GW1-2021-07402_Well Construction - GW1_20210921

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WELL CONSTR UCTION RECORD For Internal Use Only:
1.Well Contractor Information:
w -I /� .tI I. 14+.:W --M ZONE$ n :r
TiI•Ly+I'y �+ I tti'e(�S� " FROM TO DESCRIPTION
'.� Well Contractor Name ��(C gQ,l\O� R I ) fL wr► smelly aw4"
>t\O S
K1Y98 \r�������`�Q` it ft- X0 fL clever l�5 Sr�bll
NC Well Contractor Certification Number ,45.F?iTl`ERfiA G§*Jz h coseii..
FROM TO DIAMETER THICKNESS MATERIAL
Garo va Serv1�E+ rt+tol CstaS�rKGfioa LC C ft, ft in.
Company Name Y' sEi IIII�RC8B1PF _.- _ s Ty` _
2.Well Construction Permit#: 3` 2`�3 IN w �� FROM I TO I DIAMETER THICKNESS MATERIAL
list all applicable well Construction permits t i.e.U1C.Counts.State.Variance,err.) ft ` ft I lm ra sch VC
fL fL is
3.Well Use(check well rise): 'j
-
Water Supply Well: I FROM I TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural [3 ntcipalfpublic b ft ft t�� m ,Ob SGH y� pve-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft jn
Industrial/Commercial Residential Water Supply(shared) -
#ffi;GROffi' �=r`^�.. �:-�•'�":�--, :,=r -sue
Irrigation FROM I TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IL S fL I/ .Cft eMle�
Monitoring QRecovery I'(- ft
Injection Well: fL ft
Aquifer Recharge ©Groundwater Remediation r +3 r ..
V.SANDIGR;i :P-+�£K
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage S- ft Z ft (/ -U4 Ourrej
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer
20i1)RII:L1NtsaOG atmsLd'alleidti� ` .�_'�;�,. - _. -,
FROM TO DESCRIPTION(eater.hardness,
l/tuck etm
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
o ft fL rawn sand
4.Date Well(s)Completed: a hqJW1 Well ID# ft ft Ire
Sa.Well Location: fL s fL re SI` f'sl wd C
.lames P N66ileddfy fL Zd fL
Facility/Owner Name Facility lD=(if applicable) ft. ft
Z113 SI►rtdjejoeir Rd Corolla z7gZ7 ft. Ef'L
Physical Address.City.and Zip ft.
Conn, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latflong is sufficient) 22•Certification:
A(f° 31 1i 11 N ?e St SI W i7�/
6.Is(are)the well(s)OP"Ir manent or [3Temporary Signature of(rerfiflecVWell Contractor Date
By signing this form.1 hereby certy�•that the ivelirs),vas(were)rowirurted in accordance
7.Is this a repair to an existing well: 1Yes or [3No with 15A A'CAC 02C 0100 or 15.A!%CAC 02C.0200 Well Construrtion.Standards and that a
If this is a repair,fill out known well Construction information and erplain the nature of the ropy of this record has been provided to the well owner.
repair under#21 remarks section or on the hark of this farm. 23.Site diagram or additional well details-
You
For Geoprohe/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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: �.•f� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O`(J (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 g200'and�2/r@100') construction to the following:
10.Static water level below top of casing: 7 (ft") Division of Water Resources,Information Processing Unit,
If water level is abnve Casing,tae" 1617 Mail Semi¢e Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In,addition to sending the form to the address in 24a
above,also submit one cop) of this forth within 30 days of completion of well
12.Well construction method: e r construction to the followine:
(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
Method of test:—T Y0UN1Ip 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
13a.Yield(gpm) 345�- �— the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: amount: l• 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

Permit: 362493 Currituck
WELL PERMIT
PIN: 087AO0500190001F ALWAAR.CRl(;i6-AL HEALTH SEKVICES
Famters in PLbjk-Hesith
Owner: Applicant:
DIBENEDETTO JAMES P TIMOTHY J ENGLISH
1100 WEST CHESTER RD 2182 TEAL RD
COATSVILLE, PA 19320 COROLLA, NC 27927
Location:
2173 SANDPIPER RD
i_o� ..
-WELOMUST MAINTAji 2SIr1'*In>ttO(it.aum.DNd FOI-INDATIOV WK►P)(V "r
-WE1:L, ILIST MAIIVTAIld'SQ�FAIaG}t+IRkANY P"ART OF SEPTIC SYSTEM
AND IPAIP,AREA t
•VdF;LL MUST BE INSTALLED BY A NC CERTIFIED.KNELL DRILLER
.VVELL PSIRMIt MUST BE ON LOCATION DURING Ail_PERIODS fat.
OF WELL INSTALLATION
-r,ALL AT LEAST 1 5USINESS DAY.PRIOR•FOR REQUIRED a �fa3Tpi/g►
6NSPECTIONS OF GROUT AND WELLHEAD
..
-EXISTING WELLS) MUST 8E PRO-PERLY ASANDONED AI4D
PROPER FORM SUBMITTED INTO THIS OFFICE_
$Ale." : pt.'C r/ c - --
- � a
�00
nowv
{�iNe R"r+ic>p
Permit By: 41 leWbe
' ° Date: 08/23/2021
Certification By: Date: _
Constructor has been completed, a Residential Well Construction Record Form GW-1a has been
submitted an6 inspections have been completed in accordance with 15 A NCAC 02C.0300.

