GW1--04616_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For Nand Use ONLY:
This form can be used far single or nuihipk wells
1.Well Contractor Information:
=LLMATER ZONES
Rich Lemire FROM TO DKSCRIPi1ON
Well Cor4rtctorNano: ft. ft.
2593A rt. fL
NC Well Contractor Certification Murkier -IS.OUTER CASING(rormuI1 eUnels0R-UNER4tfap fkabkt3.
FROM TO DIAMETER THICKNESS MATERtAL
SAEDACCO Inc IL fL in.
Compare Bann: I6.IN.NLR CASING OR TUBINGygeoiltermalclosed-loop)•.'
FROM TO '-DIAMETER THICKNESS MATERIAL
2.Welt Conatn,ction Permit 4: Wi0700459 0 ft. 8 ft. 4 it. SCH-40 PVC
Lur ufl ajptliciibk weltpenaits(Le.County.Slate.trnriarre.fr)rE1CD'nan sic.) R, ft in.
3.Well Use(cheek well use): 17_SCRLEN
WaterSupplg"Well: FROM TO DtAMIETER ' SLOT SIM THiCKNf IS MATERIAL
❑Agricultural DMtmicipallPublic 8 ft. 18 R. 4 • in 010 SCH-40 PVC
®Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tf. ft: ill,
❑hidustrial/Conunercial ❑Residential Water Supply(shared) FFRUGROUT 10 MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 4 ' It. PORTLAND POURED
Non-Water Supply Well:
❑Monitoring .DRccovery' N rt.
Injection Well: ft. . rt. •
C7 Aquifer Recharge °GroundwaterRcwediation ..Iv:SAND/GRAVEL PACK(ifupplicitbte)" .
FROM TO MATRRt'I. KMPI A(:F ME T slrTtiOn
❑Ac oiler Storage and Recovey ❑Salinity Hardier 6 R. 18 ft. SAND #2
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology I°Subsidence-Co:Mot -
'20 DRILLiNG'LOG(attach additional sheets if'acccssari-I
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hanlneh.rolVniek nor.train side.He.)
❑G>otltennal(HealinglCooliug Retunl) ®Older(explain under#21 Remarks) 0 ft. 12 ft, DARK CLAY/SILT
12 ft. 18 ft. BLUISHSAND/SILT
4.Date Well(s)Completed: 6-1-2023 Well iD*IW-9
rt. fL _
S A Well Location: ft. It. h e •�? T —r
�
WEST PHARMACEUTICAL ft. ft.
Facility'rUwocrNaive Facility IDk(it-applicable) jt
R. .ft,
,�{---1-h----L-'�J�
2525 Rouse, Rd. Exd. , KINSTON, NC, 28504 U.•
h•sicalAddress.Ci City. ►rfC aS! l
Physical 0 Zip '2LRE61ARtiS' Y;}e4,.it'3;.s`.:+
LENOIR BENTONITE FROM 4 TO 6'.
County Parcel ldenlificlion Ns,(PIN)
5h.I atitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.cer'titicatuin:
(Buell field,one latdutrgis sufficient) �� { '
.-" -....1-1. -
• ]` �`, lei _p/r,nt�.t. 6/4/2023
' SiamturcofCcni Well Contractor Dale
6.Is(are)the 'eli(S): XPennanent or ❑Temporal}' fly signing this form,f hereby c•rrrffti digs rlre vdlfs1 wrtx(wen)ci.rarrnrercrl in accordance
with 15A NCAC 02C Alfk)or 154 NOW 02C.0200 14e Cotrstnicriotr Standards and char a
7.Is this a repair to an existing well: DYe or ®No copy of this record has brew provided to Mr oral owner,
if this is a repair,fill sot briny,wdl consnucilnn information mad e_eplaht Me names of the
repair wafer t731 remarks section or cat the hoc.(.of this fornr. 23.Site diagram or additional well details:
You may use tie back of this page to provide additional well she details or well
8.Number of wells constructed: 1 consttuctioit details. You may also attach additional pages if accessary.
For multiple Ldecrlon or non-Darer slrpply hills ONLY with the same construction,you can
=Iona one farm. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 18 (R.) Zia.-Far Alt Wells: Submit this fours within 30 days of completion of well
For tnulripie wells list all depths ifdlfiwctrr(example-J(4,200'and let 100'y constnictien 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 cvtsittg,toe"+" 1617 Mail Service Center,Raleigh,NC 27699-I617 .
11,Borehole diameter:18 5/8" • (in.) tab.For Initxyion Wells.ONLY: in addition to sending the form to the address in
24a above.also submit a copy of this form within 30 days of completion of well
12.Well oonsintctiou method:AUGERS cotNtmctiort to the following:
(Lc.auger.rotary.cable.direct push_etc.)
Division of Water Resources,Underground Injection Control Programs,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Censer,Raleigh,NC 27699-1636
13;a Yield(gpm) ' 24c.For Water Supply&Injection Wells:
h'Bctirad •
of test:__._ Also submit one copy of this form within 30 days of completion of
1311.Disinfection type. Amount: - well consinictron to the county health department of the county where
constntcted.
Fano GW-t Worth Carolina Dcpartnrrnt of Envinmuncm and Mantra!Resources-Division of Water R I tree Revised August 2013
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