GW1-2022-01487_Well Construction - GW1_20220126

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 � .�
tMotl'W J Irslr `14:=WATER`ZONE
r FROM TO DESCRIPTION
Well Contractor N e q ft l ft s G '
� �-
NC Well Contractor Certification Number 15i.011I) RCASiNG formnih" 13R:1i1 .R'- ' "
/+ L� FROM TO DIAMETER THICKNESS MATERIAL
I.PrOyQ SewIG! j�4'� LLB �. ' ft '� ft 1 �� in ScM T� PVC
Company Name —r—
o
2,Well Construction Permit#: 30 ui( WWA 1303 FROM 1 TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(ix.UIC.County.State.Variance,etc-)
ft ft in.
EL ft is
3.Well Use(check well use): _r
z vim-
Water Supply Well: I FROM I TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural [3 nicipal[Public J6 ft 1 t9 fL l ��� in' - �O PV�-
Geothermal(Heating!Cooling Supply) Residential Water Supply(single) ft, ft. in
Industrial/Commercial Residential Water Supply(shared) S ..... -
Irrigation FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUN
Non-Water Supply Well: b ft (g IL
Monitoring ©Recovery ft ft
Injection Well: ft ft
Aquifer Recharge QGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage l g ft Z.I ft > Z u�
Experimental Technology Subsidence Control ft- ft
Geothermal(Closed Loop) Tracer 20i DRILLINGiOC'att:ek,ateliee#sff s-.
FROM TO DESCRIPTION(color hardness,so!Vrmk ete.)
Geothermal(Heatin Coolin Return) Other(explain under=21 Remarks) d
ft' S fL bry r'W -;-444
4.Date We1I(s)Completed: I ?bZ2 Well ID# ft l 2 ft �+e
Sa.Well Location: Z ft ft -,✓ , t�J r,'�-r
Shclb ale ft L ft
e
Facility/Ownit Name Facility IDS(if applicable) ft- ft
Z1,70 Salmoki Rd , (*roll& . 2?927 ft ft
Physical Address.City.and Zip ft ft
County Parcel Identification No.(PIN)
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one;vlong is sufficient) t 22.Certification:
3(.° 31 is N 1S° 52 13 w -i---�� 7hozz
6.Is(are)the well(s)EIP/ermanent or 13Temporary Signanue�Cem d Weil ontractor Daz
i y signing thtr form.I hereby rertll that the well(sl was(were)cowaucted in accordance
7.Is this a repair to an existing well: ffyes or [3No with 15A.CAC 02C D100 or ISA NCAC 02C.0200 Nell Consirurrion Standards and that a
if this is a repair,fill out Mown welt construction information and explain the nature of the ropy r f this rerord has been provided to the well nwner.
repair under#21 remarks section or on the hark of this form.
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-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: let (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple,vells list all depths if different(example-3@200'and 2 ct,100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If waxer level is above rasing,ace- " 1617 Mail Service 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 form within 30 days of completion of well
U Well construction method: A M 6r construction to the following:
(i.e.auger-rotary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
L13a.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ield(gpm) Method of test: 445 p pf 24c•For Water Suouly&Injection Wells: In addition to sending the form to
f�.� the addresses) above, also submit one copy of this form within 30 days of
isinfection type: [T 1 �- Amount: l•�OZ, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qualir`-Division of Water Resources Revised 2-22-2016

Permit: 367269 __ Currituck
w
WELL PERMIT
PIN: G'9'7jk-00l ., ♦or y -� OOD,S
AL BE►1ARLE REGONAL HCALIH SER';(c Cs
Partners in PCblic Health
Owner: Applicant:
PALLLTTE,SHELBY PALLETTE,SHELBY
1212 KITTIWAKE COURT 1212 KITTIWAKE COURT
VIRGINIA BEACH, VA 23451 VIRGINIA BEACH,VA 23451
Location ---� f
2170 SALMON RD Nppir64" I
k-WELL MUST MAINTAIN Sb,FEET MINIMUM FROM ANY .I,Sj -�6• "•~ }.�'
PART OF SEPTIC SYSTEM/RE1VAIR AREA r— ' _ B• p
-WELL MUST BE LOCATED AT LEAST 25 FEET FROM B YPi /SAS ND ` �.'�� i2eC
-WELL N 4UST STAY AT LEAST 25 FEET FROM ANY BUILDING I 6ti
FOUNDATION
-WELL MUST BE INSTALLED BY A NC LICENSED VVELL DRILLER
-WELL PERMIT MUST BE ON LOCATION DURING ALLPERIODS
OF WELL INSTALLATION r.
-CALL A7 LEAST 1 BUSI
NESS DAY PRIOR FOR REQUIRED 4 '
INSPECTIONS OF GROUT AND WELLHEAD ` I �++/*
-EXISTING WELL(S) MUST BE PROPERLY ABANDONED.AND.
ROPER FORM SUBMITTED INTO THIS OFFICE .
P
Aoco� '00,
V 9�1' L o��I •'��,� �
So ft.
. can's
aovm
Permit By: Date: 12/30/2021
Ho 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.

THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALT,BE VALID FOR
A PERIOD OF 60 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 APPROVAL IS OBTAINED FROM
THE HEALTH DEPARTMENT. IF THE.INFORMATION SUBMITTED.IN-THE APPLICATION FOR• .
DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT,:CHANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME INVALM AND MAY BE
SUSPENDED OR REVOKED.
When contacting the Environmental Health office concerning this document,be sure to know the application -
number. The number must be used in all inquiries and inspection requests.. . .
The Environmental Health Staff can be located at the following telephone numbers between 8:00 am. and 8:30 a.m,
Monday through Friday,except holidays. The office telephone numbers are:
Camden. . . . . . . . . .. . 3384460 Pasquotank. . . . . . ... . . . 338-4490
Chowan. : . . . .. . . . . . 482-6023 Perquimans . . . . . . . . . . . 426-2100
Curiituck. . . . . . . . . . . 232-6603 Berne. . . . :. . . . . . .. 794-5303
Gates . . . . . . . . . . . ... 357-1380
Well Contractors are responsible for notifying the Environmental Health Offices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspe&d and approved by a representative
of the Environmental Health staff before any portion of the installation is covered and/or used.
-ISSUANNCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATI019S,BUT SHALL IN
NO BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRINKINGWATER.
**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 existing septic tank,drainfteld,repair area,
or area permitted for an on-site wastewater system that has f
not been installed, and a designated repair area for that system)
2) Other Subsurface Ground Absorption Waste Disposal Systems. . . . . . . . 100 ft.
3) Industrial or minicipal sludge-spreadiMg or wastewater-irrigation sites . . 100 ft
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 ft '
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
January 7,2022
Shelby Pallette
1212 Kittiwake Ct.
Virginia Beach,VA 23451
RE: Approval No.WWM1303
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2170 Salmon Rd.
Corolla,NC 27927
Dear Ms.Pallette,
On January 7,2022,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 2170 Salmon 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. 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.
W W W.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