GW1-2021-00095_Well Construction - GW1_20210509

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Page 1
Submission ID#
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
2598 A TIMOTHY MATHIS AAA GREENE BROS.WELL DRILLING
OF SYLVA
2.Well Construction Permit#:
0405 SWAIN COUNTY
List all applicable well construction permits(i.e.IVbnitoring 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

1/6/2021 3/4
(gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name* Facility ID#
PHILLIPS BROTHERS JASON PHILLIPS JOB
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Swain
Physical Address* Street Address
295 CRESCENT DRIVE
Address Line 2
ALARKA HIGHLANDS LOT 58
City State/Province/Region
BRYSON CITY NC
Postal/ZZp Code Country
28713 USA
Latitude* 35.3724000000 Longitude*83.3819000000
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 F No
If this is a repair,fill out known well construction information and e)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 GWA 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
1000 surface?
For multiple wells listall depths if different 90
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
480 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)
3/4 13a. Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH GRANULAR 22.50

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
300 305
in feet in feet
920 925
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 90.00 SDR21
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
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 90.00
in feet in feet
90.00 300.00 GRANITE
in feet in feet
300.00 305.00 CAVITY
in feet in feet
305.00 920.00 GRANITE
in feet in feet
920.00 925.00 CAVITY
in feet in feet
925.00 1,000.00 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*
TIP MATPU
Signature of Certified Well Contractor
Submittal Date 5/9/2021