GW1-2022-08252_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
TI iM D'�'�1y .� . EV1q 1511� 14.tW.ATER°ZDN
FROM I TO DESCRIPTION
Well Contractor Name fL • o f,- IA a SMel
L[ g l S ft ft.
NC Well Contractor CertificationNumber 75OCITEHCASIItiGf6a:utalhrsse %' i3R'$
L_--L
t ConS{Yvwl'►o A �� FROM TO DIAMETER THICKNESS MATERIAL
nova Serv�tc a '� ft. -� fL II! is 5.CA 0 �C
Company Name -a,- ,--
P 1�5`I� If�WIIA I�{28 -��:,:;.,�-.�;;,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permils(i.e.UIC.C'ounn,State.Variance.eir.) ft to
3.Well Use(check well use): it- ft. to
r"
Water Supply Well: 3�s3t�£SDI
PP Y FROM TO DIAMETER SLOT SIZE �THICKNESS MATERIAL
Agricultural I3 unicipal/Public 11 ft. 20 f- I in. .16 C (Jd VC
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. fl. in. `
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft 1 ` fti e4a;k tr reOf
Monitoring 13Recovery fL ft.
Injection Well: fL fL
Aquifer Recharge ©Groundwater Remediation
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drainage fL fL Ottf� d(Ate Of
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 3a:DRII;LINOLOG attat:h'attdltfiiva
Geothermal(HeatineiCoolin Return) Other(explain under=21 Remarks) FROM TO DESCRIPTION(color,hmdnes,wiVroek sia.ete.)
fL fL tTG W an $'rch
4.Date WeU(s)Completed: Well ID# ft ft. O� b1K I eaf
Sa.Well Location: ft S fr_ pe 'SQL
)QleMere LLC- fL 20 fL �, (,-#Ie sfe!( es
Facili /Owner Name p /' Facility ID-(if applicable) it. fL
Z` pne Ida 1 5p0f . l.Of01lm . z'tap ZT ft. ft.
Physical Address,City.and Zip ft. ft.
C,u►�r1♦wc� Oa1/b0100b7"dS zt,R t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiel(.one 111long is sufficient) 22.Certification:
.9 31 1" N 7S° �5Z 9" W / Zo22
6.Is(are)the well(s)j3fPermanent or Temporary Signature of Caffified W Con for Date
1y signing this form,I hereby rerto-that the well(s)was(were)consiruried in accordance
7.Is this a repair to an ertisting well: Yes or nNo with I5A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction.Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well o1 nem i_"t"$(7"•'p. ,eir
S
repair under#2I remarks sertion or on the bark of this form. LF -§ ! '
23.Site diagram or additional well details: E� J
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide a�djiipnw si;g dg,}ails or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells Construction details. You may also attach additi na g i ec "�dsa{}t'
drilled: SUBMITTAL INSTRUCTIONS lnfo r5i;3'�-2-i ?'i vt}iri;I� I)Ri¢
9.Total well depth below land surface: 26 A) 24a. For All Wells: Submit this form within 3RFla tR4Npletion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2 t@100') construction to the following:
10.Static water level below top of casing: S (ft.) Division of Water Resources,Information Processing Unit,
If hater level is above rasing,use" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method A"eK above,also submit one cop; of this form within 30 days of completion of well
(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
13a.Yield(gpm) o Method of test: CTOf PALUC 24c.For Water SuDDIv&Injection 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 type: TL Amount: 1•S e. 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

` Permit: 378549 Cureitwck
PIN: 087A001000700015i WELL PERMIT
ALHmAruRigx.xAl, _sER�f r�,
Nmim in Pt;hlk Fle8lrh ICES Plot t
Owner: __... - A i_c_ f j
Kylemere LLC Kylemere LLC
302 48th St 302 48th St
Virginia Beach,VA 23451 Virginia Beach,VA 2345.1
Location;
2181 Spot Rd seawa•,sri : 'Ira ri
l.oE 7
WELL MUST MAINT'A1KC tt N(►AUM FROM ANY ��y
PART OF'SEOMC SYS AREA � L!
sso V
-1WLL MUST. BE LOCATED AT LEAST 21r kW FROM B' 1F�NO
� 1
��orah P 1
- 4L MUST.S"fAY AT LEAST 25 FEET FROM ANY BUILDING;
FOONDATION s �\ 14.0• .xran,.No;to. 1
-WELL MUST BE INSTALLED 13YA NC'LICENSED WELL DRILLER . N. Dvo I
-WEILL,PERMIT MUST BE 4N;LQCATION DURING ALLPERlOOS 'a -Orr sr. "
OF.WELL INSTALLATION • .' •��
-CALL AT LI^AST 1 BUSINESS DAY PA(q_.FOR REQUIRED
INSREC'fIONS OF GROUT ANt7 VIlEKH ' • .. �� - ^--* -`
i z
-EXISTING;%MLL(S)MUST 5E,b ROP..:ALY ABe�Ei;3OP1ED.ANU. y�'"!� �.:t
PROPCR FORM 3U8ItiI17TED ;NTO-fHi: 041E ;E ro 41P
�� •P�atAlm a
1 V\�,��'
WL
Permit By: Date: 0711312022
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.

r
THE AUTHORIZATION FOR DRINKING WATER NVELL COMTRUCTION SHALL BMA 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.
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 IN THIS DOCUMENT ARE.ALLOWED'fJIVLESS PRIOR APPROVAL IS OBTAINED FROM �. . ' ...
THE HEALTH DEPARTMENT: IF THE.INFORMATION SUB1bI MD.IN•T .APPLICATION FOR•
-• :.' DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT;:CHANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME INVALID AND MAY BE
SUSPENDED OR REVOKED.
When contacting the Environmental-Health office concerning this document,be:srtre to.know the application .
mmriber. 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:
Camden. .. . . .. ..... 338-4460 Pasquotank.. .. . .:.. ... 338-4490
Chowan. : .. ... . ... . 482-6023 Perquimans. ,..... . .. . 426-2-100
Curiituck. . . .. . .. ... 232-6603 Bertie. . .. :... . ... . 794-5303
Gates... . . . ... ... .....
.. . . . ... . . ... " 357-1380 ,
Well'Contractors are responsible for notifying the Environmental Health Ofices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspeed and approved by a repxeseritative '
of the Environmental Health staff before any portion of the installation is covered and/or'used. .
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS NT FORTH IN THE REGULATI01gS,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 exisuirig septic Yank,drain&ld-,repairarFa, -—--
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 licquid-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 ... ..... ..... .... ... . . .. . . .. .. 50 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 .. .. . . .. . .. . . ... ...... .\. . . . . . . .. 160 ft t
12) Animal barns. . . . . . . . ... .. .. . .• . ... .. ._...... . .... . •I. . . .. . . . . 100 ft

z
"aie$�f51(ry'.
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 14,2022
Kylemere,LLC
302 4P St.
Virginia Beach,VA 23451
RE: Approval No. WWM1420
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2181 Spot Rd.
Corolla,NC 27927
On July 14,2022,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 2181 Spot 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-Weir ConstructionStandards,or any other applicab Elaw;-rule,'or'regulatioh that niay-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