GW1-2022-01784_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.WeU Contractor Information: rr--� �>!` �n
►�K6 1 rylf W S/ v V gs�` 14 RYAIER''Z(31+IEfi :; .,7_77. R; 4,,:.:,. .,
FEB •n FROM TO DESCRIFTION
(� Well Contractor Name f, , 2e 41fitic
ft
p .Z( �` l!' �1C /yv t ¢soul!
NC Well Contractor Certification\umber Int1N ASIfdG
• -"- TO DIAMETER THICKNESS MATERIAL
Ca ro V4 Scr o► e arj CdK� on LL G l$ ft 1 16 la .AA Yo PVC,
Company Name 161PiI'i£Ii Gi1S1Nli QE175$Iltits;
2.Well Construction Permit#: 34 1T?5
/ w W tA['Sol FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC.County.State.Varianre.etr.) ft. ft rtr
3.Well Use(check well use): ft ft.
t in.
Water Supply Well: ;13„3C��1:-, __ -.�::, ,,r>' .•-s>....:� �.��>.=(�"=• cfl'`�`�-
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3 icipal.,Public 119 ft 2t ft. �/ in. Grp SCM fE� PV(,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No
Supply Well: O ft '7 ft J btr Ott- u r
Monitoring QRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge ©Groundwater Remediation 19.SANDIGRilVEI::PA'CK- y fY
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage IL Z ( ft �rJ2 .5.2 Ot.r'
Experimental Technolog)' Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 28:BRIILII!1SsLM,attaidfadtiltfi>nd
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,w!Yrodc type,grain size,eta
u D 1' " bra wK sa
4.Date Well(s)Completed: { Well ID# ft. ft ✓C s4/4
Sa.Well Location: Z. 13 ft 4 r
. din &a Wlrmy Er bow- 13 ft Z I ft arcy sand sd s /!f1rjees
Facility/Owner Name Facility IDS(if applicable) fL ft
pblej said( idd ef, Corolla f Z7g27 ft. ft
Physical Address,City.and Zip ft. ft
CAArri'�W.4 07A coo 0N62 000?
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lablong is sufficient) 22.Certification:
9V 3o t c, " N -7 5f 5-1 ' 39
of W �-
6.Is(are)the well(s)JE(Permanent or 13Temporary TignartmeCYCertififflVell CAtractor Date
By signing this form.I hereby rertiA�that the well(s)was(were)constructed in accordance
7.Is this a repair to an erdsting well: ©Yes or JNo with/5.A n'CAC 02C.0100 or'15.A.VCAC 02C.0200 Well Construction.Standards and that a
If this is a repair,fill out known well construction information urnsl erp/ain the nature of the ropy c jthis record 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-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SLBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .21 A) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(esample-3@200'and 2 t(,`r,100') construction to the following:
10.Static water level below top of casing: (ft.} Division of Water-Resources,Information Processing Unit,
If water level is above casing,use- - 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. L (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: Aml e✓ 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
13a.Yield(gpm) 3�+ Method of test: PAcer 1?wMo 24c.For Water SunOly&�Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection tvpe: T�- Amount: i f 's O L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qualin-Division of water Resources Revised 2-22-2016

Permit: 361485 Currituck
WELL PERMIT
PIN: 087A000006200OR
Ai 5WARLE REGIONAL HEAL?H SERUJUS
Fatt7iers in PCUIic Health
Owner: Applicant:
ERBACH,JOHN&TIFFANY ERSACH,JOHN&TIFFANY
11531 FAIR ISLE DRIVE 11531 FAIR ISLE DRIVE
CHESTERFIELD,VA 23838 CHESTERFIELD,'VA 23838
43 LAflantrc e.
Location: n
2029 SANDFIDDLER ROAD o
N N
C2 l'lAI�3mRfFiS7kv�.., '
WELL°AlUSF.If�frlit�fTAliN�t + QAt:atlHL'OUNG"FOUNElAT10N
F
'i
LVELL U I�ST AINT-A-1 k SG?*.FFLQtYA'1ANY PAAT OF SEPTIC.S`ISTIEM
AND RSPAIR AREA
` 4
-WELL 011k1ST'SE INSTALLED SY A NC CERTIFIED WELL;DRILLER
'
-Wr=gL PERMIT MUST'BI. ON LOCATION DiJRINO FF S
ALL PEIOD ''
OF WELLJN5TALLATIONiweo
-CALL"AT LEAST 1 laUSINESS.DAY PRIOR FOR REdOIREU I
INSPECTIONS OF GROUT AND•WELL•HI AD. <1 -
fo
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1� .Roared 417A
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Permit By: '- ' d r Date: 07C26I2021
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 15 A NCAC 02C.0300.

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 10,2022
John&Tiffany Erbach
11531 Fair Isle Dr.
Chesterfield,VA 238383
RE: Approval No.WWM1309
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2029 Sandfiddler Rd.
Corolla,NC 27927
Dear Mr.&Mrs.Erbach,
On January 10,2022,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 2029 Sandfiddler 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 fdr the inigration 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