GW1-2023-01974_Well Construction - GW1_20230227

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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.
2480
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 0.010 r"' I seh40 pvc
List all applicable well permits•(i.e.County,Stare,Variance,h jeciion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS DATERIAL
❑Agricultural ❑Municipal/Public 10 ft• 30 ft. 2 1°' .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 6 ft. portland cemE pour
-Non=Water-Supply Well: - - - -
MMonitoring ❑Recovery Y 6 fr. 8 ft. bentonite chip pour
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity BaRier g 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,soiUrock t e,gnin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft. ,_a,
1-16-23 MW-1 ft. ft. i e't+,w i L.-I y 14-
4.Date Well(s)Completed: Well ID# ft. ft. FEB 9 7 7023
Sa.Well Location: Pt. ft. '
Jovian Holdings LLC ft ft - 'tea ,�;�==�Ws•.Tt,� "NI
Ir;r:�f,��:�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
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)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica'
(ifwell field,one lat/long is sufficient)
35.41967000147143 N -78.80150065337189
• a ure of 71 if! W Contractor Dale
6.is(are)the well(s): Permanent or ❑Temporary y signing this form,1 hereby certify that the we/l(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Cons•truciton Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z]No copy ofthis record has been prorided to the well owner.
ifthis is a repair,fell au laiown well construction information and explain the nature of the
repair under=21 remarks section or on the back of ibis 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 nmdliple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mudtiple wells list all depths rf'dii ferent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifu•aierlevel is above casing,use•'a" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8„/4n (in.) 24b. For Injection Wells ONLY; In addition to sending the form to the address in
HSA/alr rotary 24a above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to time county liealth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013