GW1-2022-06652_Well Construction - GW1_20220722

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-06652
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#:
13358
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
6/3/2021 (gallons per minute)"

5.Well Location
................................................................................................
Facility/Owner Name*
Freedom Homes Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Gaston
Physical Address* Street Address
615 8th Ave Ext
Address Line 2
City State/Province/Region
Cramerton NC
Postal/Zip Code Country
28032-1104 US
Latitude* 35.2508288000 Longitude*-81.0869130000
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
105 surface?
For multiple wells list all depths if different 38
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.)
20 11.Borehole diameter:
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)
20 13a. Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:
HTH 1.5
14.WATER BEARING/FRACTURE ZONES

From To Description
in feet 64 95 ft
in feet
in feet 95
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
.....................
From To Diameter Thickness Material
in feet 38.00 in inches
in feet
18.GROUT
From To Material Emplacment Method&Amount
in feet in feet Bentonite 27 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 20.00 red dirt
in feet in feet
20.00 34.00 orange dirt
in feet in feet
34.00 105.00 hard blue rock
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
Signature of Certified Well Contractor