GW1-2023-01061_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
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1.Well Contractor Information: i
Landon Phillips
14,WATER ZONES I
Well Contractor Name �?''' - FROM TO DFSCRIP.TION -
3441 A e2 j ft. Z b rt. 0 I . /r1
4151,. O rt.
NC Well Contractor Certification Number -
15.OUTER CASING for i ndil-cnsc wells OR LINER if n licnblc
NW Poole Well and Pump Company FROM To UTAM1 ETER' TIIICICNESS MATERIAL
ft. ft. 4n. r Q fit)
Company Name V "
4UIC.,County,
�� 16.INNER CASING ORTUBING colh rerntal closed-loo2.Well Construction Permit tl: p FROMTO DIAMETER Tiucimss a!ATEnIAL
ULsr all applicable well con truction perndt S are,Partance,etc.) ft. ft. In.
i.'
3,Well Use(cheep well use): rt. ft. I` im
t
Water Supply Well: 17.SCREEN
p FROM TO UTAMETE„I I SLOTSILE I THICKNESS MATERIAL
❑Agricultimil O0lviunici al/Public
❑Geothermal(I Icaling/Cooling Supply) Residential Water ft. ft.
Supply(single) D. ft. In.
❑industrial/Commercini -' /❑.tcsidenthd Water Supply(shared) -18.
❑Irrl alion ❑Wells>100,000GPD MOat TO NIATERIAL 'EMPLACEatENTa1L-MOD&AaIOUNT
Nun-1VaterSupply Well: ft. J
❑Monitoring ❑Recovery ft. It.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK If n licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I ENIPLACE111ENThIETI101)
❑Aquifer'fest ❑Stor i%vater Drainage
ClLxperimenlalTechnology ­OSubsidenceControl ft. ft.
❑Geollterinal(Closed Loop) ❑'['racer 20.DRILLING LOG altach additional streets if necessary)
[]Geothermal(1leating/Cooling Return) []Other(explain under N2L Remarks) Fltont TO DESCttu"ION color,hardness soll/ruck type,grain size etc.
ft. ft. Ir L
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4.Dale Well(s)Completed:7ii`_ZL WellIDN ft. ft.
( �1
5a.Well Location: ft: fl. �y
CO f Q�a#I'd ll rt. a.
I'acilily/Owner Naiiie 'Ito -"'l Facility IllfJ(ifapplicable) ft. ft.
UE�1� 1�- �li �-t;,, uriOGlcS NG . i JAN 2 6 2UZ3
Physical Address.City,and
Zip ft. ft./y�` I "'jl °;yl;.' �•�� 21.REMARKS
County Parcel Identification No.(PIN)
51).Latitude land longitude In degrees/nlhntles/seconds or decimal degrees:
(ifwell field,one Iatilong is sullicicat) 22.CerllRcat'
N
�,5. �D27Cc 7�iil5'Z41`�-`t
6:Is(are)the well(s): INPerninnent or,,, 'bTe iiporltry :ignatureoCCertilied Well Contaclor ° Dole
By st phig this farm,\hereby certll(y drat the uleN(v)u•as(were)constructed in accordance with
7.Is this a repair to-.in existing well:' ❑1'es.;;Or, 8No RSA NGIC 02C.0100 or ISA NCAC 02C.0200 11 el/Consiniction Standards and that a copy
Ifthls is a repair'fill out known well cons/ructioit h foriit'ndah find explain the nature of/he ajdils retort/has been provided to the urll owner.
ropoir under 1121 remarks section or on the back ojthis jonn.
23.Site diagram or additional well details:
3.for Geoprobe/DPT or Closed-Loop Gee(Ilcriiial Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (ndd'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t !I4,. ,r^ i
•I ll�.1i i+:l'^I": 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: So (ft.),
For amlliple uel&As(all deprlts lfW69crent(example-3 tt 200'and 2Q100') Submit this GW-I within 30 days brtrell completion per the rollowing:
10.Static water level below lop oCcnsing: ( ft. 24n. For All Wells: Original form to Division of Water Resources (DWR),
\/'water level is above casing,ase'•t•' ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (ill.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 2f7699-1636
12u construction method: :'il 24c.For Watr Sue 1 and O en-Loa Gcothernial Return Wells:Copy to the
(i.e.
mrgor,romry,cable,direct pasty etc.) 1; county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:. I '
;!,;,�I;�.,�.; , 24d.For Water Wells producingover lUU OOU GPD:Copy to DWR CCPCUA
13a.Yicid ill) O I1lethti8 attest: Blow Permit Program,I611 SC,RRletgh,NC 27699-161 l
HTH 1 lb.
13b.Disinfection type: Amount:
Conn OW-I NorthlCarolina Department ofEuvironmental Quality-Division of Wnter Resources Revised 6.6-2018

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WELL PERMIT Permit No:180825
Johnston County.Environmental Health
309 E:Macke. ., Smithfield,.NC M77 Date: 1/21/22
Phone:[phone]o I
Name: Beveiiy Place Phase 1 Address: 185 Beverly PL Four Oaks,NC 27524 i
Location: Take Hwy 210 to L rr on Reedy Creek,T/R on Beverly PL lot on R
Beverly Place Open Space
S/D&Lot#. 3
Construction Type of Well: o4iied T I,
ype of Facility: Irdgatlon Number of Connections: NIA
Use(check one): Private x Agricultural/Irrigation Semi-Public/Non Community
Well Contractor: Phone Number:
Permit Issued By: Sean Osbourne
�m Systems shell be installed as shown in sketch This permit is valid for 5 years from date of issue
1 0..
V-eVe'l y
ev so
cll ' � ✓
3u
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:1!;;;I•. Mull
Inspections:
Sitting/Location: ` ' ''::
GPS Coordinate:Lat- Long-
,Grouting Inspection: Slab: Well Head: Well Tag: Pump Tag:
Water Samples:Date: Office: Private'Lab: Disinfection Device:Yes No
***To be filled out,signed by well contractor and returned to the Johnston County Environmental Health office*.*
SS '
Depth of Well: O " An on-site Investigation has concluded that the area designated on the permit
�(�
Depth of Concrete Grout:_ c) I should meet all necessary setbacks as provided by the Johnston County Well
Static Water Level: f Regulations. The well:site,has been:located using the best available
Depth of Casing: -7 C) ) information as provided by the pioperty owner/or his agent.The Health
Department will not be responsible for improper location of wells due to
Well Diameter. (O )/� erroneous Information provided by the Health Department,mislocation of
Capacity of Well: _ Gals./Min: wells by the contractor,or quality,o{quantity of the water supply.
Date Completed: I certify that the well designated on the property
I certify that the well constructed on the above roe meets all g P P rty meets the setbacks from all
property rty property lines,easements,rights-of or structures indicated on the permit
requirements of the Johnston County Well Regulations in eff[,ed on this ate. and that I am the a ner ogthe, pe 'or his/her designated agent.
signed by:
1 r '' I
Certified W If Op rator) I (Certification ) signed: ar i Date: z ��-
WXA1 Z (PropeityOwne/Agent)%
(Well Company) �1'flV (D7ata)
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Certificate of Completion: i Date:
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