GW1-2021-03630_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) �.� For Internal Use Only:
1.Well Contractor Information:
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G J 14:rxlrATER'ZONES 9 v.,..:
'i R04t TO DESCRIPTION i
Well Contractor Name `\( �j (�� ft ft ,�
18'1 g P24 •
P 4�� J 7si:OMZRCASING fcrs�tl fen Gf!{e sMCI�
p �. ft. 1,
NC Well Contractor Certification Number �.� �
J�`,. FROM TO .DIAMETER THICKNESS MATERIAL
Corov(a 5crvi cc %Ad (AotdfajjZl ('T/(, *1 IL 1 t3 fL cA is scA FV6
Company Name 16INi+t€1t::GA$$ R!TFI$iPIG � =
2,Well Construction Permit#: 35 7n�y O-7 0 •'
��//WM 12-q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.U1C.County.State.Variance,err.) ft. fL in.
3.Well Use(check well use): ft ft in
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©MunicipaliPublic ft. `10 ft l rn. AID SCh�[Q Ve
Geothermal(Heating(Cooling Supply) WResidential Water Supply(single) fL ft.
industrial/Commercial Residential Water Supply(shared) -
Ini Lion FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 13 ft Itd(t�
Monitoring ©Recovery tt ft
Injection Well:
n ft
Aquifer Recharge ©Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT
EMPLACEMENTMETHOD�
Aquifer Test 13Stormwater Drainage 3 fL 'tp ft tsdaµ OKrt:�
Experimental Technology Subsidence Control ft- I ft.
i
Geothermal(Closed Loop) Tracer t.20:.DRIILII LOG attaehtsd�tf 6M&Abiets:i�
Geothermal(HeatingCoolin Return) Other(explain under=21 Remarks) FROM To DESCRIPTION(eoior,hardness wil/rwk type, m size,etc.)
Q� ft. S It.
4.Date Well(s)Completed: v Well ID# 'L It ft A 54 1 30
Sa.Well Location: Z ft ap ft t RP( W he S
ft. 1"
Ffederick L. Boll Mr.YI
Facility/(Tuner Name Facility TDP(if applicable) tL ft
;Mo7 saa p!l air . Corolla Z19 7.7 It ft
Physical Address.City,and Zip ft. ft
Cumh�ck OTIAooeool low X
County ParcelldentificationNO.(PI\) aSs, "rewt &4eVW / 4�y Parker
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JeParileir PAtj Rieke'
(if well field.one laUlong is sufficient) 22.Certification: Q� 6 1�,,
3V 31, W of N 1e 5 1 SS« W • 0 1 W
6.Is(are)the well(s)EIP"ermanent or 13Temporary Signaore ofCerfified Yell Con or Dar
By signing this form.1 hereby rertify that the weli(s)was(were)constructed in accordance
7.Is this a repair to an easdng well: QYes or CJNo with 15A.NC.AC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
lfthis is a repair,fill out known well ronsiruction information and explain the nature of the ropy ofthis record has been provided to the well mvrier.
repair under#21 remark;section or on the hack of this farm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SL-BMITTAL INSTRUCTIONS
9.Total well depth below land surface: /to A) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3`rd,100'and 2 m100') construction to the following:'
10.Static water level below top of rasing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use" - 1617 Mail Sertiice Center,Raleigh,NC 27699.1617
11.Borehole diameter: �(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy)of this form within 30 days of completion of well
12.Well construction method: AL&I r construction to the following::
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Ptngram,
[13a.
R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) oil1 Method of test: aS Ylhti 24c.For Water Suonly&Injection Wells: In addition to sending the form to
the addresses) above, alsosubmit one copy of this form within 30 days of
b.Disinfection type:�� Amount: •S OZ• completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COHEN,MD,MPH
GOVERNOR SECRETARY
MARK BENTON
DIRECTOR
Onsite Water Protection Branch
August 17,2021
Frederick Bollman
851 Saratoga Rd.
Wilton,FL 12831
RE: Approval No.WWM1243
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2207 Sandpiper Rd.
Carova Beach,NC 27927
Dear Mr.Bollman,
On August 17,2021,the On-site Water Protection Section received your request to approve construction of a well obtaining water
from a depth less than 20 feet in an area not covered by 15A NCAC 02C .0116(b). The approval request is for the construction of one
(1)water supply well at 2207 Sandpiper Rd.,Carova Beach,NC. In your request,you indicated that due the inability to obtain potable
water at deeper depths,a shallow well was the most reasonable option at this property.
Based upon available information provided by Albemarle Regional Health Services staff,you are approved to construct a well
obtaining water from a depth less than 20 feet below land surface,in conformity with the requirements of 15A NCAC 02C
.0116(c)(3),that will serve the above referenced site. A copy of this approval should be attached to the required Well Construction
Record(GW-1)as well as the county well permit at such time that it is issued. Furthermore,it is strongly recommended that you
sample your well annually for bacteriological contamination,as shallow wells can be more susceptible to bacteria.
0
The approval of this variance does not affect any of the other requirements or limitations of the Well Construction Standards,
including but not limited to the requirements in 15A NCAC 2C .0113(b)to repair or to abandon any well which acts as a source or
channel for the migration of contamination or to your responsibility to comply with any other applicable Federal, State,or local laws
or regulations.
The granting of this approval is for the well location only,and in no way relieves the owner or agent from other requirements of the
North Carolina Well Construction Standards,or any other applicable law,rule,or regulation that may be regulated by other agencies,
nor does it imply sufficient water quality.
If you have any questions regarding this variance,please contact Wilson Mize at(919) -270-9665
Sincerely,
Wilson Mize R.E.H.S.
WWW.NCDHHS.GOV
TEL [phone]•FAx [phone]
LOCATION:5605 Six FORKS RD-RALEIGH,NC 27609 i .
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

Permit: 356070 Currituck
WELL PERMIT.
PIN: 08Z 00600160002
ALaEMARLERECOXALMEALTH SERVICES
Partners in ftk HE+eitt,
Owner: Applicant:
BOLLMAN FREDERICK L CAROVA BEACH BUILDERS
851 SARATOGA RD 2162 SALMON RD
WILTON,FL 12831 COROLLA, NC 27927
Location:
2207 SANDPIPER RD
594- A &-K 4 1.0r 14 low-, S014-S&WE
-WELL-MUST MAIN tAIPItl�Et MlNIMkIM FROM ANY--
PART OF'SEPTIC SY*VkMffdPNk AREAc` /
-WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING ' Ba, 1Oa -rt-t-r
FOUNDATION
-WELL MUST BE INSTALLED BY'A NC LICENSED WELL DRILLER �o� f ff r : -
-WELL PERMIT,MUST BE ON LOCATIQN DURING ALLVERIODS
OF WELL iNSTALLATION
-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQU[RED ill
INSPECTIONS OF GROUT AND WELLHEAD i �►
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Permit By: , Date: 05/24/2021
ob , Joe
Certification By: Date:
Construction has been completed, a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15A NCAC'02C.0300.