GW1--04590_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I .WATER ZONES '
Scott Hunt, Jr FROM ' TO DESCRIPTION
Won Cot'ardclorName 12 ft. 18 ft. blue/gray silty sand
4561A ft. fL
NC Well Con niiarCcrtiftcalion Number IS.OUTER CASING(ref mif(1-rascd ncflsl O&LiNER 41f"El tleahkl:
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc ft. fL hi.
Conically Name Id:INNER CASING OR•TUBING'fSeoit ernal ckised-loop):
FROM TO - DIAMETER THICKNESS MA TER7AL
2.Well Construetinn Permit#: W10700459 0 R. 8 ft. 4 hi. SCH-40 PVC
Lisr4Rapplicable w-ellpenrrits(Lc.County.State,Variance,lrjadat erc.) ft. ft. in.
3.Well Use(cheek well use): I7:SCREEN
Water Supply•Well: FRo?I TO DIAMETER SLOT SIZE THICKN S I MATERIAL,
°Agricultural OMunicipallPttblie 8 ft. 18 R. 4 in oio sex-4o PVC
®Geothermal(Iieatingrooling Supply) ❑Residential Water Supply(single) fL fL in,
rm
❑hidusrria1fContmercial ❑Residential Water Supply(shared) •tF OUT TO - MATERIAL ' EMPLACEMENT METHOD&AMOUNT
CI Irrigation ' 0 ft. 4 fL Portland Poured
Non-Water Supply Well:
°Monitoring • ❑Recovery R• R
InJecllon Well: tL fL '
❑Aquifer Recharge °Groundwater Rentcdiation •19 SANDIGRAVEL PACK lit a 1plicibte)
FROM' 10 - 11ATERIAt, EMPLACEMENT MET/1011
❑Agnifcr Storage and Recovery ❑Salinity Ramer 6 , ft. 18 ft. Sand ' #2
❑AgiriferTest ❑Storm atcrDrtinage •ft. ft..
• ❑Experimental Technology ❑Subsidence Control •
"30.DRILLING LOG(attach additional sheets if nceessan•1
❑Geodtemtal(Closed Loop) ❑Tracer FROM TO D.ESCRIrriox roar.hardncn,wR'nkk tri r.'nnin Am,Hal •
❑Geotltennal tilleatiug1Caoling Return) ®outer(ecplaiu under#21 Remarks) 0 fL 12 ft. grey silty clay
12 ft. 18 It. blue/grey silty sand
4.Date Well(s)Completed: 6-7'23 Well mDgIw-20
ft. fL ",,•-_ :-a ,7
So.Well Location: .....r ? . 4,1 ` , '
fL fL �„�Ned a •`.� ti- .'..r
West Pharmaceuticals Facility ft. it. I` I +1 ! 21173
FacilitythmerNanme Facility IDM(if applicable) R. ft
2525 Rouse.Rd. Exd. Kinston, NC, 28504 R fL Invs:Avr,as<;r,l P.. . .;.;,,r;j h,•;I '
Physical Address.City.and Zip :2L REMARKS
Lenoir Bentonite seal from 4-6'
Comity Parcel 4i,;eilifiellion No,(PIN)
Sb.Lititude'and Longitude in degrees/minutes/seconds or decimal degrees: 22 Cci•hf"rcat O :
(Ifss It field,one[Along is sidl1cictd) '
' N w 5Ctg cat 6/14/2023
SignatureafCaliftcd piel(Co, or. Dale
6.IS(are)the wells}: $IPertllanett! or ❑Tetnporat}' By signing thin fumy.I hereby certify than the ire/I(.$)'Far(were)artrrnreterl in accordance
with!SA NCAC 02C.0100 or 15A NCAC 02C,0200 Well Constrzwrion Standards and Om cr
7.Is this a repair to an existing w'ell; ❑Yes or END • copy of Chit record hay been provided to:lie urn owner,
if this Is n repair.fill oar kooifrt willcosslnrct(on information amp esp(uhl the volute of the
repair tinder PI remarks welkin or or the hock of this form. 23.Site dial;r•ann or additional well details: '
You may use the back of this page to provide additional well sire details or well
8..Numherof wells constructed: 1 construction details. You relay also attach.addiliotml pages if necessary.
For mallipie mnfecrlon or aryl-miter supply wells ONLY with the wise cotrsrrtrcriotr,�+on can '
.satrniit one form. - Sf1BMITTAL INSTITCTiONS
9.Total well depth below land surface 18 (tit.) 24a. Far All Wells: Submit this form within 30 days of completion of well
For tat&iple wells list all depths ifdlfr''ereus(example-3 200'and 20I00) construction to the following:
10.Static water level below tap of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
if moot lev.el is above cos*,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1G17
•l1.Borehole diameter:1°.625" (ice) 24b.Fnr Injection Wells ONLY::In addiition ta sending the form to the address in
• 24a above. also submit a copy of'this form within 30'days'of completion of mil
12.Well construetiou method:RSA cotuimction to the following:
(i.e.auger.minty,cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Progrun,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: 24e.For Water Supply&•Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: wctl constntction to the county health department of the county where
constructed. , I
Forte GW-t North Carolina D:pannwnl of Envilotuucta and Natural Resources-Division of Water Rau Revised August 2013