GW1-2021-00519_Well Construction - GW1_20210729

�wn
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#
GW1-2021-00519
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#:
EHW21-03997
Listall applicablewell construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
C 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
7/2/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Scott E Maxwell Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Lincoln 85169
Physical Address* Street Address
217 blossom hill rd
Address Line 2
City State/Province/Region
Iincolnton NC
Postal/ZZp Code Country
28092 USA
Latitude* 35.4685798000 Longitude*81.2925668000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent (" Temporary
7. Is this a repair to an existing well:* r Yes r 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 GWA 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
820 surface?
For multiple wells list all depths if different 108
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
60 6
If water level is above casing,use"+" in inches
12.Well construction method:
C Auger r Air Rotary r Cable Tool
C Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
1 13a. Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:*
hth 2 Ibs
14.WATER BEARING/FRACTURE ZONES

From To Description
in feet 115 1/2 gpm
in feet
in feet 780 1/2 gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 108.00 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 24.00 bentonite 15 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 10.00 red dirt
in feet in feet
10.00 48.00 tan dirt
in feet in feet
48.00 85.00 soft tan rock
in feet in feet
85.00 260.00 hard grey rock
in feet in feet
260.00 680.00 chocolate brown rock
in feet in feet
680.00 720.00 green grey rock
in feet in feet
720.00 820.00 brown grey 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
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
*N7 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*
AN6el A gook
Signature of Certified Well Contractor
Submittal Date 7/29/2021