GW1--03642_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. It.
NC Well Contractor Certification Number 15..OUTER CASING formed wells)
esOR aGcable
FROM T DMETER
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. 25 ft. 0.010 in. sch40 pvc
List all applicable hell permits(i.e.County,Slate,Variance,Injection,etc.)
ft. f[. in.
3..Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 ft. 30 ft. 2 in. .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(sin(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 21 ft. portland cemE pour
Non-Water Supply Well:
21 fr. 23 fr. beritonite chip pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
23 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,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
5-5-23 MW-4 ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft.
5a..Well Location: ft. ft. MAY 2 b Z023
Jovian Holdings LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) 5,„,f.,I„-^ rr•g ��� 1.;
ft. ft.
unknown - vacant lot ft. ft.
Physical Address,City,and Zip 21.REMARKS
Harnett 0650-97-6978.000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iflvell field,one[at/long is sufficient)
35.421167 N -78.798955 w
Signature of Certified Well Contractor Date
6.Is(are)theAwell(s): ©Permanent or ❑Temporary 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
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well corner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under,11 remarks.section or on the back of llus 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-waer supply wells ONLY with the same 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 undliple wells list all depths ifdifjerenl(example-3@a 200'and 2 a I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
//baler level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8aa/4aa (in.) o
246.For Infection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 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
13a.Yield m Method of test: lac.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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