GW1-2022-01601_Well Construction - GW1_20220210

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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 1-2022-01601
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Michael 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 W21-05865
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,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
10/28/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Alena Belton Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Lincoln 103482
Physical Address* Street Address
Union Grove Rd
Address Line 2
City State/Province/Region
Lincolnton NC
Postal/Zip Code Country
28092 US
Latitude* 35.3056100000 Longitude*-81.1033900000
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.)
640 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(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)
1 13a. Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:
hth 2 lb
14.WATER BEARING/FRACTURE ZONES

From To Description
in feet 580 1 gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 108.00 6.25
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 42 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 15.00 red dirt
in feet in feet
15.00 45.00 tan dirt
in feet in feet
45.00 55.00 hard grey rock lenze
in feet in feet
55.00 85.00 soft rock
in feet in feet
85.00 115.00 red rock
in feet in feet
115.00 200.00 grey rock
in feet in feet
200.00 250.00 light grey rock
in feet in feet
250.00 280.00 white rock
in feet in feet
280.00 320.00 chocolate rock
in feet in feet
320.00 385.00 light grey rock
in feet in feet

385.00 400.00 grey rock
in feet in feet
400.00 520.00 hard black rock
in feet in feet
520.00 640.00 blue rock/mica
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
.............. ........................... ........................... ........................... ........................... ........................... ......
* 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
Arh,jel A gt-ook
Signature of Certified Well Contractor