GW1-2022-06691_Well Construction - GW1_20220725

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 1-2022-06691
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#:
20-400
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
3/21/2022 (gallons per minute)"

5.Well Location
................................................................................................
Facility/Owner Name*
Henry Mims Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cabarrus
Physical Address* Street Address
8618 Arbor Oaks Circle
Address Line 2
City State/Province/Region
Concord NC
Postal/Zip Code Country
28027-3559 US
Latitude* 35.4308188000 Longitude*80.7209653000
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
840 surface?
For multiple wells list all depths if different 72
(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)
7 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:
HTH 2.5 Ibs
14.WATER BEARING/FRACTURE ZONES

From To Description
in feet 685 7gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 72.00 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 70 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 10.00 red dirt
in feet in feet
10.00 65.00 soft tan sand
in feet in feet
65.00 75.00 grey river rock
in feet in feet
75.00 580.00 hard grey rock
in feet in feet
580.00 680.00 pink brown rock
in feet in feet
680.00 820.00 hard grey rock
in feet in feet
820.00 840.00 dark red 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