GW1-2021-01160_Well Construction - GW1_20210827

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01160
Are you submitting a printed form?* r Yes
F No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Cheryl Brook [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4210 A MICHAEL BROOK ROCKWATER WELL&PUMP LLC
2.Well Construction Permit#:
13411
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/4/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
David Howe Facility ID#
(Required) (If applicable)
County* Parcel Identification No. (PIN)
Gaston
Physical Address* Street Address
821 hephaah church rd
Address Line 2
City State/Province/Region
Crouse NC
Postal/Zip Code Country
28033 USA
Latitude* 35.4034310000 Longitude tl.3022810000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* �` Permanent C Temporary
7. Is this a repair to an existing well:* (' Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction, only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.)
160 9a.What is the depth of the casing from ground
Formultiplewells Iistall depths ifdifferent surface?
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary Cable Tool
C' Direct Push Mud Rotary Rotosonic
C Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
25 13a. Method of test:
If applicable
13b. Disinfection type:* 13b.Amount:*
hth II
14.WATER BEARING/FRACTURE ZONES
From To Description

118 in feet 10 gpm
in feet
145 in feet 15 gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 114.00 in inches
in feet in feet
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Bentonite 37 bags
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 85.00 red brown dirt
in feet in feet
85.00 105.00 white blue and black gravel
in feet in feet
105.00 120.00 tan rock
in feet in feet
120.00 160.00 blue rock
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
*W By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.

23.Certification*
Achael gyDok
Signature of Certified Well Contractor
Submittal Date 8/27/2021