GW1--04617_Well Construction - GW1_20230714

WELL CONSTRUCITION RECORD For Internal(Ise ONLY: '
This form can be used COT single or rnultipk wells
1.Well Contractor Information:
TJ:WASLR ZONES
Rich Lemire most TO D6_1(IRIPTION
Wc)1 Contractor None ft. ft. I '
ft. ft. 1
2593A
NC Well Contracfar Ccniftc ition Numb 15.OUTER CASING(foe mutll-erisedrictlO OR LiNER(Kali Fleabk
MOM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc (L ft. in.
Cangr:ury Name t6.1INNER CASING OR TUBING(geaihernial closed-loop).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction permit#: WI0700459 0 •ft. 8 ft. 4 nr. SCH-40 PVC
List allalprlicuble Wei!permits(i a.County.Sturm.Variarrre.fryre boor*err.)
R. ft, ht.
3.Well Use(cheer;well use): 17:SCREEN — '
Water Supply Well: morn TO DiAMETER SLOT SUE THICKNESS I MATERi.AL,
°Agricultural Ohlunicipal/PubliC 8 ft. 18 ft 4 itr .010 SCH-40 PVC
OGeothemtal(NeatingrCcolitg Supply) °Residential Water Supply(single) . rt. ft. tn.
DhidusiriallContntcrcial °Residential Water Supply(shared) T8:GROUT T.-
FROU TO MATERIAL EMPLACEMLNT hiEf1IOD R AmouNT'
❑lnilation ' 0 ft. 4 ft. PORTLAND POURED
Non:Water Supply Well: •
R. ft.
❑Monitoring •
lJRccocct)
Injection Well: ft.' ft. •
ElAquifer Recharge °Groundwater Rentcdialion .t9.SANDIGRAVEL'?ACKlif•rggdkeribte)=, '
F'ROat TO MATE.RLU• IMPI..%(DJENT METHOD
°Aquifer Storage and Recovery °Salinity Harrier 6 ft. 18 ft. SAND , #2
El Aquifer Test OStormnatcrDrainage R. ft •
❑Experimental Technology °Stthsidcnce Control
•20.DRILLE G'LOG7auach addltiorial9hcelt If'neccsseni _ •OGeolitemlal(Closed Loop) °Tracer .FROM TO ' DESCRIPTION(e»br.n.r,inert.urt>,'ntck hilt.crAin fir.ck:l
❑Geodtennal(Hearin lCoollue Return) :'E101ker(explain under#21 Retuaths) o ft, iz ft, DARK CLAY/SILT
12 ft. 18 rt. BLUISHSAND/SILT
4.Date Wett(s)Corpleled: 6-1-2023 well ID#IW-la
ft. It..
5a.Well location: fr. h. .,7"--.r i .:".'7" ,s
•
,�r,�4,.: .,...
WEST PHARMACEUTICAL ft. ft. ' ii r z-..>E.,
Facility )wncr Nasve Facility IDk(if-applicable) ft. ft.
spy 1r2117
2525 Rouse Rd. Exd. , KINSTON, NC, 28504 . . ft. ft.
Physical Address.City.and Zip -.21.REIifA1t1:S' It-li.".c:c.t: 'Z`l : .. . .-'.:.:j tilt
LENOIR • BENTONITE FROM 4 TO 6', l;Vr'+`;•=?LX..4
Grundy parcel Identification No,(PIN)
•
5h.L atitude'and Longitude in de rres/minutes/sceonds or decimal degrees: 22.Certifientiun:
(Ifuell field,one Iailluugis sufficient) ,
. sf, �.
N W oe ....F/r`nt�..C.. 6/4/2023
SigaitureafCcni ;NellContractor Date
6.is(are)the well(s)t xlPennanent or °Temporary Ih•signing thin farm,i hereby certify than the melt(s)wax(iirreJ corrrrruered ire accordance
'with I SA NCAC 02C.0100 or I SA NCrtC 02C.0200 hill Cons(roction Srarrdards and tlrar a
7.Is this a repair to en existing well: DYes or EINn copy of al it rcconS has hrrvr prorirled rube urn mown
if turfs is a repair,fill oat l?cn rr well corutnrctlan trrforowitort and etplalst the nature of the
repair under 021 rearrrrkr srcriarr or on the brisk 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 constrnetion details. You may also attach additional pages if necessary.
For ntnlrlple lefecrkin or as t-nnrer supply wells ONLY with the same cwrstructlotr,you can .
submit mm form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 ((t.) 24a Fur Alt Wells:_ Submit this form-within 30 days of completion of well
For rmrlrlpleWells list at!depths ifdtflivens(crumple-3'200•and 2@WO) construction to Oro fotlaning:
10.Static water level below top of easing: 4.5 (fl.•) Division of Water Resources,information Processing Unit,
if Water level Is above rria.asc"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
El.Bareholc diameter.18 5/8' (in..) 24b.For Inleednn Wellv.ONLY: in addition to sending the form to the address in
24a above.also submit a copy of this foam within 30 days of completion of well
12.Well constntctiou method: AUGERS consirnctlou to the following:
(i.c.anger.ratan'.cable disco pissk etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigh,NC 27699-I636
t3a Yield(gflm) Method of test: 2dc.For Watcr'Supplv&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. Amount: well consin:ellen to the cotmly health department of the counts'where
constructed. i
II
Farm GW-I Nash Catalina Deptutmenr of Fuvitonnrnl and Natural Resources—Division of Water tlemrtcr Revised August 1013