GW1--04619_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For[Mental Use ONLY:
This form can be used for single or multiple wells
V.Well Contractor Information:
`LEAVATER'ZONES'
Rich Lemire FROM To DKSCRIPtION '
Well Cor4tucler N<lnt4: ft. ft. 1
2593A ft. ft. r
'
NC WellCmnnrctarConifiatianNwdaet 15:OUTER CASING'tfoe.untli[•cas�eths lhiOR-LINER[[9-ap fleabte),-
FROM TO DIAMETER THICKNESS MATERiAL
SAEDACCO Inc ft. ft la
.
COMMIT Nanw T6'INNERTCASiNG ORTUBING'I,9;eothermal closed-lanW. .
FROM TO DIAMETER THICKNESS MATERIAL
2.Wclli Construction Permit#: WI0700459 0 R. v 8 ft: 4 its. SCH-40 PVC
Mr we.f pcnrrits(i_e.Comity,State.Variranre,fajetiorb etc..)
ft. ft. in. ..
3.Well Use(cht cicwell use): I7:SCREEN,
A FROM TO Dtn'+1ETKR St.OTSr7,H. , Tincur tsS 1 Minium.
Water Supply Well:
ClAgricultutal °Municipal/Public 8 ft. 18 ft. 4 in, .010 SCH-40 PVC
. ©Geotliennal(HealingICooling Supply} :Residential Water Supply(single) R. if. in,
-
©ludustri,Il/Commercial ©Residential Water Supply(shared') lac GROUT: . - . - 1
FROM TO • MATERIAL r EMPLACEMFVT MEiHOD&AMOUNT i
❑irrigation 0 ft, 4 R. PORTLAND i POURED
Noa:Water Supply Well:
❑Monitoring ❑Recovery' • ft. ft..
Injection'Well: ft, ft„
❑Aquifer Recharge AGroulrdlsater Renrcdiation ,19:SANDlGILWEL•PACK if applicubtcy .. .
-FROM TO • ' stATERrAl. P.MPI.A(VAIENT HI_rrlfn
❑Aquifer Storage aril Recovery 17Salinity Barites 6 ft. •18 ft. SAND , #2
❑AgniferTcst DSlnm:waterl3ruinagc R. ft.
❑Expciimcntal Technology i3Subsidcncc Control
1f;DRiLL1t1G'LOG(attach nddihonal.Nheds if nceessall')
❑Gee henna}(Closed Loup) ❑Tracer FROM TO DESCRIPTION(cobnhanrncet,wn'ntckirite.tn*in tare.cu.1
❑Geotltenual(Heating/Cooling Return} . ®Otter(eplain under#21 Retua6s) o tL 12 ft DARK CLAY/SILT
12 ft. 18 ft. BLUISHSAND/SILT
4.Date Well(s)Completed: 6-1-2023 . Welt iD#IW-7 ft. ft.
5a,Well Location: ft. ft. e r_ ����
WEST PHARMACEUTICAL • .r. ��'
Facility,t3wnerNtmic Facility IDk(ifapplicable) R. ft.
J!J! I % 2023
2525 Rouse,Rd. Exd. ,, KINSTON, NC, 28504 ft. ft.
Physical Address,City.and Zip• '21:REMARKS lf,ii.Ca" S:1^:l t•7':-7-:',-;_ '', t;t--
LENOIR BENTONITE FROM 4 TO 6'. D.,r,•' „,:'<�'..1
Calmly • Panel Idetiliticidion No;(PIN)
5b,Latitude and Longitude in dcgrtees&minutcs/3cconds or decimal degrees: 22 Certification:
quell field,One I;dilong,is sufficient)
N W —f.4MVti.-G-• 6/4/2023
' SibrnturcofCcni WelConlractar Dale
6.IS(are)the.{{'ell(s): SlPerwal)ent or ❑Temporal}' By signing tat.Pm,.1 hereby certify that the mdI(sl war(kerel cvorfrutted ire rrc'earrlamce
with 15.1 NCAC O2C.01(k7 or 151 NCIC OW.0200 Well Conservact(on Standards and that a
7.Is this a reps rtu en eshtinj well: EYe-s or No ropy ofthir record'has been an-witted fo IN!'arilmvner.
if this is a ri')salr,fill carat laioitva well cansinrcrlaa brforaiatlon mad explain the totrtsre of tie
repair ruttier021 rernarksseiliao or on the hark of'this foray. • 23.Site diagram or additional well details: -
You-may use tie back of this page to•provide additional well site details or welt
S.Number of wells constructed: 1 constmction details. You may also attach additional pages if ttecessaty.
For malteple.lafeerhsn or oon-wafer snpplr heels ONLY with rhe.samb cuarstructiou,sea ears
SW27'rrit Miff form. SUBMITTAL iNSTUCT IONS
9.Total welt depth below land surface: • 18 (ft.) 24a. Ftsr All Wells:- Submit this,fain within 30 days of completion of well
For analripie Wells list aftdepths Ifdlffixrnr(example-3@200'and 2@ llil)) consintotion to the fol[oz<ing: ,
In.Static water level below top of casings 4.5 ((f•) - Division•of Water Rooftrees,Information Prneessing Unit,
if niter level is tehove vasGa„,ease"+" 1617 Mail Service Center,Ralei r,NC 27699-1617
➢1,Borehole diameter;10 5/8" Om) 2lb.For Injection Wejls ONLY: ;in addition to sending the fame to the address in
• 24a above,also submit a copy of this hum within 30 days of completion of well
12.Well construction method:AUGERS conSlnictiotl to the following:
(Lc.auger.rotary,cable direct pasts_ere.) ' ,
Division of Water Resaurces.IUnderground Injection Control Prograni,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test Ile.For Water•Supply&Lnjcetior Weds:
Also submit one copy of this fortis within 30 days of completion of
113b.Disinfection typo Amount:
well construction to the county health department of the county where
constnictcd
Faun GW-t North Carolina Dcpartntem of Env'ironmcrn and Natural Resources-Dit'iilon of Water ReSdiites Revised August 2013