GW1-2022-08563_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES
,442WATER.ZONES-.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft.
NC Well Contractor Certification NumberISOUTERC�SING for.ioulti=cased:wells:ORLINER(if a 7icatile
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
Company Name
0.0 ft. 61.0 ft.
6.0 in- SCH 40 1 PVC
-16ANNER CASING OR'TUBING- eothermal`closed-loo '
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) & ft. in.
3.Well Use(check well use): ft. & im
Water Supply Well: �17SCREEN '°
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
❑IITI ation ❑WellS>100,000GPD FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑ �11
Aquifer Recharge ❑Groundwater Remediation 9.`SAIVD ftIGRAV=RL PACK.if a' 6csitile
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer �20.DRILLING LOG°attach additi6natishe6ts ifuecessii '
❑Geothermal(Heating/Cooling Return) LhOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhuck a rain size,etc
0.0 tr• 28.0 rr• RED CLAY
4.Date Well(s)Completed: 04/01/22 WeII ID# OW-6D 280 ft' 56.0 ft- BROWN SILTY PWR
5a.Well Location: 56.0 It' 61.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM 61.0 ft- 500.0 fL 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
County Parcel Identification No.(PIN) OPEN HOLE-61.0-500.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 22' 41.63" N 810 16' 55.86" W 05/19/22
6.Is(are)the well(s): [EPermanent 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 ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction StalWand that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the ivell owner. �„j�
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: �d � �ta�cAa
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additigU�Iv vyell�ogstructtllorLnfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages i necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 500.0 (ft.)
For multiple ivells list all depths ifdifferent(ezanple-3@200'and 2@I00) 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),
Ifivater 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 hiection 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