GW1--04627_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD For(menial Use ONLY: ,
Tits faun can be used for single ar multiple wells
1.Well Contractor Information:
-ta:WATERZONFS
Scott Hunt, Jr FROM 113 ' DESCRIPTION
Welt Contractor Nam: 12 ft; 18 ft. blue/gray silty sand
• 4561A R. ft. j
NCWc11CaNractorCcnifrralionNwube: ,tS.OUTER CASING(forraufll.€ eilve(Isl••ORLINERfillip Flcabk)•.
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc f4 rt. io.
Company Name t6:1NNFR CASING OR TUBING1uoihermal closed-ball). '
FROM TO DIAMETER THICKNESS MATERIAL
2.WCII COnstnUCth)n PCI'Init# WI0700459 0 ft, 8 ft. 4 in. SCH-40 PVC
Liu all applicable wolf pennies(he.Comity,,Sta.'e,Variative.If}'eCt!'cel etc.) ft. ft.
3.Well Use(cheClkw ell use); [7-SCREEN
Water Supply Well: - FROM TO DIAMETER SLOTSIM TlI CHNI i5 MATERi L
DAgricultutai OIGItmicipal/PtibliC 8 R. 18 A. 4 in O10 SCH-40 PVC
DGeothemial(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in,
OindustriallCommercial DResidential Water Supply(slimed) :Urn.-To MATERIAL EMPLACEMENT METHOD S AMOUNT
❑lnipation 0 ft. 4 ft. Portland Poured
Non Water Supply Well:
(]Monitoring °Recovery rt
Injection Welt: ff. rt.
°AquiferRcchargc. 13GroundwatcrRemcdialion -rl9.SAND/GRAVEL-PACK(if afiplicabteY- .. -
FROM TO • M,VrRRIAt. - 1 RMPI,ACTAIENT METllpn
❑Aquifer Storage and Recovery ❑Salinity Uarriei 6 ft. 18 ft. Sand #2
❑Aquifer Test DSlormwater Drainage
ft. ft.
DExperimcntal Technology ❑Subsidcn:c Control • .
20:DRILLINGLOG(attach additional`shcetd if necessary)
°Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(ohm hnrctiod,wR'nkktype.Frsln rife.eitt
DGeottenual(Heating/Cooling Return) ®Otter(eplain under#21 Retuai s) 0 ft. 12 ft.. grey silty clay
12 ft. 18 , ft blue gray silty sand
4.Date Well(s)Completed: 6-5-23 Well 1D#III-2 ft. ft.
Sa.Well Location: ft. ft.
West Pharmaceuticals.Facility ft. ft. [.... r ' a Sy'"'7',),Facilityl(hvncrNamc Facility iD✓(((ifapplicablc) �" 's t' - ..
ft. ft. {t
2525 Rouse-Rd. Exd. , Kinston, NC, 28504 g, rt. JUJU 1 ' Z023
Plrysical Address.City_and Zip '.2t.REMARHS - •
Lenoir Bentonite seal from 4-6' tft,\ir rt.<sm':,.i F.'s: j OW.
Div(,..'A It
'County Parcel Idcsitiriention No,(PIN)
Mt.latitude and Longitude in degr'ecslminutcs/seconds or decimal degrees: 22.Ccrtifratior:
(if well field.once l.1ttlongis sufficient) -
N W 5'0,ett" u0rt 6/14/2023
Sigluturc afCcitified Well Con tar Date
6.Is(are)thewell(s): $IPernlanen! or DTCnlporary Ity signing this force,I hereby certify that the well(s)rsys(tsrrel constructed in accordance
with 15,1 NCAC 02C.0100 or 1 Sel NCAC 02C.0200 Weil Coastrncth nu Standards and sb az a
7.Is this a repair to an existing well: DYes or ®ND copy(Tiflis reconl Inv beat pmrirh'd to the rrrli owner,
if this is a repair.fill oat ktroiva well corutructloa hrforrnarior and rtplaht the aware of the
repair tinder02i remarks section or on the brat of this form. 23.Site ding am or additional well details:
You may use the back of-this page to provide additional well site details or well
8.Number of wells constntcted: 1 constiuction debits. You may also attach additional pages if necessary.
For tuultiple ilkellon or non-ntirer supply wells ONLY with the some eeirstruetlotr.you con
.sub»Tit one form. 811RhIITTAL INST[TCTIONS
9.Total well depth below land surface, 18 (ft.) 24a. Far Alt Wells: Submit this form within 30 days of completion of well
For rrnlrlplo wells list a9depthsifdtfl'r'rent([e-mail]2@100) construction to the following:
10.Static water level below top of casing: 5 • (ft.) Division of Water Resources,Information Pnicessing Unit,
if waves level Is abore cashag,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:10.625" (in.) 24b.Fnr Enlecti0n Wells ONLY: In addition to sending the form to the address in
2-la above.also submit a copy of this form within 30 days of completion of well
12.Well construction method:RSA cotlstmctian 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
13a Yield(fgtm) Method of test: 14c.For Water Supply&Injection'Wens:
Also submit one copy of this fame Within 30 days of completion of
13h.Disinfection type: Amount: wctl construction to the county health department of the county where
�' constructed_
Form GW-I . North Camlina Depaulnient of E aviroam:m and Natural Resources-Division of Water R atrtm Revised August 20t:1