GW1-2021-00212_Well Construction - GW1_20210625

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Page 1
Submission ID#
GW 1-2021-00212
CONTACT INFORMATION
......................................................................................................................................................................................... ................... ..........
Email Address*
Contact Name* [e-mail]
Christopher D Singleton m
Is this a revision to the form you have previously submitted?
r 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
3328 B CHRISTOPHER SINGLETON SINGLETON ENVIRONMENTAL, INC
2.Well Construction Permit#:
List all applicable well construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUP,etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/14/2021 TMW-1 (gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name* Facility ID#
JSJW Jackson 64, LLC. 00-0-0000035613
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Jackson
Physical Address* Street Address
630 US Hwy 64 E
Address Line 2
City State/Province/Region
Cashiers NC
Postal/ZZp Code Country
28717 Jackson
Latitude* 35.1178000000 Longitude*83.0903000000
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.) 9a.What is the depth of the casing from ground
12 surface?
For multiple wells Iistall depths if different 2
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
4.03 2
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

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
4.03
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
2.00 12.00 1.00 sch 40
in feet in feet in inches
18.GROUT
................
From To Material Emplacment Method &Amount
0.00 0.00
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
1.50 12.00 #2 sand
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 1.00 ashphalt and gravel
in feet in feet
1.00 4.00 clayey sandy silt
in feet in feet
4.00 12.00 sandy silt
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
Figure 2.pdf 144.45KB
pdf only

*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*
L-• Ci� lit �2tJ6/
Signature of Certified Well Contractor
Submittal Date 6/25/2021

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C. Singleton
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