GW1-2022-08251_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Informati1on: r
24;.AVATER�ZONES '
FROM TO DESCRIPTION -
WellContrara'ctoprNatne fL 1Z ft- c1 eat. &W SMC(
ALVIA-_! Q FJ It ft- 2'd fL GICGr low 00t0r
NC Well Contractor Certification Number .%5,0UTE1tCAMG foa.moihtased% ' - b i J '
FROM TO DIAMETER THICKNESS MATERIAL
(,aroya Sere►tc ortA� cons{rVe oll L-L� {( fL 11 ft. (t� 3 Ka pve
Company Name q Q y : C.I?V1 R CA9NG_.7IBiA1G eteeEr2:
2.Well Construction Permit#: 31 `Q t/� MAMA � r 5 �O"r ro DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC.County..State.Variance,etrJ
fL fL m
fL ft is
3.Well Use(check well use):
Water Supply Well: FROM TO _.DIAMETER SLOT SIZE THiChYESS MATERIAL
Agricultural 6VResnideintial
uicPal/Public '� ft /� fL 1 f` in. ,DID L4 D vL
Geothermal(Heating/Cooling Supply) Water supply(single) ft _ fL in.
Industrial/Commercial Residential Water Supply(shared)
Irti2ation -FROM TO lip �M/ATL•RIAL EMPLACEMENT METHOD&AMOIINT
ft ft 7 #_14b oxed
Non-Water Supply Well: b
Monitoring QRecovery ft ft
Injection Well: fL ft
Aquifer Recharge QGroundwaterRemediation
'19:SANDTGRAY�YA�K if''" L:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEN-r METHOD
Aquifer Test OStormwater Drainaae 1(D K- W ft �4 / tA.red
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20:I3RIILING:IAG atttich adsfieiis �.k :y .`-`,'c
Geothermal(Heatin Conlin Retum) Other(explain under=21 Remarks) FROM ro DESCRIPTION(mbr hardness,wtVroek m siae eta)
O ft ft /alrh s41
4.Date Well(s)Completed: 1 Z1 LoZZ Well ID# 1 fz •� ft /�� 011 d
5a.Well Location: Z- ft ft
A cNittl t Cfheriow FJW(O( ft ft
Facility/Owner t
.Owner Name Facility ID_'((if applicable) ft. f
Ili(1 D��It1 I�Or� 1�". 1A�01 i Zi1R7i� fL ft
Physical Address.City.and Zip ft ft
Caerl1we-iL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well�eld.one latnong is sufficient) , f 22.Certification:
36 2'J 4 LI N ?So 51 3 9 W 7 z W4,
6.Is(—)the well(s)�ermanent or.Temporary signatureof 'fled ell Con aor Date
By signing this form.i hereby certify that the rvell(.$)was(were)ronsrructed in accordance
7.Is this a repair to an existing well: EYes or J3No with 15A.VC.AC 02C.0100 nr 15.4,VCAC 02C.0200 Well Consr ar. A [radar, a
If[his is a repair,fill out known well construction information and explain the mtare of the rapt'•of this retard has been provided to the well m e .1 RI i
repair under#21 remarks section or on the hack ojthis form. R �-'� ° !:
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 provide ad il� rat s(lal mjell?sit is or well
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach addition ages if ary.
drilled: SLBNETTAL INSTRUCTIONS ICrrF k'1 fL`C {�U0
9.Total well depth below land surface: ZO (ft.) Rn?9YBOG
P _4a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2tr 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 rasing,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
�1
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: &Axed 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) 21 Method of test: (rAs Pah.� 24c.For Water Sti°nly&Injection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: TL Amount: 1.3 d'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
•

07 Permit: 379086 Currituck
PIN: 099A000014400 WELL PERMIT
• � � �AL6EtitARIE REGIU\aL HEALTH SERA%ICES
Pament in Ptwtic Heelth
Owner: Applicant:
Michael &Catherine Naylor Michael&Catherine Naylor
2799 Creekside Rd 2799 Creekside Rd
Sumter, SC 29150 Sumter, SC 29150
Location:
„dl�Jis 30eNld�1a. ,oz
1982 Ocean Pearl
;00•001,
Al
WELOMUSTMAINTAIN AFT$MIA F31JL0IN!P FOUNDATI0N/Pr4KYL 1 a
WELL MUST i AINTAIt► *W*- FE-0"Ab�t�;'PART OF SEPTIC SYSTEM
AND RsPAIR AREA
.WELL MUST BE INSTALLED BY A NC CERTIFIED WELL DRILLER
.WE PERMIT MUST HE ON'LOCATION OURINC ALL PI FZlQDS' • . 300N3S
L=�L I Z
OF WELL..INSTALLATION001
-CALL-AT LEAST 1 BUSINESS-DAY PRIOR FOR REaUlI:ED O .j
INSPECTIONS OF GROUT ANR WELLHEAD O -gz ;1 0D
OI o. o C
-EX137ING VVELL(S)NIUST BE PROPERLY ASAL�.IDCL�IED:J�NU.' m '07L m O
PROPF_R FORM 3U8>W11TTEfl INTO THIS 01=1=ICE r ,( N I r M
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Permit By: Date: 07/25/2022
H J
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 15A NCAC 02C.0300.

THE AUTHORIZATION FOR DR24KING 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.
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 APPRO.YAL 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 IN-VALID AND MAYBE
SUSPENDED OR REVOKED.
When contacting the Environmental Health office concerning this document,be.sure tolnow the application
number. The number must be uses(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:
Camden. . . . . . . . . . . . 338-4460 Pasquotank. . . . .. :.. , , . 338-4490
Chowan. : . . . : . . . . . . 482-6023 Perquimans . . . . . . . . . . . 426-2100
Cur'rituck. . . . . . . . . . . 232-6603 Bertie. . . . : . . . . ... .. 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 insp led and approved by a representative
of the Environmental Healt}staff before any portion of the installation is covered and/or used. -
1
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIONS,BUT SHALL IN
NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRINKINGWATER.
**Minimum Distances**
Private Drinking Water Wells to:.
(This listing is not all inclusive,please sm.15A.NCAC.02C,0107 for complete listing)
1) Ground Absorption Wastewater Systems. . . . .. .. . . .. ... . . . . . . . . . . . 100 ft
(includes existing septic tank,drainfield,repair area,
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 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 wellhead . . . . . . . . . . . .. .. . ... .. . . . . .. ... . . . . . . . . . . . 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
such as ponds,lakes and reservoirs .. . . . . .. .. . .. . .. . .... . . . . ..:. . . 5-0 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
July 29,2022
Michael&Catherine Naylor
2799 Creekside Rd.
Sumter,NC 29150
RE: Approval No.WWM1434
Well CasedLe to Than 20 Feet—Rule 15A NCAC 2C .0116
Less
1982 Ocean Pearl Rd.
Corolla,NC 27927
On July 28,2022,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 1982 Ocean Pearl 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.
WWW.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