GW1-2022-08722_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Nm -7it t Sk:e:
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NC Well Contractor Certification Number .15:t?LMER CASING for:mslh cased. OR i€IiVB)It'.f$,
FROM TO DIAMETER THICKNESS � MATERIAL
(,GitroVa Serv►�c at+� Cons{trvltl►on I,L� L Ic Ili fL I1 'n sck %0 PoC
Company Name Q�-y y i 16 RMRCASING'Q$EfJ$IAIG" - ' `
-1 {4 1 W W iM 1 4 3 r FROM TO DIA1tEfER THICKNESS MATERIAL
2.Well Construction Permit�: � fL fL m
List all applicable well construction permits(i.e.U1C.County,State.Variance,eir.)
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3.Well Use(check well use): :
Water Supply Well: Ffq��O DIAMETER SLOT SIZE THIC[•tiESs MATERIAL
Agricultural [unicipalt-Public t/ '"• (p PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) itt
Industrial/Commercial l3Residential Water Supply(shared) 1ffGRUi} :r n .— '
Irrieation FROM 11TO IMATERIAL EWLACEME\T METHOD&AMOUNT
Non-Water Supply Well: (� ft �' ft 7 L4 n.- o tred
Monitoring Recovery fL fL
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
IR.SANDIGRA�G:P-tSCK'ifi
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEh-rMETHOD
Aquifer Test 13StormwaterDrainage . ft. Zo ft if? Oared
Experimental Technology 13Subsidence Control fL fL
Geothermal(Closed Loop) Tracer '.20.DPJL1 NG-Lt3G ifattkhad�tlwi
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Geothermal(Heating/Cooling Retum) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,wilhwk type.
<e. in sim ern)
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4.Date Well(s)Completed: 8 q WZ& Well ID# fL (Z fL f EE
5a Well Location: L Z fL fL[3 'uJ— GP
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20 ft-
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Facility/6wncr Name Facility IDS(if applicable) fL It.
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3.2I I Sav►il C Wer ROL C.o r-o l l a Zz q Z? fL
Physical Address,City.and Zip �{ ft ft•
:-ZL:REM'ARKS k ✓; ,; ..:.:' .. . ,..:,.`Fd:�'rz�:��x.'r'v.;w':
C.I.1vrt +W Lk- Le l well hooked d
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latllong is sufficient) 22.Certification:
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36b 311 S-q If N �S-o 5 1 S�t� W —.�- y Ste— 8" Z Zo
6.Is(are)the well(s)EIrPermanent or OTemporary Signature of Cenrfied ell ContrIctor Dat
1 y signing this form..1 hereby certl`that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: YYes or 13No ivith 15A NGAC 02C.0100 or 15A,vCAC 02C.020 Well Construction.Standards and that a
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If this is a repair,ftll out known well rnutrurtion information and explain the nature of file rap-�othis record has been to the well owner.
J provided
repair under#21 remarks section or on the bark of this form. r^�
23.Site diagram or additional well details, l! V
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provite a�diFonah we`il site detaz"Is or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additiogal ppge4if ggce�$gryq
drilled: SLBMITT.AL INSTRUCTIONS �IJ I ,I
9.Total well depth below land surface: {ft.) ^'^ �r xYP>'.1t� U it
p .4a. For All Wells: Submit this form lwit5in53,?fvtr}plenc�it oPwell
For multiple wells list all depths if different(example-3@200'and 2 tL1001 construction to the following: �.a �uu
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If svater level is above casing,rise"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter, l//0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one cop; of this form within 30 days of completion of well
12.Well construction method: 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) 3 b Method of test: L7Af PkVKV 24c.For Water Suoaly&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: nTL Amount: I•S dZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit: 379747 Currituck /
PIN: .087A001QQ04000A WELL PERMIT
AMMA a ttFeteiwu He��7 Seauaees
Owner: P8[Ot&g m Fh�lk keeftDH Applicant:
Tammy Ramberger - Tammy Ram berger
22 Finch Ct 22 Finch Ct
Stafford,VA 22556 Stafford,VA 22556.
Location: } yA o
2291 Sandfiddler Road 9 _ It a
Joe- $ or-iC I L-PT I
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=WELL`MU9T ibtAJblTit@i '+FROM Buil'.owpp FOUNoasl£�Pf -
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.WEI.L'MUST IViAtliSiTAil+fi sue«FI�QM'A1NY PAOT OF Sw:,TIC SYSTEM;'
ANC RSPAIR AROA . • �
.WELL MUST BE INSTALLED BY A NO CERTIFIED WELL DRILLER-
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-WELL-PERM17 MUST&E©N LOCATION DURIAG ALL PEf�IQDwi I——°'! ..
OF WELL JIUSTALLATION
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-CALL'AT LEAST 1 $uS1NESS DAY PRIOR FOR RE(ZJIFED �
114SPF-CTICNS OF GROUT ANO 1fVELfrHEdlQ-
-MSTING WELL(S)MUST BE PROPEAL.Y ABANDONECLAND-
PROPf_'R FORibi 3U$PuliTT90 i.'fTO YNis•OFFIt s i{
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Permit By: Date: 08/08/2022
Hobjf/be
-Certification By: Date:
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Construction has been completed,a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15A NCAC 02C.0300.

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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
August 9,2022
Tammy Remberger
22 Finch Ct.
Stafford,VA 22556
RE: Approval No.WWM1438
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2291 Sandfiddler Rd.
Corolla,NC 27927
On August 9,2022,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 2291 Sandfiddler 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
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