GW1-2022-08557_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 fL fL
NC Well Contractor Certification Number 15.OUTER CASING for mWti-cased'welis OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKINESS MATERIAL
0.0 ft• 44.0 ft. 6.0 1O SCH 40 PVC
Company Name .
16.INNER CASING OR INGIeeothermal closed-loop)
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. % 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.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT'
❑Irr( 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
79.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
0.0 ft. 6.0 ft• RED CLAY
4.Date Well(s)Completed: 03/18/22 Well ID# OW-5D 6.0 ft. 36.0 ft- BROWN SILTY PWR
Sa.Well Location: 36.0 It' 41.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM 41.0 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':
County Parcel Identification No.(PIN) OPEN HOLE-44.0-500.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***OBSERVATION***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 22' 43.25" N 810 16' 53.82" W
lip"A10 * 05/19/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the lvell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and 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 tivell owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details: DJ
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional-wefrconstruction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additionalpages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS MAY 2 l J0422
9.Total well depth below land surface: 500.0 (ft,)
For multiple wells list all depths iJ dierent(example-3@200'and 2@100) 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: 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(gP m) 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 Wafer Resources Revised 6-6-2018