GW1-2022-08558_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. ft.
A - 4121
ft. tr.
NC Well Contractor Certification Number 15.OUTER CASING
formulti-caedwelsOINapIliE
able)
DIAMGEOLOGIC EXPLORATION FROM
MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) 0.0 It. 6.0 ft- 2.0 h` SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ,17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 IL 41.0 it' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) °-is.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 it. PORTIANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
1`19.SANDIGRAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
El Aquifer Test ❑StormwaterDrainage 4.0 It. 41.0 It- 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) itOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 6.0 ft- RED CLAY
4.Date Well(s)Completed: 03/02/22 Well M# OW-5S 6.0 ft. 36.0 ft- BROWN SILTY PWR
Sa.Well Location: 36.0 it' 41.0 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) BENTONITE SEAL-3.0-4.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(if well field,one lat/long is sufficient) 22.Certification:
350 22' 43.25" N 810 16' 53.82" W 05/19/22
6.Is(are)the well(s): 11flPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(ivere)constructed in accordance with
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
If this is a repair,fill out known ivell construction information and explain the nature of the of this 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 we construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
2
64AY 2 t1 202
drilled: 24.SUBMITTAL INSTRUCTIONS c`
9.Total well depth below land surface: 41.0 (ft.)
For multiple wells list all depths ifeli ferent(example-3 a 00'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
If water level is above casing,use"+'If 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,rota
ry,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
Permit Program,1611 MSC Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
g g ,
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018