GW1-2022-08552_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES A4::WATER ZONES-'--
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Aor'multi=cased wells'OR LINER grap licable
GEOLOGIC EXPLORATION FROM I TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 ft 38.0 ft 6.0 in- SCH 40 PVC
°>16.INNER CASINGOR TUBING"geothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: `�17:SCREEN,, '4 •• `�� ti-
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18.GROUT
❑Irrt ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK if a licnblc - '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology El Subsidence Control ft. %
❑Geothermal(Closed Loop) ❑Tracer 20:"DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) CJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltruck type,grain size,etc.
0.0 ft. 5.0 ft. RED CLAY
4.Date Well(s)Completed: 03/22/22 Well ID# OW-3D 5.0 It• 35.0 It- BROWN SILTY PWR
5a.Well Location: 35.0 It. 500.0 It. ROCK
PIEDMONT LITHIUM ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
231 HASTINGS ROAD BESSEMER CITY 28016 ft. ft.
Physical Address,City,and Zip ft. ft.
GASTON :2L REMARKS ,�;t��I
County Parcel Identification No.(PIN) OPEN HOLE-38.0-500.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 22' 42.28" N 810 16' 53.63" W 05/19/22
6.Is(are)the well(s): 11flPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known tivell construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well Diction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS Ar�f °t 7 fl,
h'
9.Total well depth below land surface: 500.0 (ft.)
212
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 12.0/6.0/7.875 (in) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: AUGER/AIR Program,1636 MSC,Raleigh,NC 27699-1636
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018