GW1-2021-06239_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
I
1.Well Contractor Information:
Time% .1 ERM(«h 14.F1?EiMZ0NE6
FROM I TO I DESCRIPTION'
Well Contractor` a ft 1 3 ft to -.sal
N B fL Lc ft clear be& TI.l
NC Well Contractor Certification Number
IS:;O[iTER CASEIG ftir melt+c6sed," :1 r =
•�17 / FROM TO DIAMETER THICKNESS MATERIAL
�.OK
CGfoya &ryrct aow( �.L.( f 1 H- 17 IL I I� in vL
Company Name
6q ?g1 vwwMlzl I. FROM ....
2.Well Construction Permit#: � FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.LTC.County.State.Varianre.err.) ft. fL in.
ft ft is
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THtcKNESS MATERIAL
Agricultural ®Municipal/Public (� fL Z ft. t�� in 60 O Pv
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL It is
Industrial/Commercial Residential Water Supply(shared)
- -
PP (
0-
Irrigation tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No
Supply Well: O ft. ft d
Monitoring ©Recovery ft- ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT�MIETHOD
Aquifer Test DStormwater Drainage ft- �ti IL Oz. 4� dt<rCL`
Experimental Technology DSubsidence Control fL ft
Geothermal(Closed Loop) DTracer 28 DRiI:LIND:3:iG atts� ttdael'al�t� -
Geothermal(Heating/Coolin Retum) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color.lt rdnr$,willrwk sim eto
D fL fL 6. / wT Sa
4.Date Well(s)Completed: Well ID# fL Z fL
fL ft.
5a.Well Location:
6ea% 94 Awols f. fr.
Facility/Owner Name Facility 1D=(if applicable) ft. ftrX
lf.4l Sarwl veer � �trall� 21Qt? ft' f`
Physical Address,City.and Zip —� it. ft. 2 2021
C.rril-wtk- 161d66t0OU6001 informa rooessing Unit
County Parcel Identification No.(PIN)
n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laving is sufficient) 22.Certification:
3(' a7 9" N 'l'S 5a g�,+ W —77` 7 5'i M 02/
6.Is(are)the well(s) Permanent or DTemporary Signa K ofCe ed We onnactor Daz
1 y signing this form.i hereby ceri f•that the well(s)was(were)constructed in aecordawe
7.Is this a repair to an eidsdng well: DYes or UfNo with 15A NC.4C 02C.0100 or 15.A NCAC 02C.0200 Well Construction Standards and that a
ljthis is a repair,fill out known well ronsirurtion information and explain the nature of the rope of this record has been provided to the well owner.
repair under#21 remarks section or on the bark ojthis form.
23.Site diagram or additional well details:
S.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-i is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ;L I (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3y100-and 2 2)00') construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above rasing,rise" - 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter.�_(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Jgt4elr construction to the following:
(i.e.auger,rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
� Q
13a.Yield(gpm) Method of test: S 1"N 24c.For Water Supply&Injection Wells: In addition to sending the form to
`—' I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4rL Amount:�+��t. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit: 335420 Currituck
WELL PERMIT
PIN: 099B000001 000p
AtaeMAsPamnMs n PCwiccF{ee(th SEaF�eces Applicant:
Owner:
SIERRA EDWARD SIERRA EDWARD
1960 BRATTEN WAY 1960 BRATTEN WAY
COROLLA, NC 27927 COROLLA, NC 27927
WEI_LVUST NV IR4TAIN•2fFT+,F'RQM.1Pt-:DING FOUNCA'r1,E},Ai
Location:
-WELL WST:MAAINTA1P4'3Qt FRq.M AWf PART OF SEPTIC SY�SrTEIWI
1960 BRATTEN WAY AND RgPA.lR AREAor ''• .:.,
f o •WELL MUST Be INST'ALLI 13Y A NO OtAtIFIED WELL-ORi(L60--
T#%'/rpx'lr#,*t Jim/ WELL'.PEFtMET M ST B. tsi LOC�t�ON DUFt1N(3 ALL 1.'�IQQ�-:
i�-�Y'4T�if'•• �1'LI�i,�" OF WELG.'iN�'t�fCfi. rf4�'I�i�1: "', .• .. • .
MPECTIONS
Ll.t+AT.L&ST i f3t� pAY Pf�t.Q•$L-.POPE REQt fiRlsA.
QF, p WeLLI'd AD
N 11tt
•R•a P�N,KNTK
ti'rr WMAN0S ►raio e�727472 5.F �
RUVW 16.70 AC.
{ i9
i?� I
~~ 1g
ssr x UPLANDS
181 S.
on MIN ..y,L, 8
1'
r ' M4i009CiTWO
a n �
\ pIIEWXO ON
LOT 9fit
\#• r r• ' e
{ p 305.05
PULTrAL •-.
ORA77EN WAY 6 PWAIE AM
RHA•��.Pik -.—rtgY—ipl.P''•I'P r
� K1Mq,Y
Permit By: Date: 12/07/2020
s, Jae
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.

c
I
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
September 13,2021
Edward Sierra
1960 Bratten Way
Corolla,NC 27927
RE: Approval No.WWM1254
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1960 Bratten Way
Corolla,NC 27927
Dear Mr. Sierra,
On September 13,2021,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 1960 Bratten Way,Corolla,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.
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
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

Permit: 354787 Currituck tGpS �
PIN: 101600 O8 021000� WE4> "PERMIT .+
ALOWARIA R EGItj-4,tL HEALTH SERVICES
Owner: PamminPUllrtcHBaltf. Applicant:
RICHARDS BEAU RICHARDS BEAU
2113 PARK AVE 2113 PARK AVE
RICHMOND,VA 23220 RICHMOND,VA23220
- ioo.oa•
b_
Location: I
— -----
1691 SANDPIPER RD F_n� _+ ._ - -�
r— t g1'(`fipite
f� y.I y _9���_�� —�B.a}•.Q.6__— 'HE fAHlf j '3 (P4Nt"ANk
IL C.
S y�r+J d t y 4fpTIC t p
lot
ilbrbi _ rArix � ,�, I-WELL•MUST MAINTAIN ¢FEET MINIMUM FROM ANY
PART OF'SEPTIC SYST'EM/R PAIR AREA dr '
t
t — P�
WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING
FOUNDATION
WELL MUST BE INSTALLED BY'A NC LICENSED WELL DRILLER
VYEtL PERMIT MUST BE ON t OGATION DURINGAL,L'pERIODS s ,
a
OF WELL INSTALLATI©N
3 i
-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED
INSPECTIONS OF GROUT AND WELLHEAD 1
' I `
Ul—
i p •3 ::�t�.c
I tos'
SwIVIWtiC o
s.POM 9t " 9
M w,ax�
If
iL
01�
: :......_......_. ........
Permit By: r7< Date: 03/26/2021
o bs, Joe
Certification By: Date:
Construction has been completed, a Residential Well Construction Record Form GW-1 a has been
submitted and inspections have been completed in accordance with 15A NCAC 02C.0300.

Mt
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
September 24,2021
Beau Richards
2113 Park Ave.
Richmond,VA 23220
RE: Approval No.WWM1262
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1691 Sandpiper Rd.
Corolla,NC 27927
Dear Mr.Richards,
On September 24,2021,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 1691 Sandpiper Rd.,Corolla,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. Furtheripore,it is strongly recommended that you
sample your well annually for bacteriological contamination,as shallow wells can be more susceptible to bacteria.
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
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER