GW1--04586_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multipk wells
1.Nell Contractor Information: •
II.WATER ZONES
Rich Lemire FROM TO DESCRIPTION
Well Contractor Name R. ft,
2593A ft. ft.
• NC Well Contractor Certification Number :IS,OUTER CASING(for mulliirisct n-cflsl OR LINER{Wan Fiesbk),.
FROM TO DMMF.TER THICKNESS MATERIAL
SAEDACCO Inc
ft. rt. 1n.
C osi i ut y Nana: I6,'INNER`CASING OR TUBING'(gealhenna1 clascd-IOOP)•' _•
FROM TO • DIAMETER THICKNESS MATERIAL
2.Weil ConstTUetion permit#: WI0700459 0 'ft. 8 ft, 4 ht. SCH-40 PVC
Mau all aFplicotk well permits fax.County.State,;Ynriarrce.Inert err.) ft, ft, in
3.Wdl Use(check well use): I7:SCREEN
Water Supply Well: - FROM TO DiAMETBR SLOT SIZE I THICKNESS I MATERIAL
• ❑Agricultural D MunicipaliPublic 8 R. 18 ft. 4 In• O10 SCH-40 PVC
®Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) fL ft, in,
• ❑hidusnialiConmmercial DResidentlalWater Supply(shared) F[Rm0 0UT TO - • —MATERIAL E rPLICEMENTMEiiIODsASIOONT '
❑hricatiott 0 ft. 4 IL PORTLAND POURED
Non-Water Supply Well:
glidonitoring IDRccovrry R, •ft
Injection Welt: ft. • ft. •
❑AgtiiferRecharge • 1:1GroundwntcrRcmcdiation l9:SANDlGRAVEL•PACK'iif,yspliottge)
FROM • TO MATERIAL EMPL CITH:NTMITri(rn
❑Agnifcr Storagc and Recover}' I7Salinity Harrier 6 ft. 18 ft,' SAND #2
❑Aquifer Test • ❑Stormwatcr Drainage
'ft, a.
❑Experimental Technology • ❑Subsidence Control '
2111 DRILLiNG'LOG(attach additional'sbcets if neeessan)
❑Geotkennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(oils r,hardncn,wtYr cksstx.fsain wc.ctc.I
❑Geolhennal(IleatinglCaoling Reknit) , ®Other(explain under#21 Remarks) 0 IL 12 ft. DARK CLAY/SILT
12 ft. 18 rt. BLUISHSAND/SILT
4.Date Well(s)Completed: 6-1-2023 well iDIIIW-5 ft. it.
3a Well Iaucttiuu r--:r--- r- r• i- "�''
WEST PHARMACEUTICAL ft. - • fL
I
�I
FacildyitiwncrNamc FaciiityiDt(if appiieaable) R. ft, JUJ► 1 2023-
2525 Rouse Rd. , KINSTON, NC, 28504 • rt. ft. IRf.�,i•rr«`, zn-I Pr7'7FjT+'v j l.R
Plnsieal Address,City.and Zip '.21.REMARKS' C,tif.':r 11:
LENOIR •
BENTONITE FROM 4 TO 6r.
Calmly Parcel Ideulifieatlr)nNo,(PIN)
•
ib.I atitude and i ongttude in degree' s/minutrs/seconds or decimal degrees; 22.Certification:
(ifsselt IeId,air:.4m41omg.l5 rullicierd)
ffA !�
SigrutuseofCerti ;9ell Canaaator Date
6.iS(are)the well(s): Z PertiHttnent or ❑Temporal}'. • B signing this form,I hereby certify that.hr w•ell(s,woe(wrnl can.5'tnrcterf Err accordance
with IM NCAC 02C Alto or 15A NCAC 02C A200 Well Construction Standards and ilmn a
7.Is this a repair to an existing well: ❑Yes or IRNo ropy Of this reron'l hasIxtn provirkd to OM 5r141 rnrm-r,
lf this is a repair,fill nett kriuisv well carurnrciioei brforrrurrlwt and explain the rurrnre of n w
repair carder1P21 remarkssrctina or on the back of this form. 23.Site diagram or additional well details:
You may use the back.of this page to provide additional well site details or well
S.Number of wells constructed: 1 constmetion details. You may also attach additional pages if necessary.
For mukluk!infection or nom-wares supply wells ONLY with the snare construction, 'cal can
sabnritone form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 18 (tp,) 241a. Far All Welin- Submit this farm within 30 days of completion of well
For rnr8tlple wells list all cleprks ifdleirenr(example-3@2200'and 20.7 WO'y construction to the foltowingg:
•
10.Static water level below top of casing: 4.5 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above eddlig,ore"+" 1617 Mail Service Center.Raleigh,NC 27699-1617
I1,Borehole diameter.io 5/8" am.) 24b.For infection Wells ONLY: -In addition to sending the form to the address in
• 244 above.also submit a copy of this fonts within 30 days of completion of well
12.Weil construction method:AUGERS construction to the following:
(Lc.auger.rotary,cable.direct posh-etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gym) Method of test: 24e.For.Water Supply&Injection Wells:
Also submit one copy of this form•ivitbin 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
i
Form GW-t North Carolina Depmnnms of Envitoivacua and Natural Resources-Division of Water Reso'trces Revised Atgust 2013