GW1-2023-01972_Well Construction - GW1_20230227

i
i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lewis Lefever 14.WATER ZONES {
FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. I in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 0.010 i in' sch40 pvc
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 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 30 fl- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 ft. portland ceme pour
Non-Water-Supply-Well:Monitoring ❑Recoveq�- -
g ft. g ft. bentonit'e chip pour
injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 ft. 30 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(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 421 Remarks) ft. ft.
1-16-23 MW-3 ft. ft.
4.Date Well(s)Completed: Well ID# tr. ft.
5a.Well Location: fr. ft. FEB 21 ; NO
Jovian Holdings LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
JdoQ1rS.7�
unknown - vacant lot ft. ft.
Physical Address,City,and Zip
21.REMARKS
Harnett 0650-97-6978.000 4"stick up with 24"sonotube
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certifica
(ifwell field,one[at/long is sufficient)
35.41967000147143 N -78.80150065337189
S' nature ofCertitied Contractor Date '
6.Is(are)the well(s): OPermanent or ❑Temporary y signing f y fy ( '
13 si min this Drum,1 hereby certify that due well(s)was mere)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 lYell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
/('this•is a repair,fill au known well construction information and explain the nature ofthe
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
S.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 sane construction,you can
submit one form SUBMITTAL iNSTUCTIONS
I
9.Total well depth below land surface: 30 (ft.) 2.4a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwatar lerel i3 above casing,rise"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11. 8"/4"Borehole diameter: (in.) , 246. For infection Wells ONLY: Iti addition to sending the form to the address in
HSA/air rotary 24a above, also submit a copy ofithis form within 30 days of completion of well
12.Well construction method: construction to the following: I
(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.
(gP ) 24c.For Water Supply&For Water Supply&Injectio�o Wells:13a.Yield m Method of test:
Also submit one copy of this form,within 30 days of completion of
I3b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013
t ,