GW1-2021-00206_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOlby Mitchell Sawyers 1RWATERZONES
FROM TO I DESCRIPTION
Well Contractor Name
4471-A
NC Well Contactor Certification Number 75.OUTER CASING(for multi-cased wells)OR LINER(if a blell
FROM TO DIAMETER THICKNESS MGcaATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 50 16.25 2 i" #21 PVC
Company Name 16.INNER CASING OR TUBING eothermalclosed400`,
21 1 001 08454 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc)
ft. ft. in.
3,Well Use(check well use): 17.SCREEN ,
Water Supply Well: FROM TO DIAMEJ-ER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply 18.GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 fl- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. -
❑Aquifer Test ❑Stormwatcr Drainage
rt. a.
❑Experimental Technology ❑Subsidence Control
-20.DRILLINGLOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft. 50 rt. OVER BURDEN
11-16-2021 50 ft 185 ft GRANITE
4.Date Well(s)Completed: Well tD#
ft. ft.
5a.Well Location:
CHAD CABE
Facility/Owner Name Facility ID#(if applicable) ft. ft. D E
438 KRISTY CABE DRIVE HENDERSONVILLE, NC 28792 e, rt.
Phvsical Address,City,and Zip 21.REMARKS
Hendersonville 9662765749
County Parcel ldcntification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(ifwell field,one tat/long is sufficient)
yj't� )
_ N w
11/12/2021
Signature of Certifi Well Contractor I Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereb,certifi,that the we/l(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy gfthis record has been provided to the well owner.
If this is a repair,ji/l out known well construction information and ccrplain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one fmnr. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use"+., 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24aabove, also submit a copy of this form within 30 days of completion of .ell
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) 8 Method of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I