GW1-2022-06860_Well Construction - GW1_20220729

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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 1-2022-06860
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#:
AP-321453
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
7/22/2022 (gallons per minute)"

5.Well Location
................................................................................................
Facility/Owner Name*
Cornerstone 3 Prop Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Iredell
Physical Address* Street Address
152 Bevis Ln
Address Line 2
City State/Province/Region
Statesville NC
Postal/Zip Code Country
28677 UA
Latitude* 35.7232400000 Long itude*80.8190800000
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
360 surface?
For multiple wells list all depths if different 112
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 6
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)
2 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 135 1 gpm
in feet
in feet 345 2 gpm
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 112.00 6.00 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 19.5 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 Tan dirt
in feet in feet
20.00 45.00 Tan sand
in feet in feet
45.00 85.00 Tan Stone
in feet in feet
85.00 105.00 Grey Rock
in feet in feet
105.00 360.00 Dark 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
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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
Signature of Certified Well Contractor