GW1-2021-00552_Well Construction - GW1_20210803

�wn
WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
GW1-2021-00552
Are you submitting a printed form?* r Yes
F No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Steve King [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
4055 A JOEY VELASCO CRAIG'S WELL DRILLING
2.Well Construction Permit#:
WC20-000149
List all applicable well construction permits(i.e.IVbnitoring 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
1/21/2021 8
(gallons per minute)"

5.Well Location
Facility/Owner Name
Addison Tyler Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Sampson 2338710937
Physical Address* Street Address
251 Delway Highway
Address Line 2
City State/Province/Region
Rose Hill NC
Postal/ZZp Code Country
28458 us
Latitude* 34.7973118000 Longitude*-78.2131250000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r 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 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
190 surface?
Formultiplewells Iistall depths if different 160
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
48 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
8 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
HTH 2 Ibs
14.WATER BEARING/FRACTURE ZONES

From To Description
160 190 Medium Sand
in feet 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
160.00 190.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 3.00 Hole Plug 2 bags
in feet in feet
3.00 20.00 Quick Grout 3 bags
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
158.00 190.00 #2 Well Gravel Gravity
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 18.00 Medium Sand
in feet in feet
18.00 57.00 Black Clay
in feet in feet
57.00 95.00 Gray Clay
in feet in feet
95.00 130.00 Fine Gray Sand
in feet in feet
130.00 137.00 Rock
in feet in feet
137.00 155.00 Black Clay
in feet in feet
155.00 160.00 Rock
in feet in feet
160.00 190.00 Medium Sand
in feet in feet
21.Remarks

22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
...............................................................................................................................................................
*I7 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
Submittal Date 8/3/2021