GW1-2021-06240_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Onlv:
1.Well Contractor Information.
Ti^dky J Am(Cs
FROM I TO I DESCRIPTION
well Contractor\aAe , ft %V ft L'ea�;
q'gq B ft ft
NC Well Contactor Certification Number 1&0ITM CASM ":mid "' `
FROM TO DIAMETER THICKNESS MATERIAL
Garova rjcwiat 4tti l C.•w�}rwakln LLL t tt 17 fL 11/k in CCk t PVC
Company Name 6Ilvrt€�tcl► x .,__. _
2.Wen Construction Permit#: 35yW WWMIzs*q FROM TO I DIAMETER I THICKNESS I MATERIAL
list all applicable well construction permits lie.UIC.County.State.Varianre.err.) fL ft in.
R ft is
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER! I SLOT SIZE I THICKNESS MATERIAL
Agricultural [3Municipal:Public ft Zo fL ( in �� ISO Q yG
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) ft. fL in. t
Industrial/Commercial Residential Water Supply(shared) -_
Irrigation FROM! TO MATERIAL EMPLACEMENTMETHOD 8 AMOUNT
lGeothermal
on-Water Supply Well: 0 ft ft �{
Monitoring ©Recovery ft. ft
jection Well: ft. ft-
Aquifer
Recharge Groundwater Remediation
19'SANDI6Ri4��L-P•AYB' _" �vr+:'=,K;'r..`s�`�
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL / EMPLACEMENTTMETHOD
Aquifer Test 13StormwaterDrainage f- Z ft it?, s(/►q Or►f'CT
Experimental Technolo, [3Subsidence Control tt FL
n ..
Geothermal(Closed Loop) Tracer 20:DRTLLIPtToOG attr
(Heating/Coolin Return) Other(ea lain under=21 Remarks) FROM To DESCRIPTION(color.hardness,solllroek type, Size.etz.
D ft ft rown Shota(
4.Date Well(s)Completed: S ZO Well ID# I ' 157 ft mart qrvVok,K
Sa.Well Location: ft- Z f ft !1.
QW&Cd Sierra ft ft
Facility/Owner Name Facility IDS(if applicable) fL I ft
JJW 6r&++er► fL ft
Phvsical Address.Citv.and Zip ft ft
County Parcel Identification No.(PIN) 9.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: unit
(if well field one latlong is sufficient) 22.Certification loolmat,jFt S+ Qn
3(*° 2? see N ?S' so 0, W 16 Zo
Zl
6.Is(are)the well(s)dpermanent or 13Temporar y Signature of Qfnifiedpell grtractor Du
e I
J y signing this farm,i hereby certife that the welits)isas(were)ramtrurted in accordance
7.Is this a repair to an eidsting well: Yes or GJNo with 15A:4'C'AC:02C'.0100 or 15A h'C.4C 02C'.020fi Well Construction.Standards and that a
If this is a repair,fill out known well construction informaiinn and explain the nature of the ropy of this record has been prewided to the well owner.
repair[order#21 remarks senior,or on the bark of this 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 OW-1 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: ape (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(dii ferenl fesample-3 g200'and 1 L100') construction to the following:
10.Static water level below top of casing: (V a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing.tyre" "r_ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 4 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
fA
above,also submit one cop) of'this form within 30 days of completion of well
12.Well construction method: A%wy construction to the following:
(i.e.auger,rotary.cable,direct push.ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
13a.Yield(gpm)_�c _ Method of test: 24c.For Water SuoDly&Iniection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
Lab.Disinfection type: to G Amount: �•�dZ, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-DiNision of water Resources Revised 1-22-2076

Permit: &35 Currituck
PIN: 1A00Qg423Q0g* k jLf" .veHm"m WELL PERMIT
v Wk yot
Owner Applicant:
MENCHINGER, ROB MENCHINGER, ROB
789 LOS COLONIS DR 789 LOS COLONIS OR
VIRGINIA BEACH,VA:23456 VIRGINIA BEACH,VA 23456
Location:
902 PLOVER CT
'004, A4 f WOW 'his 13G" 6Xofo o 04 t-jz"
CrG 9411,00c7pow eatP117 4 or C° crab
pitJlr
5 �
f7
fd
PerTnkey: Date. 09108/2020
Swinrtey,David
CerB Cation By: Date
z
Construction has been completed,a Residential Well Construction Record Fomn GW-1a has been
submitted:and inspections have been completed in accordance With 15A NCAC 02C.0300.

51
Ih
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 29,2021
Rob Menchinger
789 Los Colonis Dr.
Virginia Beach,VA 23456
RE: Approval No.WWM1264
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
902 Plover Ct.
Corolla,NC 27927
Dear Mr.Menchinger,
On September 29,2021,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 902 Plover Ct.,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