GW1-2022-08561_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES "MWATERZONEs ,
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 4121
ft. ft.
NC Well Contractor Certification Number r15:OUTEWCASING'for multi-cased wells`OR LINER if a 'licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIQVESs MATERIAL
ft. ft. in
Company Name
16"'INNER CASING;011- BING e6th6r`aial closed-loo -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 n- 8.0 ft. 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17:SCREEN 1;' „
Water supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 tt• 43.0 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) 18siGROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 & PORTLAND aENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ii "licatile-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 6.0 ft. 43.0 It. 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer %20 113RILLING LOG attach additioual'sheets if necessa
❑Geothermal(Heating/Cooling Return) PJOther(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,soiurock a rain size,etc.
0.0 ft. 13.0 ft, RED CLAY
4.Date Well(s)Completed: 03/03/22 Well ID# OW-4S 13.0 ft. 39.0 ft. BROWN SILTY PWR
5a.Well Location: 39.0 ft' 43.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM ft. ft.
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 21REMARKS.:«.
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-6.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***OBSERVATION***
(if well field,one lat/long is sufficient) 22.Certification:
350 22' 42.96" N 810 16' 55.59" W
/ 05/19/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. D J
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 Ovee in Remarks Box).You may also attach dditionakpagesQiftg6essary.
drilled: PIN � t L"d-
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 43.0 (ft.)
For multiple wells list all depths ifdifferent(example-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),
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter•' 8.0 (in.) 24b.For Injection 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
13a.Yield m Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018