GW1-2021-00224_Well Construction - GW1_20210701

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
NorthCarolina Department of •
Di\Asion
April 1,2021
Page 1
Submission ID#
GW 1-2021-00224
CONTACT INFORMATION
..................................................................................................................................... ...............................................................................................................................
Contact Name* Email Address*
Jimmy Wilson [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
4303 A JAMES WILSON WILSON WELL DRILLING
2.Well Construction Permit#:
022-0766
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* 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
6/17/2021 022-0766 75
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
Anna D.Anderson Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Clay
Physical Address* Street Address
Bob Penland Road
Address Line 2
City State/Province/Region
Hayesvil le NC
Postal/ZZp Code Country
28904 US
Latitude* 35.0365399000 Longitude*83.6479978000
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
166 surface?
For multiple wells Iistall depths if different 30
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
50 6
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)
75 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
HTH Pellets 30

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 30.00 6.25 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 Portland Gravity
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 6.00 Red Clay
in feet in feet
6.00 22.00 Sand Stone
in feet in feet
22.00 166.00 Granite
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
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*
04ww Iuw WkIdAr
Signature of Certified Well Contractor
Submittal Date 7/1/2021