GW1--04628_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD Far henna Usc ONLY:
This fano can be used for single or tntdtipk wells i i
1.Well Contractor Information:
`1.1.WATER ZONES'
Rich Lemire FROM TO ' DKSCRIPTIOY
Well Cor4radorKaifu: ft. ft. 1
2593A fit. rt.
NC WellColrtmctarCcnifuationNuntier •
•15.OIITER_CASING[for-atilti�easedwwetlshOR•LiNER(flaii Tlcabk)•.
FROM TO , DIAMETRR THICKNESS MATERIAL
SAEDACCO Inc ft. rt. is
Comgi:no Name I6.'INNER CASING OR'TUBING(SeoIharmal cloud-loop)' '
FROM TO DLLIIETER. THICKNESS MMATEREIL
2.Well Construction Permit il: WI0700459 0 R. 8 ft, 4 'ne SCH-40 PVC
/In all applirahle wellpenatils(ix.County.Stale,Variance.frjab't.FF car_l R. ft. in,
• 3.Well Use(check well usc): '
17.SCREEN
Water Supply Well: • FROM TO istmit ThR st,(rSrrt: THICKNSS 1 MATFRIM.
❑Agiiculultal ❑Municipal/Pttblic 8 ft. 18 R. 4 ill. .010 SCH-40 PVC
®Geotltemlal(Heating/Cooling Supply) ®Residential Water Supply(single) R. ft. in;
©ludustriaUContmerciai ®Residential Water Supply(shared) i8;GROUT• -.-
FROM TO MATERIAL I EMPLACEMENT MEr11OD&AMOUNT
❑Irrigation 0 ft, 4 " ft. PORTLAND POURED
Non-Water Supply Well:
❑Monitoring CIRccovery R. It,
Injection Well: R. ft.
❑Aquifer Recharge l°GroundwaterRemcdialion t9:SANIWGRAVEL,PACK(if upirlieabtc) -
FROM TO DL1TtiRL1i, EMPLICEMENTMF.TIIOn
17Aquifer Storage and Recovery 17Salinity Harriet 6 ft. 18 R. SAND ; #2
❑Aquifer Tcst ❑StomnvaterDrrinage •It. R.
❑l xirCrimcnlal Technology ❑Snhsidcncc Control -10.DRILLING'LOGiatlacli additional sheets if neccssan•)
OGeothemsal(Closed Loop) ❑Tracer FROM TO DFSCRWP11U hnbr.h:Inkier,soWnrckh11t.grain n,e,alga
❑Geotliennal(Heating+Cooling Return) ®Other(explain under lk2l Retuaika) 0 ft. 12 ft. DARK CLAY/SILT
12 ft. 18 , It. BLUISHSAND/SILT
4.Date Well(s)Completed: 6-2=2023 Well iD('IW-1
fit. It,
SSti,Well Location: ft rt.
WEST PHARMACEUTICAL ft. ft.. f 3...,:.I .•
i''.1=y...'1,v,4 tit' 4,...L,,
FacfityADwocrName Facility ID8(ifapplicable) R. ft, t (]7
2525 Rouse Rd. , KINSTON, NC,. 28504 it. II. JUG t i 2023
Physical Address.City.and Zip '21.REMARKS'
LENOIR BENTONITE FROM 4 TO 6'. tii+veer'+ "� ' J
County Pared identification No,(PIN)
5b.I atitude and Longitude in dcgrce&/minuteslscconds or decimal degrees: 22.Certification:quell field,one lat0ori5 is gnllleterd) '
:= r _ ;�.
N �V =ry /..�c� 6/4/2023
Signature afCc rti Wcll Connnctar Date
6.Is(are)the wells): ElPennanent or. .DTemporat}' tar signing Air Juno,1 herchv certify dial Mr well(s)writ(orrel corartrneted Err accordance
with 15A tVCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards mud 1lxir a
7.Is this a repair to an existing well: fYcs or ElNo copy of Muir record hos been provided to the bell owner.
If this is a rcprlr,fill out k.nthm well construction IRfnrvmixkor end explain the wrote of the
re rrircinder8121 rrmarkrsectian or cm the hark of this forme 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple i.tJectIon or non-water supply welts ONLY with the same construction,you eau
submit one form. SiiIINIITTAL INSTi7CTIONS
9.Total Weil depth below land surface:. 18 (fit.) 24a. For All Wellu:: Submit this'farm within 30 days of completion of well
For multiple wells list nil depths ifdiP-ercnt(example-tn:(Jt1'and 20)100) constnietipn to the following:
10.Static Water level below top of casing: 4.5 (It,) Division of Water Resources,Information Processing Unit,
If Writer level is above cast ta,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter 10 5/8^ (in.) 24b.For infection Weill ONLY: in addition to sending the form to the address in
24a above. also submit a copy of this fops within 30 days of completion of well
12.Well construction method:AUGERS eonsftijctloo 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 Mall Service Center,Raleigh,NC 27699-1636
13a Yield(arm) Method of test: 24e.For Water Supply&Injection:Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type Amount: well construction to the county health'department of the county where
constructed.
Form OW-1. North Carolina Department ent of Env ironnktoand Natural Resources—Division of WaterRraoirces Revised August2013