GW1-2022-08076_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
1.Well Contractor Information:
Ti+M,o-�ln� J . English 1,CW Am,ZOIIES �
FROM TO DESCRIPTION
' Well Contractor Name j
ti
N ( g9 B p fL , Ic or a #Ae
ft. fL
NC Well Contractor Certification Number ,Is 017M.CASII�IG for mi:>ti assert O)lr I7N€R"R: ."
Carova SerVca al4 ( ns r"RyQ LL( FROM TO DIAMETER THICKNESS MATERIAL K
W �T1AVf� It. q It- to (�
1 ` f S "a^ V
Company Name
3?z�{gI wwMi�iot� ;.16'-I �:� .�IN�-
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC.County..State.Variance,err.) f. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM !TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. 0 ft. �( in- •010 � d pvc
Geothermal(Heating/Cooling Supply) VRsidential Water Supply(single) fl. f. in.
Industrial/Commercial Residential Water Supply(shared)
Irritation FROM TO MATERIAL {I EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 ft, 14 fc ! f ®fie
Monitoring 13 Recovery ft ft.
Injection Well:
ft fL
Aquifer Recharge Groundwater Remediation
�'19:St1i9i?IGRAYBIS`.P-tiiLK ifa`
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storm W waterDrainage fL 9 ft b-&
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20:DRII I ItfG'LOG attaeh�ihiie s�"`'
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(mtor,hardness,soilfr ek (n sia,eta.)
ft t- ft- w San
4.Date Well(s)Completed: 7 Z? Z0fZ We11 ID# ft. Z ft. a d
Sa.Well Location: fi' ZO ft. I Lr
1 RoV45hQIlk Wig ;nson ft. ft
Fact tyFact ty/f�OwnerName Facility iD9(ifapplicable) ft ft.
2315" Occah S,nds Rol, Corol�•� r 21?Z? ft. ft
Physical Address,City.and Zip f fL ft
CumfKcK 017401SMAlcoor
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat11ong is sufficient) 22.Certification:
N W / '7 ZL
6.Is(are)the well(s)arpermanent or 13Temporary Signature of C ied Well Ctifefictor Dad
By signing this_form.i hereby:xrty�•that the icell(s)was(were)coastrurted in acrardance
7.Is this a repair to an existing well: ❑Yes or No with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construrtion Standards and chat a
Ifthis is a repair,fill out known well construction information and ecplain the nature of the ropy of this record has been provided to the well owner.
repair under#21 remarks sertion or on the hark of this farm. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro additiorta rnxll Tiite�( ai well
construction,only i GWA is needed. indicate TOTAL NUMBER ofwells construction details. You may also attach ,ditidhlr�age�i#'tf ch sad_
drilled: Z SUBMITTAL INSTRUCTIONS /(II II � 2�ZZ
9.Total well depth below land surface: (ft.) �, For All Wells: Submit this form within 30�days of completion of well
For multiple wells list all depths ifdierem(example-3@200'and 2@I00') construction to the following: i
a �^�".^ .1
� f�...,�.�.:t�Ut^h
10.Static water level below top of casing: T (ft.) Division of Water Resources,Informatit�nt>jtti"1Wb it,
If water level is above rasing,rive" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injecton Wells: in addition to sending the form to the address in 24a
12.Well construction method: AIAw ef
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary.cable•direct push.etc.)
Division of Water Resources,underground Injection Control Program,
L3a.
ATER SUPPLY/W�WELLS ONLY: p 1636 Mail Service Center,Raleigh,NC 27699-1636
t eld(gpm) ` (r Method of test: �7Qs f kht� 24c•For Water Supply&Injection Wells: In addition to sending the form to
iT the address(es) above, also submit one copy of this form within 30 days of
sinfection type: �f 1 L Amount: •S d'l: completion of well construction to the county health department of the county
where constructed.
Form GW-i' North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

