GW1-2021-07294_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells �Y
1.Well Contractor Information: 14.WATER ZONES
Mark E. Holland �° 1 ti FROM TO DESCRUMON
Well Contractor Name ���'O� t 5 ft
2178-A Q� Qi���; ft. t>
NC Well Contractor Certification Number ��:�\� 15.OUTER CASING for matti-eaud welh OR L1NER ita 61e
r�`. �~ FROM TO DIAMETER TH[CI4VESS MATERIAL
Dennis Holland Well Drilling, Inc. A16 ft. ft. 5Qi,-d!I PVG
Company Name 16.INNER CASING OR TUBING eothernud cloud-loop)
^ .g' , 1 f �1 n�-Q y FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: O[ J`s Y�( 7- / ft. ft in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER :1 SLOTSIZE THICKNM I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply), ❑Res dential Water Supply(single) ft. ft in.
❑Industrial/Commercial esidential Water Supply(shared) Is.GROUT
FROM I TO MATERIAL EMPLACEMEM17METHOD&AMOUNT
❑Irri ation_ ft. ft I%4�
Non-Water Supply Well: r
❑Monitoring ❑Recovery Livytft tt e-
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ble
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g ft
❑Aquifer Test ❑Stormwater Drainage
ft it
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional.sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION rotor,hoduess,soil/rock type,grain size eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft ft
4.Date Well(s)Completed: -�y-a r Well ID# ft ft
Sa.Well Location: / ft. ft
k2AS f -ig) 6!22 i' V"if IV IA ft ft
Facility/Owner Name Facility ID (if applicable)
(/C)4 V -5 64 ft ft
Physical Address,City,and Zip 21.REMARKS
Ju.t✓u yen _757a�a­9a 5
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2WC-errtnifllion•
(if well field,one lat/long is sufficient)
3?z5_f�15-710 N --1 L6 q idte)0 W - -30-2)
Signature ofCe ied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of(his record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
s.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit one form. I SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: /0 5- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2@100') construction to the following:
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1 C: Z Division of Water Resources,Information Processing Unit,
0.Static water level below top of casing: (ft)
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Infection Wells ONLY:, In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
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
13s.Yield(gpm) 3 Method of test: Air lift 24c.For Water Supply&Injection Wells:
Also submit one copy of this fbim within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county hi alth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

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Jackson County Department of Public Health
538 Scotts Creek Road, Suite 100
CPYNT Y X Iva, NC 28779 Well Permit
CO, UN
P.c
°�v��,�� Phone: [phone] FA?:: (828) 585-1 207
Reference Number: Permit Number: 2021-21482-9-
11172
PIN: 7572-62-9257 Application Date: 7/20/2021
Owner: INDUSTRIAL CONNECTOR VENTURE-WELL PERMIT City: BOCA RATON FL
Address: 4755 TECHNOLOGY WAY STE 203 Zip Code: 33431
Lot Number- TR A US 64
Service 'Type: Well Permit Bedrooms: 0
Directions To Site: 64E; RT JUST PAST FIREST CITIZENS BANK; BUT BEFORE SPINX; FOLLOW TO
WELL SITE.
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Prop
100
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Fee: $ 20.00 Receipt:
issue ®.ate: Z)
EHS: Approval Date.
aig Mere•
f Date: