GW1-2022-06651_Well Construction - GW1_20220722

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-06651
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Michael A Brook [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner 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#:
EH W21-05039
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

10/21/2021 25 gpm
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Leonard C Beasley Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Lincoln
Physical Address* Street Address
5758 Gilbert Hilton Road
Address Line 2
city State/Province/Region
Vale NC
Postal/Zip Code Country
28168-8787 US
Latitude* 35.5573083000 Longitude*81.3527719000
Decimal degrees Decimal degrees
................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain 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: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
205 surface?
For multiple wells list all depths if different 48
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 6.25
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
25 13a.Method of test:
If applicable iair
13b. Disinfection type:* 13b.Amount:*
HTH 1.5lbs

14.WATER BEARING/FRACTURE ZONES
From To Description
in feet 170 25gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 48.00 6.25 PVC
in feet in feet in inches
17.SCREEN
...............................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
in feet in feet Bentonite 32 bags
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 22.00 red clay
in feet in feet
22.00 30.00 sappenite
in feet in feet
30.00 35.00 blue granite rock
in feet in feet
35.00 48.00 hard granite rock
in feet in feet
48.00 205.00 granite
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
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* 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
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Signature of Certified Well Contractor