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Home My WebLink AboutGW1-2023-01064_Well Construction - GW1_20230125 • li WELL CONSTRUCTION RECORD(GW-1) Por Internal Use only: 1.Well Conlrnctor Information: ` Landon Phillips 14.wAT MZONES Well Contractor Name FROM TO DESCRIPTION - 3441 A l S Ir. t,70 rt. j S I cyren S ft. 'Ass ft. S 1 NC Well Conlrnclar Ccrlifieation Number 15.OUTER CASING for multi-cased wells OR LINER 1f n r licablc NW Poole Well and Pump Company snort TO I)MVI TER. I THICKNESS I MATERIAL Company Nanw 4 0 16.INNER CASING OIL TUDING 'cotherntat closed-loon) 2.Well Construction Permit H: d �� ]FROM TO DIAMETER THICKNESS MATERIAL List all applicable well conrtrriction perndtr(i.c.UIC,Cotany,State,irartance,etc.) ri. fi. I• in. 3,Well Use(check well use): ft. rr. na Water Supply Well: 17.SCREEN ❑Agricuhuml ❑Municipal/Public FROM TO DIAMETER SLOTSI•LE I THICKNESS I MATERIAL rt. ff. in. ❑Geolllennal(1-icating/Cooling Supply) 'Vltesidential Water Supply(single) fL fL ia. ❑Industrial/Commercial - ❑Residential Water Supply(shared) 18.GROUT ❑Irri atioll ❑Wells>100,000GPD FROM I TO MATERIAL EAIPLACEM ENT METHOD&AMOUNT Non-)ValcrSupply Well: b "' ft. le ❑Monitoring, ❑Recovery ft. It. Injeclion Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation ❑AcuiCerSlora Storage OSalinit Barrier 19,SAND/GRAVELPACK ifn lichble 1 g Recovery y FROM I TO I MATERIAL I EIIIPLACEIIIENTMETHOD ❑AquilbrTest ❑StonnwaterDrainage ft. ft, ❑Experimental Technology ! !OSubsidence Control it. it. ❑Geothermal(Closed Loop) ❑'tracer 20.DRILLING LOG nttacli additional sheets ICnecessa FROM TO DESCRH•,'11ON color,hardness soNrock type. rnln sin etc. ❑Geothermal(I-leating/CoolingReWgm) )❑Other(explain underH2lRemarks) ft ft �/rG 4.Dale Well(s)Completed: ~ /' G' Well IDH ft. 73 ft. c /,�t $n.\1'CII Location: rt. .3105 n. rt. n. �. . . q Iracility/Own m 3 er Nn c pncilily ID#(ifopplicable) ft. ft. � t 173 Dunn k`Ct• Selnik /UL Z2 7S 7� ft. If AN 2 Physical Address,City,and Zip ft. I 21.REMARKS h c e:.. _ na �T�hhS�'b'n � - -J;•'t�ir's�v County Parcel Identification No.(PIN) 51).Latitude rind longitude in degrees/minutes/seconds or decimal degrees: (ifwell fiieeld,onrre__Int/looAng is sufficient) 22.CCrlifCat' 16 6:Is(are)(lie well(s): ®Permnnent or ,iOTempornry Signalure ofCcrtiFied Well Contractor ` Dale Uysignbrg this form,I hereby cart j.that ilia well(i)was(were)constructed in accordance idth 7.is this a repair to all existing well: ❑Ycsi or InNo 15A NCAC 02C.0100 or 15A NCAC 01C:.0100 11 ell Const erton Standards and that a cope !f this is a repair,fill out knou•tt well construction hiforotation and explain the nature of the afthis record har been prorlded to the welt owner. rcpoh•corder tell remarks sectlun or all the bock ojUds jams. I' t hi,, 23.Site diagram or additional well details: 8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info construction,only 1 GW-1 is needed. ]ndicaledTAL NUMBER of wells (add'See Over'in Remarks Box).You,,tnay also attach additional pages if necessary. drilled: 1 .,TO; r _I I 24.SUBMITTAL INSTRUCTIONS, 9.Total well depth below land surface:_ 30 (ft.) !' Formoliiple wells list all depths tfdocrettt(example-3 g100'and 1 rQt 100') Submit this GW-I within 30 Jays Orwell complelioD per the following: 10.Strike water level below lop of casing: 1. 