GW1-2022-01817_Well Construction - GW1_20220218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1W�'ell Cont
trra(ctor Information:
_
I FROM I TO I DESCRIPTION
Well Contractor Name 3 R O fL r�y4 eoblr SMGI�
111" Q to iL 20 fL tlu� '� (•'MIS � l
NC Well Contractor Certification Number
15::0[fl'ER.CASIPIG'(for:iaralheased::.
FROM TO DIAMETER THICKNESS MATERIAL
�areya S�w�� GV�d t"en5 svt LLG f I ft. < IN it Caw I pvc-
C.-Pany Name 2 U(/ �/ 'j/�`) I&1NIVERi.0 8Bllr1G :- - -_
2.Well Construction Permit#:`��--l •• �- wtA 1✓V L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits tie.U'IC.County.State.Varianre.err.) ft ft to
ft. fL is
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IN.'
gricultural ® rcipaLPublic fL ft (! in Q ►PVeothermal(Heating/Cooling Supply) Residential Water Supply(single) f fL in.
dustrial/Commercial Residential Water Supply(shared) LFFydeation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 6 ft- {-k
Monitoring 13Recovery tt ft.Well: fL fLquifer Recharge Groundwater Remediation _ 3 �quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEhTMETHOD
quifer Test [3Stormwater Drainage 4ft- ZQfL
xperimental Technology Subsidence Control fL fLeothermal(Closed Loop) Tracer �DRiLLIIYGOM I attedD �sNsif f�eothermal(Heatin 'Coolin Return) Other(ex lain under#21 Remarks) CRIpTIO\(eobr ha,slncg saureek sia ere
o fL � � br»wvet kd
4.Date Well(s)Completed: LIkO Well ID# fL fL
5a.Well Location: Z n 3 fL
Jona�kaK klo�a13n a
Facility/Owner Name Facility IDS(if applicable) ft. fL
IZ311 544por Rc! ,corolla, z 122 ft. ft.
Physical Address,City.and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) O t (` 22.Certification:
36 $2� 13 N SZ �w s Z a zd
6.Is(are)the well(s)dtmanent or Tempo�No
Signat»re Ce ' d Well"Contractor Dail
ily signing this form.I hereby rertifi-that the sell(s),vas(were)constructed in accordance
7.Is thisa repair to an erdsting well: 13Yes or with 15A A CAC 02C.0100 or/S.A NCAC 02C.0200 Well Consrucrion Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been pro%ided to the well mvner.
repair raider#21 remarks sertion 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 belowland surface: l L�] A) 24a• For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(erample-3@200'and 2`e^a,100') construction to the following: y p
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use" 1617 Mail Ser•viIce Center,Raleigh,NC 27699.1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above, also submit one cop)' of this form within 30 days of completion of well
A�.uL/
(i.e.auger,rotary,cable,direct push etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
` M.Yield(gpm) 28 Method of test: P4cer p P6 0 24c.For Water.Supply&Iniection Wells: 1.addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'Ti— , Amount: (•S O Z. 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: 362141 Currituck 1
WELL PERMIT
PIN: 087A0050018000'1 •
ALOEMARu'.RQGid-ALHEAM SeAVICES
Partners m PG6Gc Heettfi
Owner. Applicant:
WONG JONATHAN CAROVA BEACH BUILDERS
103 55TH ST 2162 SALMON RD
VIRGINIA BEACH,VA 23451 COROLLA, NC 27927
Location:
2311 SANDPIPER RD
G*AoYA-• k3rAtA—
we MUst-MAINT + BW%D*4G FOUNDATtcx�i�`m
-WELL.MEfW MAjW*%'=+FROM'ANY PINT of SEP11C SYSTSM.'
AND RS*,NR AREA'
.WELL PbIUST BE INSTALLED BY A NC CERTIFIED YUELL DRILLER-
-Wej ..PERMIT MUST 8E ON LOCATION 0*UFU+0 ALL PMQDS'
LOfi t8 '�s
OF WELL iNaTALt.ATIOIVso
nt5aaS,.QxF
-OALL•AT LEAST 1 SUSINESS,DAY PRIOR FOR RECJEIIREDFF
:�
INSPECTIONS OF GROUT ANq WELLHEAD F, 3 gowizwp
t HOIUSf ?PiQACl% O
i. U-W
ROAD 1 -1 _
so'nay r-cz-war 11 !� �.• -
Afr
Permit By: ` Date: 08/25/2021
Hob
r'-
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 1-5 A NCAC 02C.0300.

THE AUTHORIZATION FOR DRUMING WATER WELL CONSTRUCTION SHALL 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.
4 •
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 APPROYAL IS OBTAINED FROM 7 .
THE HEALTH DEPARTMENT.' IF THE.INFORMATION SUBMITTED-INT :AI?PLICATION FOR.
DRINKING WATER WELL CONSTRUCTION,IS FOUND TO BE INCORREC.T,: HANGED,OR IF THE SITE
IS AfTERED,THE CONSTRUCTION AUTHRORI7ATION SHALL BECOME T.NVALID AND MAY BE
SUSPENDED OR REVOKED.
Whei2 contacting the Environinental-Health office concerning this document,be.sure toimow 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 a.m.and 8.30 a.m.,
Monday through Friday,except holidays. The office telephone numbers are:,
Cainden. .. . . .. . ... . 3384460 PasquoWik. . . .. .:.. . .. 338-4490
Chowan.. .. . . . . . . . . 482-6023 Perquimans. .. . . . . . .. . 426-2-100
Curiituck. . . . . . . . .. . 232-6603 Bertie. . .. :. .. . .. . . 794-5303
Gates. . . . . .. . . . . . . .. 357-1380
We11'Contractors are responsible for notifying the Environmental Health 0$"ices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells iiaust 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 INDICATETHE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS MT FORTH IN THE REGULATIONS,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 existing septic tank,drainfzeld,repair area,
P
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 minicipal sludge-spreading or wastewater-irrigation sites . . 100 ft
4) Water-tight sewage or li(juid-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 . . . .. .. . .. . .. .. SO 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. . . . . . . . . . .. . .. . .. . .. :�. . . . . . . .. l00 ft +
12) Animal bains. . . . . . . .. ... . . . . . .. .. . . . . .. . . . . . .. .. . . . . . . . . . . .. 100 ft

At
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
Jonathan Wong
103 551'St.
Virginia Beach,VA 23451
RE: Approval No.WWM1307
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2311 Sandpiper Rd.
Corolla,NC 27927
Dear Mr. Wong,
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 2311 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. 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