
5 13a. Method of test:
If applicable AIR
13b.Disinfection type:* 13b.Amount:
GRANULAR CHLORINE 8.10 OZ
.......................................................................................
14.WATER BEARING/FRACTURE ZONES

From To Description
80 85
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 69.00 6.00 SDR21 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 CONCRETE POURED 10 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 69.00 CLAY
in feet in feet
69.00 220.00 GRANITE
in feet in feet
220.00 225.00 CAVITY
in feet in feet
225.00 250.00 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
.... ......... ......... ......... ......... ..... ......... .........
* 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
lU- F�TL
Signature of Certified Well Contractor