GW1-2022-08559_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES la.-wATETf,zos..
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121 ft. ft.
NC Well Contractor Certification Number
15:OUTER CASING for'intdti-cased wells OR LINER if a`licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 45.0 ft. 8.0 1O 1 .188 GALVANIZED
Company Name
°16:.INNER"CASINGARXUBING eo`?hermal'closed=looi
2.Well Construction Permit#: FROM TO DIAMETER 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 w
FROM TO DIAMETER SLOT SIZE THICKNESS N J MATERIAL
OAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18i GROUT 3.
❑Irri 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/GRAYEL•PACK if a `licitble ,.;"� `,:_ �":`_
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer =20.'DRILLING LOG attach'additionalsheets if necessa
❑Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft. 4.0 ft• RED CLAY
4.Date Well(s)Completed: 04/04/22 Well ID# PW-2 4.0 ft- 35.0 ft- BROWN SILTY PWR
5a.Well Location: 35.0 ft' 45.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM 4.5.0 ft- 500.0 ft ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
231 HASTINGS ROAD BESSEMER CITY 28016 ft. ft.
Physical Address,City,and Zip
rt. ft.
GASTON
w 21i�REMARKS t..
County Parcel Identification No.(PIN)
OPEN HOLE-45.0-500.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***PUMPING***
(if well field,one lat/long is sufficient) 22.Certification: II
35° 22' 42.49" N 81° 16' S4.50 W
/dw / 05/19/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)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 well 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 well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additi nadges if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS r�
9.Total well depth below land surface: 500.0 (ft.) ��� F
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of Well completto'6 pert a followi l
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter:
12.0/6.0/7.875 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
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