r `
Permit: 372481 Currituck
PIN! 087AO1300210001 WELL PERMIT....
ALBWAFLI!9-EGa!?'f.%Ltie;At.TN SirpyIC[S
Fatum in Fvbifc Pleeath
Owner: Applicant:
Roy and Shelia Wilkinson Carova Beach Builders
3116 Hills Church Road 2162 Salmon Road
Export, PA 15632 Corolla, NC 27927
Location-
2315 Ocean Sands Road
Sift- I 1 8-K 13 1.0-r ZO
CA vto ot.
•WELO MUST MAINTA I *F @4UUPLANd FOi t ,TiON/ W4ICj0(.
.VVELL UST MAIN•T,ApN'S@+MdiiR+AM PART of SEP'nc 5YS` W
AND AAlRA13EA , o
S 09.56,43"E
•i!►pLL MUST BE iNSTALLED BY A NO CER- IFIEia.VNELL E)FULLE
100.00'
.-VE.L Pr=RMI;r MUST BE ON LOOATION DURING ALL FERI009
of W-ELL iNSTALL.A'TIOPa
-CALL A-i'LEAST 1 SUSI14ZS DAY.F?Rl R-6-9R REQUIRr�3
I%.si'SCTicNS OF G50UT AND 1.VE
f jor 20
a' 2 14500 S.O.FT
10
t- SB 1QO' .40 Fl11 SEPTIC SYSTEM AREA WrH
1Q0'+, IS*+ SAND FREE SOa
17• 28.0' 4 N4 4b
1 S0
f
L se
h
10Q0 'i _
i N 09'56'45'W S 09.56' 43`£
w�ir,Pu�ro4 �o,J
OCE N
50'PURIC RIGHT—a WAY
w .2 P_Ca I q _
HOyQTj,,
- ABC GRlt)jyA(7
Permit By: :; 1�4,1743r, Date: 03/25/2022
H ,J e
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 15ANCAC 02C.0300.
� I

THE AUTAORIZATION FOR DRVWNG WATER WELL CONSTRUCTION SHALL ZE 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 fedoral
permits.
A '
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 I THIS DOCUMENT ARE ALLOWED UNLESS PRIOR APPRO,',V,AL IS OBTAINED FROM
THE HEALTH DEPARTMENT." IF THE.INFORMATION S1JBM1=.IN-TV EWPL•ICATION FOR• ,; r;
- -4 DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECTi.CHANGED,OR IF•THE SITE ;' : "
IS ALTERED,THE CONSTRL'moN ATJ`TI3RORI2ATION SHALT.JJECOM WVA.LID AND MAY BB
SUSPENDED ORREVOKED.
When contacting the Erevkon3nenial•Health office concerning this document,be-sure to•know the applications :..
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. 3394460 Pasquotank. .... .:. . .. 338-4490
Chowan.: . . .... 482-604 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 faustbe inspe&d and approvedby a representative '
of the Environmental Health staff before any portion of the installation is.covered;nnd/or used
ISSUANCE OF A DRTN1<ING WATER WELL PERMIT SHALL INDICATE-ME DRINKING WATER WELL.
HAS BEEN CONSTRUCTED TO THE STANDARDS MT FORTH 1N THE REGUL kTI01p 9,,BUT SHALL Iff
NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRINKING'WATER
"Nffi imur a Distances"
Private Irinking Water Wells to:
(Thus 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,drainfield,repair arpa,
or area permitted for an on-site wastewater system that has
.-not been installed,-and a designatedrepair 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-wasto 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 R
(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 whickact as sources of groundwater recharge, "
such as ponds,lakes and reservoirs... ....... . .......
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.. .. . .... .. • ......, .. A.. . . . . ... 100 ft �
12) Animal barns. . .. . . ... ... ... .. .. ... . ........ ... ... .. .. . . .. ... 100 R

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
June 7,2022
Roy&Sheila Wilkinson
3116 Hills Church Rd.
Export,PA 15632
RE: Approval No.WWM1406
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2315 Ocean Sands Rd.
Carova Beach,NC 27927
On June 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 2315 Ocean Sands 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 SD{FORKS RD•RALEIGH,NC 27609
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER