GW1--04585_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD Fur internal Use ONLY:
This form can bc used for single or multipk wells-
1.Well.Contractor Information:
•14A ATERZONES' •
Scott Hunt, Jr FROM" TO DESCRIPTION
Well Contractor Namtc 12 ft. 18 ft. blue/gray silty"sand
4561A
ft. 1
NC�VcIICarluaciorCcnificatinnNtuoticr • :IS:OUTER CASING tfoe�enulii-easciliicllslGRUNER(tfrii liable)=
FROM TO • DIAMETER THICKNESS MATERIAL
SAEDAC.CO Inc fL fL In.
Coar(n ny Noun 16.INNER CASING ORTUBING`(rcoIhrrmal closed-loop): `
FROM TO DIAMETER THICKNESS MATERIAL •
2.Well Construction Permit#: WI0700459 0 ft. 8 ' ft. 4 hi. SCH-40 PVC '
lrsr oil engirabla w /tponirits(i:c.County,S(ale.Variance.Nation etc)
ft. ft." in.
3.Wc1l.Usc(check well use): -!7f SCJREEN
Water Supply Well: -. -'` FROM TO nTAntEThR st:OTSIZE TH(TCKyf S I MATERIAL.
LlAgricultural - ClItIonicipaliPI)blic 8 R. 18 • R. 4 Iry .010 SCH-40 PVC
r fL in.DGeothermal(Heating/CoolingSupply) ®Residential Water Supply(single t
0ittdustrial/Comtotercial • DResidential Water Supply(shared) 'Ta cROaT
FROM TO MATERIAL EMPLICEMRNT IIIETHOD S AMOUNT •
Dhri titian - 0 ft. 4 ft: Portland Poured
Non-Water Supply Well: . ft
Dhlonitoring . °Recmrry - .
Injection Welt: - - R, ft.
Cl Agnarc*Recharge °Groundwater Reittcdiallon 19:'SANDIGRAVELEACK(if ultplieabti:)'.
PROM TO MATERCAI. EMPLACEMENT Hi:TROD
I7Agnifcr Storage and Recovery []Salinity Barrier 6 ft. 18 ft. Sand #2
• ClAquifcrTesl DSlormR'atcrDrainagc .
ft. ft.
❑Experimental Mettleolo ' DSitbsidcrtec Control:
2(lDRILLiNG'LOG tanned addilimialsbeetsif necessary)
17Geodtewal(Closed.Loop) °Tracer - . .FROM TO DESCRIPTION(color.etmcloci+.so['hockrytst.^,r.tin Am,d el
°Geotltennal(Heating/Cooling Return) IIlI0ther(explain under 1121 Remarks) 0 ft. 12 -ft,- grey ,silty sand
12 ft. 18 ft. blue/grey silty sand
4.DateWell(s)Completed: 6-23-23 - . Well iro#IW-23
ft. ' IL
Sa.Well Location: et. • rt. ,-. : .;i -X a
West Pharmaceuticals Facility ft. - ft • 4~ k vc '',
FseditylOwper None Factlit)ID#(ifapplicnblc) ft. It. JULZU13 .
2525 Rouse, Rd. Exd. , Kinston, NC, 28504'
ft, p.
,�. Physical Address,City.and ZipREMAnKs - intvt i=`aa=1 1 7r rL -,.,�1 tr.°
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Lenoir • Bentonite seal from "4-6' .
County' - Parcel Idenlificaalipn No;(PIN) - -
Sb.Latitude and Longitude in dcgreeshninutestseeonds or decimal degrees: 22.Ccrlifit I10n:
(If xrlI Sid,n.te I:W'luu5IS SmIliekid) '
. N - -W c5C.ett'r tt- 6/14/2023 .
Sigruiure of Certified Well Co (.tor. Dale
6.Is(arc)the"\Sell(s)t %IPerliranent or. 17TeulporarX !ly signing ilr farm,!hereby certify that the veth's)war(i i Continuity,in fwairdamce
with 15A NCAC 02C,0100 or LTA NCAC 02C,0200 Mil Construction S(anaiards and hurl tT
7.Is this a repair to an existing well: DYes or ®ND - copy of this record hos been proeidcd 0 obe urll owner.
if ibis h a repair.fill oat kenrivl tern corurnrcriota information ecru,ckpiain the;tonne of(lto
. repair ranter#21 revnorki-.Indian ar an the back of this-forr. 23.Site ding ant or additional well details:
'You may use the back of this page to provide additional well sire details or well
8.Number of wells constructed: 1 - construction details. You May also attach additional pis if necessary.
For multiple iokrrinn or retest-warm supply melts ONLY.trhh the arnne coustruetioar,you eon
submit one forrn. ' SUBMITTAL IiNSTUCTIONS
9.Total well depth below land surface: 18 (ft) 24a. For Art Wells: Submit this form within 30 days of completion of well
For maple wells list all depths ifdfPeen:(example-3@200'and 263100)- ConslniCtipn to tie fattoning:
Ill.Static water level below top Of calming: 5 (fL) Division of Water Resources,Information Processing Unit,
if omen level Is above althea:ase"+" 1617 Mail Service Center,Raleigh,NC 2769!)-I617
11,Borehole diameter:10,.625" , (in.) 24b.For totiection'We1ls ONLY:; iit addition to.sending the form to the address in.
24a above,also submit a copy of,this fano within 30 days'of completion of well
12.Well construction method:HSA construction to the following:
(Lc.aupcc rotas}•,cable.direct push.etc:} -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Malt Smite Center,Raleigh,NC 27699-1636
l3a Yield(gpm) Method of test: 2tc:For Water Supply St-injection Wells:
Also submit ore copy'of this farm(within 30 days of completion of
13h.Disinfection type: -Amount: . : well construction to the county health department of the county where
constructed. !
Fomi GW-L Noah Carolina ikp uimcnt of Environment and Natural Resources-Dinislon of Water Rtxatrces Revised August_2013