GW1--04615_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For!Menial Use ONLY:
This form can to used for single or tnultipk wells
1.Well Contractor Information: '
=ii.WATER-ZONES- ,
' Rich Lemire mom ; TO DFSC'sat'rlON
Well Contractor Nam It. ft.
2593A It. fL j
• NC Well Cotumctor Con fiaition Thurber
OTTER CASING tfoF."tuuhi-cased'eells)''OR E.INER of an Beal:IRV, .
FROM - TO DIAArETER '- THICKNESS MATERIAL
SAEDACCO Inc . ft. ft to,
Cntrsp:ut}Nome 16.iNNRR:CASiNG ORTVBING:(ipotherm31 dusedaoop►. .'
FROM TO ' DIAMETER THICKNESS MATERL%L
2.Well Construction Permit#: W20700459 0 ft. 8 ' ft. 4 ut. SCH-40 " PVC' '
List all applicable we.Npenirilr(ix.County.Star.drariarrce.Ir)t2L6icrt err.)
-
ft. ft. ht,
3.Well Use(chccksydl use): 17:SCREEN _
Water Supply Well: FROM TO DIAMETER SLOTSI7.F: TH1cKNriS 1 MATERIAL
❑Agricultural DhfunicipaUFuhiic 8 ft. 18 ft. 4 •in .010 scli-4o PVC
®G rm eotheal(fH ®eatingtCooling Supply) Residential Water Supply(single)- ft. , ft. ia' .
©IndustriaUnu Conenial ©Residential Water Supply(slated) L.m GROUT'
TO AfhTERtkL Lr1tPLAC£htf VT1tIEft16D Shh10tNT
❑Irrigation '0 ft. 4 ft. PORTLAND POURED
' Non-Water Supply Well:
17Monitvring . .ORccovety ft. ft, .
injection Welt: n. ft. - .
D Aquifer Recharge GIGroundw:ttcr RI;nicdi:ttiou '19c'SAND/GRAVELIACK(ifaaplieabrel : _:,.: .,. -
FROM TTJ MATw,RIAI. " EMPI.ACr%TENT sic-noon
IJAtjuifcr Storage and Recovery• ElSalinity Barrier 6 ft. 18 ft.' SAND. #2
❑Aquifer Test • I7Stonmvatcr Drainage
-rt.. rt.
❑Experimental Technology • ❑Stibsideincc Control:. '
-10.'DRILLiNG'LOG(attnch additionkil.sheetSif necessarvt - '
❑Geotltemnal(Closed Loop), ❑Tracer FROM TO DESCRIFTION(c*br.hardocrr,willniekhnc.e alms e.de.)
•
❑Geaodiem al(Heatiirg'Cooliue Return} ®Other(explain under#21 Retuatl s) 0 (L 12 ft, DARK CLAY/SILT
12 ft. 18 f. BLUISHSAND/SILT
4.Date Well(s)Completed: 5-31-2023 Weil lDIl III-13 ft. iL
Sa.Well Location: ft.. r4
;' ^7.—.:i s''y"-::"
' WEST PHARMACEUTICAL _ ft, ft, t .� •h.."' ..-i i,.' fi %,,
Facu7ii},itvocrNantc Facility IDtclfapplrable) ft. ft, II II A lt 2�23 .
,2525 Rouse Rd. Exd. , KINSTON, NC, 28504 rt.- f. - •
J J1 -
Physical Address.City.Hid Zip :.2I.REMARKS'• IFS3ci'F. i1^,"1 ''..7-G•*:14Y:;.)iiIii=
LENOIR
BENTONITE FROM 4 TO 6'. ,R,W% '811+ci
CoUntl' Parcel Idemlifieoliou No,(PIN)
56,Latitude and laingitude in di.greeslminutcsfsecnnds or decimal degrees: 22.Certification:-
•
(it svett rsald,obi:Totten Is sufficient)
N �y +--FJi't+,t:n.t. 6/4/2023.
Signuure of'CO.Well Contractor Dale
6.Is(are)the well(s): %IPertnanent or .❑Temporary Es'signbig thi:farm,I hereby certif'Oar the 114l0l tssts(twee(cvratnrered is mconlmtc'
with I NCAC OW,0100 or 1SA NCAC 02C.0200 well ll Constrrwr(oo Standards and Akira
7.Is this a repair to an existing well: bites or ®No copy of this rcconi rues been pmriskd et itr.'aril muter,
if rids Is a repair.fill nett krtnirw Well CONSrtifellca itrfororall9rr aid explain the rurrure of the
repair render PI remarks section grew 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 welt
8.Number of wells constructed: 1 construction details. You!nay also attach additional pages if necessary.
For multiple Infection or tiro(-inter supply wells ONLY whh the same construction,yakcaa
saburit one form. - - SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: 18 (IL) 2da. For Aft Wells:- Submit this form within 311 days of completion of well
For nuthiple wetls list oil depths If deinent(e.rarnpie-3@200'and 26,WO - constnictipnto the following: -
10.Static water level below top of casing; 4.5 . • (ft..) - Division of Water Roou rives,Information Prneessing Unit,
If uusor level is above easing,its,.•"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter:18 5/8" (in,) 24b.For iDIlectior 'j fly ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this foam within-330 days of completion of well
12.Well construction method:AUGERS consiruc►ian to the following_ -
(Le.auger.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
13a Yield(I ern) Method of test: 24e.For Water Supply&Injection Welts:
Also submit olio copy of this farm within 30 days of completion of
13h.Disinfection type: - Amount: weft construction to the county health department of the county where
• constricted.
Bann GW-1 - . North Carolina Deponent of Envirtuurs ui and Neutral Resources-DM; of Miler ft ou es Revised August )I:i