GW1-2022-08562_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
A - 4121 ft. ft
ft. ft
NC Well Contractor Certification Number '15.OUTER CASING formulti-cased wells OR LINER if a 'licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 ft 47.0 ft 6.0 ' SCH 40 PVC
-16.INNER CASING-OR TUBING` "e6thermal closed-loon)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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/GRAVEL PACK if applicable)
"
❑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 additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) In Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soi truck type,grain sire,etc.
0.0 ft• 13.0 fr• RED CLAY
4.Date Well(s)Completed: 03/17/22 Well ID# OW-4D 13.0 ft- 39.0 ft- BROWN SILTY PWR
5a.Well Location: 39.0 ft• 44.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM 44.0 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 ft. ft.
GASTON 21.REMARKS •C
County Parcel Identification No.(PIN) OPEN HOLE-47.0-500.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(if well field,one lat/long is sufficient) 22.Certification: ��
35n 22' 42.96" N 810 16' 55.59" W /' t`����"tf'�
05/19/22
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the ivell(s)ivas(were)constructed in accordance tivith
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known we//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. DJ
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,only1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional ages if necessary,
drilled: 24.SUBMITTAL INSTRUCTIONS RAY' 1 1 2U a2
9.Total well depth below land surface: 500.0 (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00D 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: 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 pushy 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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018