GW1--04613_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD Far Waned Use ONLY:
This Comma b:used for single or multiple wells .
1.Well Contractor Information:
`l.iWATERZONES
Scott Hunt, Jr • FROM TO DF.(;IttPI1ON
Well Cor4radorNann: 12 ft. 18 ft. blue/gray silty sand
4561A ft. ft.
NC Well Contractor Certification Number AS.OUTER CASING ir eutti teed OCRs)OR-LINERWan flcabk)•.
FROM TO t DTANIETER THICKNESS MATERIAL
SAEDACCO Inc It,. ft. in.
Company Name 16.1NNLR'CASING Olt TUBING geothermaiclosed-loop}
FROM "-TO DIANWETER THICKNESS SIATERLAL
2.Well Construction Permit#: WI0700459 0 - ft. 8 ft. 4 n1. SCH-40 PVC
List all alpalicrthle we(penitits(Le.County.Sher,Varimrce.IryeCtiGn etc)
H. rt. in,
3.Well Use(cheek well used 17:SCREEN
Water Supply Well: FROSI TO DUMS:T R SLOT SIZE THICKNESS I MATERIAL;
°Agricultural ❑Municipal/Pu►blic 8 R. 18 rt. 4 in 010 sCH-4o PVC
❑Geothermal(Iieati ['Residential Water Supplyft. ft. m
�Coolin Supply)g (single)
❑lndustrialiContntercial ❑Residential Water Supply(shared) -FRO,\IRQUT TO StATER(AL EMPIACEMENIT METHOD,a AMOUNT
❑1triPndal/ 0' • ft. 4 fL Portland Poured
Non:Water Supply Welt: ft, re,
❑Monitoring ❑Rccovcry
Injection Welt: ft, ft.
DAquiferRecharge °GroundwaterRentediation '19.'SANDIGRAVEL•PACK(ifutydi:abte)' ..-. . .
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FROM TO MATERIAI. EMPI AO:Aly T METRO
El Aquifer Storage and Rceovery ElSalinity Ranier 6 ft. 18 ft. Sand, #2
❑Aquifer Test ❑StormlviitcrDrainage R. ft.
❑Experimental Technology ['Subsidence Control -
20:DRILL111G'LOG(attach additional'sheds If nccessan-1
❑Geotltemtal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(robr.hard nem,wR'mcktv tot.grain taire,dc.1
❑Geodteimal(Heating/Cooling Remo)) •®Oilier(explain under#21 Rereads) o ft. 12 tL grey silty clay
12 ft. 18 ft. blue/grey silty sand
4.Date Well(s)Completed: 6-7'23 . Well ID#IW-19, ft. ft.
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Sit.Well Location: ft. rt. r . ., r7"•- { ,
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West Pharmaceuticals Facility ft. ft.
/. 2(17-
Facl3ity/OwncrNamc Facility IDir Ofapplkablc) R. ft. _ -
2525 Rouse, Rd. Exd. , Kinston, NC, 28504 ft. ft. )R ov e.,*::'•'5 (,t'.`'•I'i',"j ;.)`"
r ,:rl-y
Physical Addr'ss.City.and Zip 421.REMARKS • Ca'`,' :'
Lenoir Bentonite seal from 4-6'
County Parcel Itkidifteoilon No,(PIN) -
5h.,I.irtitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell 644 tpae 4o51oug 1s stdlickW) -
N . -, W e5' tfVI . 6/14/2023
Sig:more ofCcitil,ed Well Co tar Dale
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6.Is(are)the well(s): %IPennalrettt or .❑Temporal}' try signing this formm.I hereby certify that the irell(s)vats(roam cvarrlructed hr accordance
with/5A NCAC OW.0100 or t s 1 NCAC(CC.0200 Well Crnastrtactiou Standards and shot or
7.Is this a repair to an existingwwell: f]Yes or H1No_ copra?tills recon-1 hasbrrn pn ridt'd rothe sir/!turner.
If this is n ri,tslr,fill{-ur brown 1raroru-mrcrion biformraiorr mad i.vplaht the lunore of Me - -
repair rider 021 re,narks srclinn or on the hawk of this form. 23.Site diagram or additional well details:
You may use the hack of-this page to provide additional well site details or well
• 8.Number of wells constructed: 1 construction details: You may also attach additional pages if necessary.
For owls!ple.lrl(erdon or omt-xnrer supply wells ONLY with the same construe:log.son eats
.srttoekone form. SUBMITTAL INSTCTCTIONS
9.Total well depth below land surface,„ -18_ (ty,) 24a. For All !'ells: Submit this form within 3(1 days of completion of well
For multiple wells lisr all ekprhslfdlfiaera&sample-3@200'alul2@I0 y construction to the following:
10.Static water level below tap of easing: 5 ((1.) Dii•isiun of Water Resources,Information Processing Unit,
if water kvel is above Casttrn.last.•4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dianietcr.19.625" ( ) 24b.For Infection'Wells ONLY: In addition to sending the fowl to the address in
. 24a above.also submit a copy of this fonts within 30 days of completion of well
12.Well construction method: HSA . construction to the following: •
(Lc.auger.teeny,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
133 Yfdd(>•pm) 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: well constniction to the county health department of the county where
constricted. I I
Farm GW-1 North Carolina Depannrclu of Envtrol111Am and Natural Resources-Diet Ion of Wafer Rm.otrom Revised August2ot3
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