GW1-2022-08556_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. fL
A - 4121 ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
GEOLOGIC EXPLORATION FROM I TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING.(geothermal closed-loop!
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) 0.0 ft, 17.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. It. in.
Water Supply Well: '17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17.0 ft. 37.0 ft. 2.0 in. 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft' PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK if a licable
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEI'HOD
❑Aquifer Test ❑StormwaterDrainage 15.0 ft. 37.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain she,eta
0.0 ft• 5.0 ft. RED CLAY
4.Date Well(s)Completed: 03/02/22 Well ID# OW-3S 5.0 ft• 34.0 ft- BROWN SILTY PWR
5a.Well Location: 34.0 ft. 37.0 ft- WEATHERED 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 21.'REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-10.0-15.0 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): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature oflhe ofUds record has beenprovided to the well osvner.
repair under#21 remarks section or on the back offs is 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 weliEn
action 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: Ivl AY 2 7 2,022
24.SUBMITTAL INSTRUCTIONS 9v6�'t
9.Total well depth below land surface: 37'0 (ft.)
For multiple wells list all depths ifdifferent(example-3 a200'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),
Ifsvaier level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8•0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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 of the 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