2 6 (ft.) 24n. For All Wells: Original forml'to Division of Water Resources (DWR), ifrt•ater lerel Is abate casing,tire;i^ Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617 11.Borehole diameter: 2 (in.) 24b.For Injection Wells:Copy to DWR,Uliderground Injection Control(IUC) Rotary Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: y cr,rum 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (i.e.nu gm-,rotary,cable,direct pushy Cie.) county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY:',! 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13n.YiciJ(gpui) Za Method of test Blow Permit Program,1611 MSC,Raleigh,NQ 27699-1611' 13b.Disinfection type: HTH Amount: 1 lb. Form GW-I ,North Carolina Deparintenl offinvironmeniol Quality-Division of Water Resources Revised 6-6-2018 1 J. !` I. q 0-, ' WELL PERMIT Permit No:182478 Johnston County Environmental Health i 309 E.Market St. Smithfield NC 27577 I Date. 3-14-2022 Phone:(919)989-5180 Name: Michael Cribbs Address: 973 Dunn Rd,Selma,NC 275761 Location: Hwy 96 N TA-on Dunn Rd, i i. S/D&Lot#: NIA I ! Construction Type of Well: Dilled' Type of Facility: NSA Number of Connections: 1-2 Use(check one): Private Agricultural/Irrigation X Semi-Public/Non Community Well Contractor: Phone Number: J Permit Issued By:Tripp Bowling - Systems shall be installed ass own• sketch.This permit is valid for 5 years from date of issue. THIS PERMIT IS FOR AN IRRIGATION•WELL ONLY AND NOT FOR A DRINKING WATER WELL.THERE IS NO CROS5 CONNECTION ALLOWED WITH A PUBLIC WATER SYSTEM.AN ELECTRICAL AND PLUMBING PERMIT IS REQUIRED FROM THE BUILDING INSPECTIONS OFFICE. sBl!1'41•E J."..29. \ q0 6'L m 6��•LO �1L A pFonimat. yeti]'', ,INII�7F �dI/ fkadum a � 1 1 2T. Ai R.f.nne•1 9 plo -k 7,,Pp346 p \� u 33746T.Ul R y �♦ �611tiyj \ E.xege �] AR I. j 6n 3 IFytm•61 need 4. Zan AE FO d 6 - nd Zane% y n. • = ; ' .e7'. eYli s96.69'9\ VAS W Ibue' ! N63'34'V'W 6e7.64' to - 1466-33'46'W 1,000Z- 6 rye s W49'59•a 144A6 \ Ll � Nee'24:3PW 7716eFv I� � -�Na9•ti'OMW 109,31, 61•4� -C ' � I�Mw¢T. .. I ' • Well Setbacks-50'from Building Fo6n8ati0,,ns,'-'i00''from Septic System Areas,10'from Property Lines, Inspections:' Sitting/Location: [•'''. GPS Coordinate:Lat- i' Long- Grouting Inspection: I; II".i: 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' Depth of Well: eJ� An on-site investigation has concluded that the area designated on the permit Depth of Concrete Grout: / F should meet all necessary setbacks as provided by the Johnston County Well 1 Regulations. The well site has been located using the best available Static Water Level: Information as provided by the property owner/or his agent, The Health Depth of Casing.�q I " Department will not be responsible for improper location of wells due to Well Diameter: irr, ICL t 4 erroneous Information provided by the Health Department, mislocation of wells by the contractor,or quality;or quantity of the water supply. Capacity of Well: ',.Gals./Min: Date Completed: Z :/Z' '' 1 certifythat the well desi nated on the property g p p rty meets the setbacks from all I certify that the well constructed on'` tNe*,iab'ove'property meets all property lines,easements,rightrs-of-way or structures indicated on the permit requirements of the Johnston County Well Regulations in effect on this date. and that I am the owner of the property or his/her designated agent. o;;I.�r.' 1 ' Signed by: L� AOWEL CR/86S Mar 152022 ll(Certified We110 erator) i (Certification#) Signed: Date: (Property Owner/Agent) /U V �� V�•�Cl•Vli '��L' � (Well Company) (Date) Certificate of completion: I Date: r �