GW1-2022-08565_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 I TO DESCRIPTION
ft, fA
A - 4121 ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING for multi-cased`weRs'OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. is
Company Name
I6.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS DATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) 0.0 ft. 1 12.0 ft. 2.0 1 ' I SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS "MATERIAL
❑Agricultural ❑MunicipaVPublic 12.0 ft. 47.0 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) Is:GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fi. 5.0 It' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL''PACK(if a Icnblr.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10.0 ft' 47.0 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) in Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type rain size,etc.
0.0 ft. 28.0 ft. RED CLAY
4.Date Well(s)Completed: 03/02/22 Well ID# OW-6S 28.0 ft. 45.0- ft. BROWN SILTY PWR
5a.Well Location: 45.0 1" 47.0 ft, WEATHERED ROCK
PIEDMONT LITHIUM ft. ft.
Facility/Owner Name Facility ID#(if applicable)
- --fi. fa -
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-5.0-10.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(if well field,one lat/long is sufficient) 22.Certification: V" ' /�
35e 22' 41.63" N 810 16' 55.86" W 1A
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stan"end that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner. L J
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geo robe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additiona(Gefl construc[ii`onllnfo
P P g add'See Over'in Remarks Box).You may also attach additional r'page's ienece s
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( ) y PaS ary•
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47.0 (ft.)
For multiple wells list all depths tfdifferent(example-3@200'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.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 8.0 (in,) 24b.For Iniection 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
(gPm)
13a.Yield Method of test: Permit Program,16I I 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