GW1--04622_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD For Wand Use ONLY:
This form can be used for single or multipk wells
1.Well Contractor Information:
U.WATER ZONES
Rich Lemire FROM TO DESCRIPTION
Well Cortiraraor Name
ft. ft.
2593A ft. ft.
NC Well Contractor Certification Number 1,OUTER CASING(foe Enull l-eisedfiellsl OR LINER(if an lkable)
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc • ft- ft. la.
Covip:uy MIMIC ld.INNER CASING OR:TVBING(geothermal ceased-larkL
FROM TO DIAMETER THICKNESS MATERIAL
2.Weil Constuuttion Pcftnit#: WI0700459 0 R. 8 ft. 4 in. SCH-40 PVC
List all applicable we'll (Le.Carom,,Slur!,Variance.Irpcdc t ere.)
R. It. in.
3.Weil USC(check well use): 17:SCREEN
Water Supply Well: - FROM 1 TO DIAMETER sr,MSin: THICI<NEss I MATRRIAI.
°Agricultural C1MunicipaUP)tblic 8 ft. 18 ft, 4 itu 010 SCH-40 PVC
©Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) R. ft. in,
OludustrialiContntercial °Residential Water Supply(shared) 18.CROUT . _ -
FROST TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑IrrimEtion 0 ft. 4 ft. PORTLAND • POURED
Non-Water Supply Well: • ft. rt.
❑Monitoring °Recovery
Injection Well: ft. ft.
El Aquifer Recharge 0Groundwater Rcnicdiation 19.SANDIGRAVEL PACK(if applicabtor
FROM TO MATEDISL, IMPI.1.EVAIENT METHOD
❑Atjoifcr Storage and Recovery ❑Salinity Barrier 6 ft. 18 ft. SAND #2
❑Aquifer Test OStormwatcr Drainage
It. It.
❑Experinmental Technology ❑Stthsidcncc Conlrpl
26:DRILLING LOG(attach additional sheets if necessary' •
❑Geotltennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(miar.hanine ,StalitCktrtsc. tin re.dai
•
°Geotheal(HeatinJCooliug Return) ®Other(explain under#21 Recumks) o R. 12 ft, DARK CLAY/SILT
rm
12 ft. 18 It, BLUISHSAND/SILT
4.Date Well(s)Ciinipleted: 5-30-2023 well IDf!IW-17
ft. ft. �`
ia.1Vc11 Location: ft. ft 2 ' `1~ , .
'r ''.,,'1..t . s•r,
WEST PHARMACEUTICAL ft. ft. _.,,,
FaclpyrQsuncrNarec Facility lD (if appli able) ft, R. ____________ .tp_ _ Z023
2525 Rouse Rd. Exd., KINSTON, NC, 28504 ft, ft. 111CC,'F(l ;;^;-1 ?r.,
-7 tins
Physical Address,City.and Zip :21.REMARKS 4j."•:', ,' ,5+"
LENOIR BENTONITE FROM 4 TO 6'.
Colony Parcel klenlifention No,(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:' 22.Certification:
quell field,one iab'lqug is sufficient)
1\ W .K-2 oe _.t?/F+,,l.,c. 6/4/2023
Signature a1-Ceni z Well Contractor - Dale
6.Is(are)the woll(s)r SlPermanent or ❑TCnlporary 10 bignnrg Air funs.I irrrrbi•certify that Ihr n rlll's1 wit born cunrinrcrrd irr accordance
with 15A NCAC 02C.0100 or 154 NCAC 02C,0200{lien!Cnnstrectlar Sfarxfarils(rad firm ci
7.Is this a repair to an existing well: DYes• or ®No copy of this woof bas Nca provided ro the snrll owner,
if Ibis it a rc'po/r,Till rent kaoica well eons;ucrloa Information rtad esplahi the rhaare of the
repair ardor 922 remarks srcrlmn ar an the hark 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 construction details. You may also attach additional pages if necessary.
For malrlple.Infection or oast-roarer supply wells ONLY with the scare construction,you con
submit one form. St I IIMETTAL INSTUCTiONS
9.Total well depth below land surface. 18 (fI.) 24a. For All Wells: Submit this farm within 30 days of completion of well
For inirltlple wells list aft depths ifdl error(example-3@200'owl 2@Wily consinrctiun tonic following:
10.Static water level below top of casing: 4.5 (D,) Division of Water Resources,Information Processing Unit,
If water level is above casing,ate"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
it.Borehole diameter:10 5/8" (in,) 24b.For Infection Well!ONLY: in addition CO 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 construction method:AUGERS construction to the following:
(i.e.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
13;r Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county he:iltll department of the county where
- - • • constricted.
Form OW-l NorthCaralinaflepcartmentofEnviraturAtuandNaturalRcwurces-DivisionofWaterRaot cis Revised August_h113