GW1-2021-00040_Well Construction - GW1_20210327

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WELL CONSTRUCTION RECORD
NORTH CAROLINA
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• Construction Electronic
North • Department of • - , Quality
Di\Asion of • •
September2020
Submission ID# GW1-2021-00040
CONTACT INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
Contact Name* TIM MATHIS
Email Address* [e-mail]
This will be used to email you a copyof the submitted form.
WELL CONSTRUCTION INFORMATION
................................................................................................................................. .................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Well Contractor Name NC Well Contractor Certification# Company Name
TIM MATHIS 2598-A AAA GREENE BROS WELL DRLG
OF SYLVA, INC
2.Well Construction Permit#:
2020-16236-9-9002
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 C Geothermal(Heating/Cooling Supply) C Industrial/Commercial
C Irrigation C Municipal/Public/Community
(-- Residential Water Supply(single) C Residential Water Supply(shared)
C Wells> 100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
12/8/2020 10
(gallons per minute)"
5.Well Location
Facility/Owner Name* JASON BEASLEY BUILDERS

Facility ID# BOBBY HENKEL JOB
(If applicable)
County* Parcel Identification No. (PIN)
Jackson 7556-85-8320
Physical Address* Street Address
HUNTER JIM CREEK RD
Address Line 2
City State/Province/Region
CULLOWHEE NC
Postal/Zip Code Country
28723 US
Latitude* Longitude
35.231000 -83.157000
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.)
200
For multiple wells list all depths if different(e)(ample-3@200'and 2@100')
9a.What is the depth of the casing from ground surface?
80
in feet
10.Static water level below top of casing:(ft.)
20
If water level is abo\/e casing,use
11. Borehole diameter: 6.125
ininches
12.Well construction method:
f Auger r Air Rotary
f Cable Tool f Direct Push
f Mud Rotary f Rotosonic
f Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
10 13a. Method of test:
*If applicable AIR

13b. Disinfection type:* 13b.Amount:*
GRANULAR HTH 8.10
14.WATER BEARING/FRACTURE ZONES
From To Description
180 185
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
To From Diameter Thickness Material
80 .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
20 POURED
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 80 CLAY
in feet in feet
80 180 GRANITE
in feet in feet
180 185 CAVITY
in feet in feet
185 200 GRANITE
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only

*r1 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
RA MATPU
Signature of Certified Well Contractor
Submittal Date 3/27/2021