GW1--04623_Well Construction - GW1_20230714

i
WELL•CONSTRUCTION RECORD /�'
Y For Internal Use ONLY: ,
This form can Ix used Cm single or muhipk{setts �'` I
1.Well Contractor Information: LE WATER ZONES
Rich Lemire FROM TO DF.SCRiPt1OY
Well Cor4nicior Name rt. ft.
It. R. •
2593A '
• NC Well Contractor Certification Number '1S.OUTER CASING(foe:tutli-ej'ord.nclls)OR LINER(if'an ilenbtel.
I FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc fL r ft, hi..
Coulieuty Name i 16.•INNER CASING OR TUBING((,EoiAerrnal closed-too
FROM TO DLAME'TER THICKNESS MATERIAL
2.Well Construction Permit#:•W10700459 ' 0 ft. 8 • ft. 4 bt. SCH-40 PVC
1.1f all a i limbic wen permits(Le.Conley.Shoe.Variatrce.frffecti 4 eta..) ft. .ft, is
3,Well Use(check well use): 17:SCREEN
Water Supply Well: FROM • TO Dt4M7.TER SLOT Sin: TmCKb1ss i MATERIAL
OAgdculttlrut CDMunicipal/Public 8 ft. 18 ft. 4 i0. O10 SCH-40 PVC
®Geolhemtal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' ft. in.
❑hidustrialIConuncrcial ❑Residential Water Supply`(shared) Ta:GROUT
, FROttl • TO • MATERIAL EMPLACEMENT MEi110D R AAIOUNT
• ❑Irrigation • 0 ft. 4 (L PORTLAND POURED
Non-Water Supply Well:
❑hrlonitoring i]Rcco►•cry' R. ft,
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundteulcr Rem ediation ;19:SAND/GRAVEL PACK(if aitpticable)-.
FROM TO MATERIAL R\IPI.ACI:HENTHr7n0n
❑Aquifer Storage and Recovery ❑Salinity Barrier 6 ft. 18 ft.' SAND #2
❑Aquifer Test ❑Slormwatcr Drainage
ft. ft.
• ❑Expctimcnlal Technology ❑Stthsidsncc Control 20;DRILLiNG'LOG(attach additional sheets If necessary i
❑Geothermal(Closed Loop) ❑Tracer . . ; .FROM TO DESCIUPTIONtmbr.brrdnee.s"4'nrclttrtta'Frsinsire.drl
❑Geotitem:al(ITeatiugtCoollue Return) ®other(explain under#21 Retuatks) 0 tL 12 ft, DARK CLAY/SILT
•
12 ft. 18 ft. BLUISHSAND/SILT
4.Date Well(s)Completed: 5-30-2023 Well IN IW-18. ft. H. •
3a.Wc6 L/lcatilln: It. ft. �: r.
WEST PHARMACEUTICAL . ft: ft "`m A''' '° �' -• '._• .
Facility wocrNasnc Facility MDN(ifappltable) It. It. J;JI ,A 2023
2525 Rouse-Rd. Exd. , KINSTON, NC, 28504 • ft. It.
Physical Address.City.and Zip . I ,
LENOIR
BENTONITE FROM 4 TO 6'. '�= �r�r
County' Parcel Identi[tc1iioa No;(PIN)
Sh.Latitude and I.tingitude in degrees/minutes/seconds or decimal degrees: 22.Certification:.
(If nell few,one Ia11ong is suf(lciaal) . .
N W 6/4/2623
_�/L p1Prt4�+ L.
Signature Well-Contra' Dale
6.Is(are)the{{'ell(s): XIPervtanent or DTemporai}' ay.signing Mir fumy.1Irerebe certify that the weli(s)was(virtu)constructed la'accordance
frith 154 NCAC 02C.0100 or 154 NCAC 02C.,0200 Weil CSnstmcriar Srandanis and Om a
7.Is this a repair to an existing well: ❑Yes or RIND cam ethic ter Ord binsbeen pmrldcd torlr sir?!muter,
If this is a repair,Jill am RV(AM well cons-nucleon information and c_tplabt the;wine of the
repair ander#21 remarks sr dian ar at the buck of this farm. 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 - eotlstnictiori details. You may also attach additional pages if necessary.
For rtaerlplc Itt(ecrimi or trail-water supply.mils ONLY with the same cuustruetiatr,yob coo
sn&nur one fom. SI lBMITTA L INSTUCTIONS
9.Total well depth below land surface: 18 • (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For ronklplc wells itst all depths Ifdlfiiercot(eraarp(e-die 200'and 2611004 construction to the following;
10.Static water level•belaw tap of casing: 4.5 • (D.) Division of Water Resources,Information Processing Unit,
if na er level is above casing.aye"+" 1617 Mail Service ice Center,Raleigh,NC 27699-1G 17
11.Borehole Iliameter:10.625" (in.) 24b.,For Injection Weill ONLY: in addition to sending the fowl 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 cotrstmtainri t0 the following:
(Le.sager.rotary,cable direct cash.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC.27699-1636
13a Yield(gum) Method of test: • �4e,For Water Supply&-tared-um Weds:
Also submit one copy of this font within 30 days of completion of
r 13b.Disinfection ype:, Amount: • well construction to the county health department of the county where
• constructed.
•
Form Gut-t Noah Carolina Depanmctt of EtIVitarutaIu and Nanual Resources-Divvlon of Water EtOrarcm Revised August 2013