GW1--04587_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD • For beerrtalUseONLY:
This form can iv used Fur single at multiple netts
1.Well Contractor Information: ,
. `14.WATER ZONES,
Rich Lemire FROM TO DESCRIPTION
IPTION
Well Contractor Name
ft. It, ! I
2593A ft. rt.
• NC Well Contractor Ccrtiftcation Number "15�OUTER CASING tfoc�uii ised'n-efns1 OR LiNER(if ap fleal)lel-,
FROM TO DIAMETER; THICKNESS MATERIAL
SAEDACCO Inc fG rt. in.
- Company Name 16:INNER'CASING.OR TUBINGygeoiiermal closed-loop);.
' FROM TO DIAMETER THICKNESS MATERIAL
2.Well ConstrTrctihn Permit a WI0700459 0 ft. 8 ft, 4 'M. SCH-40 PVC
• LIU all applirabIr'rel.(jsaimits(Le..Camay.State,lrarianre.1031) (tc.)
n. .ru- it..
•
3.Well Use(Chad:well use): IT:SCREEN
Water Supply Welk • FROM TO _ DIAMETER st.OTSIZE TIITCNNF S 1 MATERTAT. ,
- tJAgicultuml .E1Municipal/P(iblic 8 R. 18 • ft. 4 ill, O10 SCH-40 PVC
DGeothe111tal(Heating Cooling Supply) ®Residential Water Supply(single) iG ft. in,
❑lndustrialiConuncrcial ®Residential Water Supply(shared) o KOUT. To MATERIAL EMPLACEMENT METHOD fi AMOUNT
• ❑Irrig,•rtion • 0 ft, 4 ft. PORTLAND POURED
- Non-Water Supply.Well:
I:Monitoring . I:Recovery ft tt
Injection Well: . .ft. ft.
DAgatiferRcchatgc. DDGiroundwatcrRccntcdiation .,I9.SANDJGItAVELFACK(ifuttplieabtel'- - .....
FROM TO MATERIAL ESIFI.ACKIIENT NF.rlrtrn
DAquifcr Storage and Rccovcty I:Salinity Harrier ' 6 ft. 18 ft, SAND #2
. El Aquifer Test ❑SlormwatcrDrainage
' ❑1 x ierimental Technology ❑Subsidence Control'.
. i0.DRILLiNGLOG(attach additioria dices ifncccssaryl •
OGeodiennal(Closed Loop) ❑Tracer FROM TO - DESCRIPTION(robr.haninea,w0.Mtchn,t.prain,5ra.dr}
❑Geotltemial(FIeatittgtCooline Return) . ®Outer(explain under#21 Reitma1ks) 0 ft 12 ft, DARK CLAY/SILT
12 ft. 18 ft. BLEISHSAND/SILT
4.Date Weil(s)Completed: 5-31-2023 Well IftIW-14 •
ft. ft. ,
34,Wdl Location: p� .
WEST PHARMACEUTICAL
ft; « i v •,. .�'l..i ` y� am.. ..r '
Faeilap,+t]tvocr iJarire Facility iOt(if applicable) «. ft,, JUL J I f_ ?0 Z 3
2525 Rouse Rd. Exd., KINSTON,. NC, 28504 . . • O. ft,•`
•Physical Address.City-and Zip ..2t REMARKS- ll:f�c:,- s:,'t "'.":.f ti L.:,r
LENOIR
BENTONITE FROM 4 TO 6,. L .A`^•'?8;.---°a
C 4' i• t'an;et trieniir itiuu No,(PIN)
fib.Latitude Longitude in dcg tes/minutes/seconds or decimal degrees: '
Z2,Ccrtifieatiga:
(If%en Rohl,one 1.•rt40ug is stdfieicrd)
j` W �.P/Av'.d^„ 6/4/2023
Sigrutnie ofCcrti -Well Contractor Date
• 6.Is(are)fhe.well(s)r %Permanent or I:Tentporaiy . . ityrivihre.drir limn,1 hereby crrh s that the n•dl x)wets• Kent amitnrcred hr nrconlmice
with 1M NCAC 02C,0100 ar 1M NCAC 02C,0200114'1J Construction Standards and Am O
7.Is this a repair to an existing well; ElYes or ElNo ropy ofrliif re(orrNheslx'ra provided roar'urn mow, -
if th(s is it repair.fill oat krioitvi 1veltcoasmrcrioa inform rkur gad rapralit the nature of rite
repair water 021 remarks srclian ar to the hack of this farm 23.Site diagram or additional well details:
You•may use the back of this page to provide additional well she details or well
8.Numberof wells constructed: 1 consttuctiolt details. You may also attach additional pages if necessary.
For mulrlpke Irderrlon or unit-xsirar.sirft*.meals ONLY mtrui the some coustruetlon,yiu+coo
sa ode one form. - ' SUBMITTAL,iNSTUCTIONS •
9.Total well depth below land surface: 18 (ff.) 24a. Fur All Wells: Subirdt this form within 3U days of completion'of well
For multiple wells list alldepthr if stifferwt7(ex wipte-J@200'atul 2@ W0) • ' construction to the following:
10.Static Water level below top of easing 4.5 - - -- (ft) Division of Water Resources,Information Processing Unit,
if Water level is above cvts(itp,.use"+" 1617 Masi Service Center,Ralei;h,NC-27699-1617
IL Borehole dianicter:18 5/8" (in.) 2-lb.for infection Wellq.@NLY: In addition to sending the foul to the address in
244above,also submit a copy of this fonts within 30 days of completion of well
12•Well construction method:AUGERS • construction to the following_ 1
(i.e.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 17699,1636
13a Yield Wpm) Method of test: 2dc,For Water Supply&Injection.WelLs:
Also submit one copy of this ferns Within 30 days of completion of
13h.Disinfection type: , Amount: well construction to the county health department of the county where
constitictcd. I
Form GW-t North Catalina Dcpenntern of Erwirarmkr i and Natural Resources—Diva;Ion of Water Reroute, Revised August 2013