GW1--04621_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For trcnrnI Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor ltlfo rmatian:
:14.WATitR ZONES
Rich Lemire FROM TO DESCRIPTION
%Pell Contractor Arne ft. ft.
2593A ft. rt.
•
NC Well Contractor Certification Mattel •t5;OUTER CASING(for mull Pained"'AMA OR LiNER(if OD fleable)-
FROM To DLt61ETRR THICKNESS MATERIAL
SAEDACCO Inc rt. ft. in.
Company Name 16.INNER CASING OR TUBING(veaihermal closed-loop).•
FROM TO DLANIETER THICKNESS MATERIAL
2.Well Construction Permit#: WI0700459 0 ft, 8 ft. 4 M. SCH-40 PVC
List ull appliratle well permits(ix.County.Sitar.Variance.iofe:ting ern.)
ft. rt. in.
3.Well Use(chock well use): • 17:S(.'RLEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS i MATRRtAI.
❑Agricultural ❑Municipal/Public 8 fr. 18 n. .4 in. oho SCH-40 PVC
❑Gcotllcrntal(HeatingfCooling Supply) ❑Residential Water Supply(single) ft. I It. is,
•
❑iudustriaUConuncrcial ❑Residentiat Water Supply(shared) FRo ROCT TO. MATERIAL EMPLACEMENThiETltoD cn`IottuT
❑kTipatian 0 ft. 4 ft. PORTLAND POURED
Non-Water Supply Well: ft. ft,
Dtolonitoring DRecovery
Injection Well: ft. ft.
DAquifcr Recharge DGronndwatcrRentediation •19:SAND/GRAVEL PACK(ifaptdicabtc)`
FROM TP M.erRR1•tt. RIPI.ACFtlr_NT SfFTfifn
DAquiler Storage and Recovery []Salinity Barrier 6 ft. 18 ft. SAND #2
❑Aquifer Test ❑Stormwatcr Drainage
ft, It.
❑Experimental Technology DSRbsidcncc Control
20r DRILLING LOG(attach additional steels-if neccssanl
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Nair.hardnel.wil'nrckOne.rrin•ira(fc:l
❑Geotilenual(IlcatiiglCooliug Return) ®Otltsr(explain under#2!Retuai s) o ft. 12 ft. DARK CLAY/SILT
12 ft. 18 ft. BLUISHSAND/SILT
4.Date We1ts)completed: 5-31-2023- Well ID#Iw-11 ft. ft.
Sea.Well Location: ft. ft
WEST PHARMACEUTICAL ft. ft. t :1 7:r- ^-•::n .
Facility: hu-srNance FacilityiDe.(ifapplicable) ft. ft, "."`"`` 'a tt �xr
2525 Rouse Rd. Exd. , KINSTON, NC, 28504 . • It. ft. JUL 1 2023
Physical Address City.and Zip :21.REMARKS J J l! J
LENOIR BENTONITE FROM 4 TO 6'. infc,o 5a1:'il ?C^.•:5,7:: •j l.Ji.:
County Niel Identifx..;dion No,(PIN) : `� .z
5b.Latitude and Longitude•in degrees/minutes/seconds or decimal degrees: 22. fK Certification:
(if;wit acid,one!Alois is statici::rd)
N W oe _P/ih 6/4/2023
Sigruture a(Ccri Well Contractor Dale
6.IS(are the R'eII(N): SlPennallent or ❑Temporar}' Dr signing whir farm,i hereby terrify that the waifs)WU'S itwrej cUnyi ndetl in cecrorcthncr
with TM NCAC 02 C,p!(kl or l M NCAC 02C.0200 Well Constracriort Standards and that a
7.Is this a repair to an existing well: ❑Yes or N No tope of Mk rewash bay bean provided ma the"rmli owner,
If this Is a repcm r.fill our kaoiuvi well corunucton inforcaarlon and c tplahn the ware of the
repair wafer i31 remards arcrian or at 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 well
8.Number of wells constructed: 1 CoISttuctltllr details. You may also attach additional pages if necessary.
For ntatinple lafecrlwn or oort-rarer supply wells OAF.)trirh rule samr construction,you can
submit one form. ' SUBMITTAL INSTi_TCTIONS
9.Total well depth hetow land surface: 18 at) 24a. For All Wells: Submit this form within 30 days of completion of well
For malt/plc wells list all depths ifd4)"ereau(example.-3 200'awl 2@ 100) construction to the following:
Ib.Static water level below top of casing: 4.5 (O,) Division of Water Resources,information Processing Unit.
Ifwrarer level Is above casing,ase•.+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I1,Borehole diameter:10 5/8" (itl•) -24b.For Injectors Wells ONLY: rn addition to sending the fonu to the address in
24a above. also submit a copy of this forth within 30 days of completion of well
12.Well constrtietiofl method:AUGERS coitstmctiort to the following:
(Lc.auger.rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
133 Yield(gpnf) Method of test: 24e.For Water Supply&lnjection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constricted, 1
Form GW-1 North Carolina Department of Enviroautom and Neutral Resources—Division of Water Rmotrncm Revised Atgust NI)