GW1-2021-02453_Well Construction - GW1_20210809

i
WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information:
David E. Meyer 14.WATERZONES
Well Contractor Name _ FROM TO DESCRIPTION
2527-A 5 ft. 15 ft surficial'water table
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING fog multi-cased wells OR LIIVER iPa" licahle) ..
Protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+3 ft. -5 ft- 2 j iq Sch.40 PVC
Company Name 16.INNER,CASING,ORTUBING(geothermalctosed-loo
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
❑Agricultural ❑Municipal/Public -5 fe -15 ft. 2 In. 0.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- -5 n- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Olzrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 R' 3•0 ft. Portland/concrete pour
MMonitoring ❑Recovery 3.0 ft. 4.0 ft- Bentonite pour
Injection Well: ft. ft
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Battier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 3.0 ft 15 ft. #2 quartz sand 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) QTracer 20.DRILLING.LOG attat:h additional sheets if necessary)-
❑Geothermal(HeatingtCooling Return) ❑Other(ex Isin under#21 Remarks) FROM TO DESCRIPTION color.hardness,soi0rockin size etc,.)0.0 it. 2.0 it' Light grayish brown silty fine sand (SM)
4.Date Well(s)Completed: Well 15,2021 well ID#PMW-3 2.0 ft• 5.0 ft- Brown silty fine sand(SM)
5a.Well Location: 5.0 ''t• 9.0 ft- Reddish brown silty fine sand(SM)
House of Raeford Farms, Inc. 9.0 ft 15.0 ft. Gray clay(CL).
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ®
Fort Knox Road & Johnson Pond Road ft. ft.
Physical Address,City,and Zip ft. ft.
TWO
Duplin 247000925814 21.REMARKs :
r�GG�St
County Parcel Identification No.(PIN)
1���4�1� " ��{50 • .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/lona is sufficient) 22.Certification:
34051.098' N 78°4.118' W 7�E�Afo 7/19/2021
6.Is(are)the well(s): I'Permanent or ❑Temporary Signature of Certified Wcl Contractor Date
By signing this form,l herehv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
18
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days o well completion per the following:
For multiple wells list all depths ifdifferent(emmple-3Oa 100'and 2t✓a�IOU1
10.Static water level below top of casing: 5.13 (ft I 24a. For All Wells: Original form)to Division of Water Resources (DWR),
I(water level is above casing,use"+" Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
i `
11.Borehole diameter: 8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: H SA 24c.For Water Supply and O en-Lo .
o,.Geothermal Return Wells:Copy to the
ty environ
(i.e.auger,rotary,cable,direct push,etc.) courtmental health department of the county where costa
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 1100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test Permit Program,1 61 1 MSC,Raleigh,N C 27 ,-1 1
13b.Disinfection type: Amount:

001
unit .33606 - _ currituck G�U'�►1�htG
WELL Rya
. a
PtN�;�9421n�,gQQ4� MIT
;a
Acrehpv4k a Rccwtic 3nrnces
Owner Htm
'Applicant„ Y
GINGERiCi 'DANAT CAROVA'BEAC14BUILDERS x ;:
t;.=F..
4100 CROSSING 8LVO APT.D-404 2162.SALMON R©
LANDCASTER,PA 17605 COROLLAA,NC 27927 — '
L.. a �.;
1323: 1N ISLAND RD
54 1 arc al ram +
P40 A wwsi too 7
*�G�i 4iV��FI1�:`�f� ,�� ��"•""'"��_"�!�"�V►"� 'uw'ti.+.r.rt•La ., ..
� � f t .we...wf•..w
•A CW ,.
AND RWAIA ' • .; .
WNLL WW In toOTAt1ED>I&A.°NC LEt 1•ft WELL DRUM'
' ; RM11'tul�i'i'9lONLCIC�1tE4NgtJfa�tQAa.Pi~A �•i
tF VVlL W$TAUA'T OH
A"t't1RAST 1$U8#NEWLtAY PRtt'?R.FC?t REdt?tREb �,
{
I��:N�fE��'10N8 C�!'-G�tGtl�'i�1�tD,MVEE:><t�kQ• �'' � - �
1A.
Awl
F •�I
v , i
N1�
- �rwwsrr
'Al
� er
PYfri'th�l: l . . Date:; 12t3W2020
t;artiRt�tlon"6y: Duty. r
ConWucoon has burn oompleted, s Residerd4l VNI Construdon Record Form GW 1a has been W V,
submitted and,inspections:hwe.been completed in accordance with 15A NCAC ic.0300.

t
-.46 WM1N.N
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
July 6,2021
Dana Gingerich
4100 Crossing Blvd.Apt.D-404
Landcaster,PA 17605
RE: Approval No.WWM1224
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2323 Swan Island Rd.
Carova Beach,NC 27927
Dear Ms.Gingerich,
On July 2,2021,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 2323 Swan Island 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
i
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