GW1-2023-01062_Well Construction - GW1_20230125

WELL CONSTRUCTION RI+;CORD(GW-1) For Illtemal Use Only:
1.Well Contractor Information:
Landon Phillips •
14.WATER ZONES I
Well Contractor Naure FROM TO DESCRIPTION
3441 A 5 ft. 12.5 rt. i
ft. ft. I I
NC Well Contractor Certification Number
15.OUTER CASING for multi-coscdiwells OR LiNER if a rlicable
NW Poole Well and Pump Company Fnonl TO DIAMETER THICKNESS MATERIAL
Company Name fL !r. L,. S c WIT
16.INNER CASING OR TUBING
tr eothermal closed-too
2.Well Construction Perutit FROM TO DIA11fETER ITIIICICNFSS nL\TER11L
Uri till alrpOcable well consn•nction permits(i.e.VIC,Coanq•,State,Variance,etc.) ft. ft. it
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER TSIZE THICKNESS MATERIAL
❑Agriculuual ❑Municipal/Public
❑Geothermal(I-Iealing/Cooling Supply) Residential Water Supply(single) ft. fr.
❑Industrial/Coinmercial ❑Residential Water Supply(shared)
18.GROUT
❑turf atjon DWel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT M1IETIIOD&AMOUNT
Nou-Water Supply Well: ft. ft. � t J0,h I& ,,S
❑Monitoring DRecovery ft. a.
Injection Well: -
❑A uiferRechar a ft. ft.
q g ❑Groundwater Reinediation
❑Aquifer Storage and Recovery DSalinil Barrier 19.SAND/GRAVEL PACK fro licablc
y FROM I TO I MATERIAL EM1IPLACEMENTMETIIOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLWG LOG attach additional sheets If necessary)
❑Geotl)ennal(Heating/Cooling Retu i) ❑Other(ex lain under#21 Remarks) Front TO DESCRIPTIO caior,hardness,solUrvck type, min size etc.)
ft. ft. I
4.Date Well(s)Completed: Za' Well ID# ft. �' ft. LL y
s1- _S r tot?
f
5n.1Wellll�Location: ft. `S ft. I DiuAe ¢
t .. 1 •`,1_ G .z,1
Facility/Owner Name Facilityll) (ifapplicable) ft ft. ,e
1 g�1�t1 �� �� c ZU?t ff. Z023
Physicn ddress,City,nail Zip ft. ft.
AS
17A 21.REMARKS .. Aor air,
County Parcel Identification No.(PIN) �� F wG7«I� ,"feil
•t
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees: z' G�
(ifwall field,one fat/long is sufficient)
22,Ccrlirrcat
Ms(are)(tie well(s)r ®Permanent or OTetnporary Signature ofCerified Well Contractor i_ DaieI
Uysigrdng dds fonn,1 hereby cerilry ilia'the wells)was(irere)constructed hi accordance Leith
7.Is this a repair to an existing well: ❑Yes ,or • InNo 15A NCAC 02C.0100 or 15A NCAC 02&0200 Well Construction Standards and that a copy
/!'this is a repair,fill out knovtr well construction b joiination and esp/ain dire nature offhe ofdds retard has been provided to the well owner.
repair under#21 remarks section or an fire back ojdds form. ,
1: 123,Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geotlurrmal Wells having the same You may use the back of(his page to provide additional well constriction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I •
t f 24,SUB1411TTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
Far•nuthiple wells 11st all depths ldAerent(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below lop of casing: ( )ft 24a. For All Wells: Original Form to Division of Water Resources (DWii),
.'fn•ater•level is above casing,rise"+ , Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
11.Borehole diameter: 4 f((7 (in-) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(fUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and O en-Loopl Geothermal� Return Wells:Co to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of lire county w Iere installed py
FOR WATER SUPPLY WELLS ONLY: ; i 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gprn) Method of test Blow Permtt Program,i 1I MSC,Raleigh)NC 27699-1611
HTH 1. lb.
13b.Disinfectidn type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-201 S
uy .

WELL PERMIT Permit No:
Johnston County Environmental Health )l
309 E. Market St. Smithfield, NC 27577 Date`. iTZjZCsZ7
Phone: [phone]
Name: .'014104�
1� � 1. _ // ))�� Address:
Location:_W&57//t0.w GjI� e, C,�l�G Gye-,,.&I.t. W.--------------------
1
S/D&Lot#:
Construction Type of Well: Type of Facility:_ 3 V F 4E Z
Number of Connections;
Use(check one): Private ✓ Agricultural/Irrigation Semi-Public/Non Community
J Well Contractor: Phone Number.
J Permit Issued By:!Systems
rill dw
shall be in allrre''d as shown in sketch.This permit is valid for 5 years from date of issue.
r\��z
-vjwa ,
Inspections:
Sitting/Location: GPS Coordinate: Lat- Long- `[
Grouting inspection: Slab: Well Head: Well Tag: i' Pump Tag:
Water Samples: Date: Office: Private Lab: Disinfec o' n Device:Yes. No
,1,: fit j
"'To be filled out,signed by'well contractor and returned to the Johnston County EnvironmentaII Health Office—
Depth of Well: i 5 n An on-site Investigation has concldddd that the area designated on the permit
Depth of Concrete Grout O � should meet all necessary setbacks as provided by the Johnston County Well
Static Water Level:__�0 j necessaryRegulations. The well site has I been located using the best available
Depth of Casing:�/ -� . !';+ information as provided by.the property owner/or his agent. The Health
Well Diameter: f� Department will not be responsible!for improper location of wells due to
(-( erroneous Information provided by the Health Department, mislocation of
Capacity of Well: _Gals./Min: wells by the contractor,or qual'rty,!.or:quantity of the water supply.
Date Completed: 1 !1�?j ! '
—=t-`—'( I certify that the well designated on the property meets the setbacks from all
certify tify that the well constructed 'on thq +above property meets all property lines,easements,rights-olf-way or structures indicated on the permit
requirements of th Johnston county well Regulations in effect on this date. and that I am the owner of the property or his/her designated agent.
Signed by: ( Jan 29 2021
(Certified Well Operator) (Certification k) Signed: ��K��4"F�'l�y Date:
A(W e_ /1� Vl/r. I n C/6(!I-VV� 5--)1 ' 2'7- (Property Owner/Agent)i
(Well Company) (Date)
Certificate of Completion: Date:
i