GW1--04591_Well Construction - GW1_20230714

•
WELL CONSTRUCTION RECORD Far lracmal Um ONLY:
This form can he used far singlet)/multipk wells• I I
1.Well Contractor Information:
'II.WATItRZONES .
Scott Hunt, Jr FROM TO 0ISCRIRI1ON
Well CooltadorName 12 ft. 17.5 ft. blue/gray silty sand
ft. I It.
4561A
NC Well CantraaorCcrtiftcation Number IS OUTER CASING:fur tot illladtxd nifls)OR LINER fi1'ap flee*);
FROM TO D1AtWTF.R THICKNESS MATERIAL
SAEDACCO Inc ft. fL in.
Conspany Name 16.-INNER CASING Oft TUBING la olliermrd eedaoap) ' '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction Permit#: WI0700459 0 ft. 7.5 ft. 4 hi. SCH-40 PVC
list all applicable well peneiti(Er..County.,SlsrJ,Vorinrrrr.Irfferarri.err.)
rt. ft, in.
3.Well Use(cheek well use); 17:SCR1f.EN
Water Supply Well: FROM TO DIAMETER SLOTS171: THICKNESS R
I MATEAI.
❑Agricultural l lMunicipal/Public 7.5 R. 17.s ft. 4 icy olo SCH-40 PVC
❑Geothermal t1Iieating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in,
Dhidustrial/Contntercial ©Residential Water Supplyiris G
(slated) FRoatRt]tTr TO • MATERIAL EMPLACEMENT MEiI10D&AMOUNT
❑irrigation 0 ft. 3.5 ft. Portland Poured
Non-Water Supply Well: ft. rt.
El Monitoring °Recovery
Injection Well: ` ft, ft.
El Aquifer Recharge DGioundwatcrRcmcdiation -,tv:'SAND!GIzt.VEL.PACKtifalytlleibrkr .
FROM TO MtrttAL rtMPI.ACE:MENrMKTIIOn
13Aquifer Storage and Recovery ['Salinity Barrier 5.5 ft. 17.5 ft. Sand. #2
❑Aquifer Tcst ❑StormwaterDrainagc R. ft.
['Experimental Technology °Subsidence Control '
'1 20:DRILLING LOG(attach additonialshcels if ecccssarVt
oGeodtennal(Closed Loop) ['Tracer 1 FROM TO DESCRIPTION ftnbr.fiaminea.tnR'ntckln*.rran AN.dti
❑Geotltemial(Heating/Cooling Return) 181011ter(explain under tilt Retnatt s) o ft. 12 It. grey silty clay
12 ft. 17.5 ft. blue/gray silty sand
4.Date Welt(s)Completed: 6-6-23 NVollm#lW-26 ft, fL
Sa.Well Location: fL ft. -- T
West Pharmaceuticals.Facility ft, rt, • `c,:4 ,,.<:,,.,,,(,..,•i k4f r!-_,4.
Faclityrt]wgcrNantc Facility IDktifappliable) R. ft. JULIl 2023
2525 Rouse Rd. Exd. , Kinston, NC, 28504 rt. It. J
PlnsicalAddress,City.and Zip :.21.REM1tARk.S'' ln;:,;r°,.5t:'^'Ti : .'r-:>.',N iat? -
Lenoir
Bentonite seal from 3.5-5.5' ,r}; .'i;,:,%•3+.T)
(lowly Parcel lderrtit`rctilioiNo,(PIN)
5b.Latitude and Longitude in degreeslminutcstsceonds or decimal dcgmccs: 22.Certification:
Orwell field,on:I;Moog it tidnelent)
N W 5GeL.12 - 6/14/2023
Signature afCeitilicd Well Can tar pale
6.Is(are)the well(s): %IFerutanent or ❑Tetnporar}' By srgrrnr5 this_limn,I hereby certify that the irrllfs)was{wrrei confrnrcted i r maonlmire
with 15A NCAC 02C.0100 or 154 NOW'02C Azar)MU Construction Standards and that a
7.Is this repair to an isting well: f]Ycs or ElNo cape off ins record has 1rten provided to the urn(riiner,
if this is a repair.fill oat(owtw well come itches hrfomrrttion aid expialn the nature of the
rrp,:lr weeder#21 remarks srcuurr'or on the bark 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 construction details. You may also attach additional pages if necessary.
For tunlalplr irtfeerlon or non-wcher wk.-iv/Us ONLY with the some construction..you.ena
sneurl.one form. . SIiBME1TALENSTITCTIONS
9.Total well depth below land surface:' 17.5 (D,) 21a. For Alt Wells: Submit olds form within 3U days of completion of well -
For multiple hells list all tiepin ifdi3Oerent(example-.t ti 200'mu!2 )100'iy construction to the following:
10.Stack water level below tap of casing 5 (ff) Division of Water Resources,Information Prueessing Unit,
If water level.Is above easing.use•'+'• 1617 Mail Service Center,Raleigh,NC 2 7699-1617
Il,Borehole ameter:l0.625" (is,) tab.For Golcctlgn V1'e`tEv ONLY: in addition to sending the fern to the address in
24aabove.also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA construction to the following:
(i.e.auk r.rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: , 1636 Mail Service Center,Raleigh,NC 27699-1636
Um'Yield WO Method of test 24e.For Water Supply&Injection,Welts:
Also submit one copy of this fern: within 30 days of completion of
1311.Disinfection type: Amount: well construction to the county health department of the county_where
P constnicted. .
Form GW-1 ttonh Carolina Department of Envirunn>orn and,anal Resources-Division of Watts Rmotren Revised August 1013