GW1-2022-08723_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
} Tir�,o�ln J . Ev► lish 14 WAiER'ZOIYES _Y 1 :, .:.
FROM1i TO DESCRIPTION
Well Contractor Name fit fit L/(Q/ / It
fL _
NC Well Contractor Certification Dumber 15i UIPTER:CASiit1G`for:nlnifi iF t)Ri ---
FROM TO DIAMETEit THICKNESS M1tATERiAL
(�arOVA StlNct,c ctt (,o„S{Yy OA LI.� {' ft 17 It
If 1D I T1 uG
Company Name —,
•:]6INls1ERGrA$ING�3H��G-
3 551-1 S 1�1 w M I g 2/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �f i V� ,_{� 7 � fL in,
List all applicable well construction permits(i.e.UiC.County.State.Varian e.etc.)
fL ft is
3.Well Use(check well use): --F _ �. .
Water Supply Well: FROM TO DIAMECER I SLOT SIZE THICKNESS MATERIAL
Agricultural I3 unicipal/Public ft ft 1[ •n• ,010 yo Re
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fL in.
Industrial/Commercial 13Residentiai Water Supply(shared) ti Y �f
Irrigation FROM1i TO I III MPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL f L fen of d
Monitoring ©Recovery fL ft
Injection Well: fL ft
Aquifer Recharge GroundwaterRemediation
Aquifer Storage and Recovery 13SalinityBarrier FROM TO MATERIAL EMPLACEMENTMEIHOD
Aquifer Test 13StormwaterDrainage ` fL ZID ft- 4�2 50d CK
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer `20i:DRILLINOLOG attach'ailditlaaeFal
Geothermal(Heatin Coolin Retum) Other(ex lain under=21 Remarks) FROM1S To DESCRIPTIOy1(rnror hardncs sotVeocic hJ to sia etc)
A ft ft. !` htt W/) 4#[I
4.Date Well(s)Completed: 7 7 ZDZ�. Well ID# V ft. Zp fL C 5b14 �✓ Slle/15
fL f.
5a.Well Location:
fL fL
Qaw b eN
- Facility/Owner Name Facility ID'.(if applicable) fit- ft
ZI 310 Scaup Rd , Corolla, W Z1 fL ft
Physical Address,City.and Zip fL ft.
Cu�rck oar? ogaoo63o007 -3diRENIARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) / I r 22.Certification:
3 6e, 301 yY N 7 e -7 S w 77� 7 L zz
6.Is(are)the well(s)Getmanent or 13Tempotary Signature of Ce fied YFell Conffictor Da
i3v signing tha farm.I hereby rerto-that the weli(s)was(were)rarrstrurted in accordance
7.IS this a repair to an eJdsting well: [3Yes or ®No with 15A NC:AC 02C.0100 or'15A NCAC 02C.0200 Well Construction Standards and that a
ijthis is a repair,fill out known well construction information anal erplain the nature of the ropy of this record has been provided to the well owner.
repair under 421 remarks section or on the hark 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 site detail or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach ad '' n hfgiHS�i,necks§ar�vaQ
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZD (ft.) 24a, For All Wells. Submit this form within AUGs�f&m 922n of well
For multiple ivells list all depths ijdii ferent(example-3C200'and 2@1001 construction to the following:
10.Static water level below top of casing: c *:. r t, UR�1
(fit) Division of Water Resourees,It�fbra3a'FlofiP e�, ,�smt,
Ijtvater level is above rasing,use"•"(- 1617 Mail Service Center,Raleigh,NM7644-1
11.Borehole diameter. Y (in.) 24b.For luiecton Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method. A-f41 ff construction to the following:
(i.e.auger.rotary.cable.direct push.etc.) T
Division of Water Resources,Underground Injection Control Program,
L3a
ATER SUPPLY WELLSWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
eld(gpm) -1�' Method of test: (Tai Pvtw►f 24c.For Water Suauly R Infection Wells: In addition[o sending the form to
the address(es) above, also submit one copy of this form within 30 days of
sinfection type: TL Amount: 1.50
z- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-DiNision of Water Resources Revised 2-22-2016

Perrrv,it: 355175 Currituck 50 AKd/ AVL_
.WELL:PERMIT. j
PIN: 087AO0000630007
ALBEMARLE KEG16NIAL HE:SLTH SEpvICEs Applicant:
Owner: Parrim m PCu6c FIealth
RISBERG PAUL RISBERG PAUL 1
440 BRANT RD 440 BRANT RD ffi
COROLLA, NC 27927 COROLLA, NC 27927
Location:
�136 SCAUP RD
30- 7 L-0'P L 3 �ir4•• o '.
=WELL•MUST MAINTAIN OV"FEET MltVIMUM FROM ANY 1 \ 1
PART OF-SEOTIC SYSTEWRgPA1R AREA
-WELL MUST BE LOCATED AT LEAST 25 FEET FROM BiVOXND � 'X o °
-WELL IVIUST STAY AT LEAST 25 FEET FROM ANY BUILDING 1 0
FOUNDATION
-WELL MUST BE INSTALLED SY'A NO LICENSED WELL DRILLERrt
°
-WELL PERMIT MUST BE ON LOCATION DURING ALL.PERIOOS 1 e
OF WELL INSTALLATION
-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED
INSPECTIONS OF GROUT AND WELLHEAD ! p�
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•:Yi 4�:1,' Y Ir lJ
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Permit By: ate' Date: 03/31/2021
/Ms, 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 15 A NCAC 02C.0300..

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1
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 25,2022
Paul Risberg
440 Brant Rd.
Corolla,NC 27927
RE: Approval No.WWM1431
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2136 Scaup Rd.
Corolla,NC 27927
On July 25,2022,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 2136 Scaup 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 noway 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.
W W W.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