THE AUTHORIZATION FOR DRINKING WATER 1VELL CONSTRUCTION SHALL BE VALID FOR
A PERIOD OF 66 MONTHS AFTER THE DATE OF ISSUANCE.
The issuance of the Certification of Completion in no way guarantees the issuance of other local,state or federal
permits.
The issuance of a Permit for Well Construction in no way guarantees the quality of the drinking water.
Wastewater systems and water supplies shall meet state and/or local regulations.
NO CHANGES IN THIS DOCUMENT ARE,ALLOWED'UNLESS PRIOR APPRO;,Y,AL IS OBTAINED FROM
THE HEALTH DEPARTMENT.' IF THE.INFORMATION SUBMITTED IN-T .APPLICATION FOR.
DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT,:CHANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME INVALID AND MAY BE
SUSPENDED OR REVOKED.
When contacting the Environmental Health office concerning this document,be:we te4mow the application .
number. The number must bemsed-in all inquiries and inspection requests,. . .
The Environmental Health Staff can be located at the following telephone numbers between 8:00 a.m. and 830 a.m.,
Monday through Friday,except holidays. Toe office telephone numbers are:.
Camden. .. . . .. . ... . 3384460 Pasquotank. ... . . :... . 338-4490
Chowan. . . . . .. . .. . . 482-6023 Perquimans. ... ... . .. . 426-2-100
Curiituck.. ... . . ... . 232-6603 Bertie. . . . ..... . . . .. 794-5303
Gates. . . . . .. .. . . .. . 357-1380
Weld-Contractors are responsible for notifying the Environmental Health Ofices for grouting•.inspection,well head
inspection,and required water sarfTling. Drinking water wells must be inspe led and approved by a representative '
of the Environmental Health.staff before any portion of the installation is covered and/or used. .
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIOVS,BUT SHALL IN
NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRINKING'WATER.
*"Minimum.Distances"
Private Drinking Water Wells to:
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
1) Ground Absorption Wastewater Systems. . ...... .... ... ... . . . . . . . 100 ft
(includes epa r—ar�i- -- -__--_
or area permitted for an on-site wastewater system that has
not been installed,and a designated repair area for that system)
2) Other Subsurface Ground Absorption Waste Disposal Systems.. . . . . . . 100 ft.
3) Industrial or minieipal sludge-spreading or wastewater-irrigation sites . . 100 R
4) Water-tight sewage or liquid-waste collection or transfer facility. . . . . .. 50 ft
5) Chemical or Petroleum Underground Storage Tank... . ... . . .. . . .. .. 100 ft
(does not provide secondary containment)
6) Chemical or Petroleum Underground Storage Tank.... .... . .. . . . . . . 50 ft
(does provide secondary containment)
7) Spray or Drip Irrigation Site. .. . . .. . .. . ........ ... ... . . . . . .. . .. 100 ft
(or any other under 15A NCAC 02T)
8) Building Foundations,excluding the foundation of the structure,
housing the well head. . . . ... . .. .. ... ...... .. .... ... :.... . .. ... 25 ft
9) Surface water bodies which act as sources of groundwater recharge, "
such as ponds, lakes and reservoirs .. .... ..... ..... 50 R '
10) All other surface water bodies,such as brooks,creeks,streams,rivers,
sounds,bays and tidal estuaries.. 25 ft
11) Animal feedlots or manure piles.. .. . .. .. . . . . . ..... ... ..\. . . . . . . .. 100 ft +
12) Animal barns . . . . .. . ... .. . . . . . . . . .. .... . . ... .. . .. . .. . . . . .. .. . 100 ft

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 24,2021
James P.Dibenedetto
1100 West Chester Rd.
Coatsville,PA 19230
RE: Approval No.WWM1246
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2173 Sandpiper Rd.
Carova Beach,NC 27927
Dear Mr.Dibenedetto,
On August 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 2173 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.
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