GW1-2022-08724_Well Construction - GW1_20220826

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tiiiiinno�ln J . En fish
. M.
FROM TO I DESCRIPTION /!
\� Well Contractor Name 5 ft. I 2 IL 101,0 WO S YN&, C5ingI
t O—1 fJ fiat, ft- , to ft color , 117MC$MCI
NC Well Contractor Certification Number // L�_�-�-"LL &OU ER.CASING formdU;
A IAKSTs�wr�0 A �� FROM TO DIAMETER THICKNESS MATERIAL
C-4ro Va S erv�K aNOL .4 ft PVC-
Company Name / { 46i0i+ RCA8ViG=OR'= INV
y�1a + �WM1�33 FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#:
ft. ft.List all applicable well construction permits(i.e.UIC.Count',State.Variance,err.)
to
ft ft la
3.Well Use(check well use): _
2Z:SCR? 5 pis-
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural © unicipal/public R ft fL '%/,t rn •olo �(I KO pvc
Geothermal(HeatinglCooling Supply) Vesidential Water Supply(single) ft ft. in
Industrial/Commercial Residential Water Supply(shared)
FROM TO MATERIALI EMPLACEMENT METHOD&AMOUNT
Irrigation
Non-Water Supply Well: 0 ft
Monitoring DRecovery ft ft
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remediation
19:SANDIGRAYB PAIg zt. ?
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MStormwaterDrainage ft 26 ft toe, s4tno( wd4
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20:73ItIILINGOG attached3lfuia�lsR "
FROM TO DESCRIPTION(color.hatriness,sorl/rmk sia.etc.)
Geothermal(Heating/CoolingRetum) Other(explain under=21 Remarks)
0 R fL �dwA Scr•-td
4.Date Well(s)Completed: �ZZ Well ID# ft IL
Sa.Well Location. IL
zo
IL Ciotti
Mic,habl +VaICrif U:Ilard� fL fL
Facility/Owner Name Facility ID,(ifapplicable) ft. ft ,
23 b`I Z19Z7 ft ft
Physical Address,City-and Zip ft. ft.
GKrri�-ack 08'I�OlSC8b1e0oDl � - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decitrral degrees:
(if well field,one la long is sufficient) 22.Certification:
to N -75* 5 4 4`� W y &zZ.
6.Is(are)the well(s)QrPermanent or 13Temporary Signature ofCsErtified Vell Con0rctor Date
By signing this form,I hereby cerfift that the svell(.$)inns(were)constructed in accordance
7-Is this a repair to an existing well: ®Yes or YNo with/3.A.NC.AC 02C.0100 or/SA NCIC 02C.0200 Well Construction Standards and that a
1f 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 mvner.
repair tinder#21 remark's section or on the back of this form. 23.Site diagram or additional well ' fa ' f
You may use the back of this a e to ryl a�lditlbnakw11 5'rta dgta{ls or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same P g P
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach onall es Tnecessary.
drilled: SUBMITTAL,INSTRUCTIONS 76 .2021
9.Total well depth below land surface: 2 (ft-) 24a, For All Wells: Submit of well
For multiple wells list all depths ifdiereni(example-3-200'and 2 m100') construction to the following: alPtr Q160r
10.Static water level below top of casing: S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,uve' 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: Au►1Cr above,also submit one cop) 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 Method of test: &*5 Pk!!►f 24c.For Water Supply&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: I•501, completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit: 365625 Currituck )
—' E1= 1T
PIN: 087A01500060001
ALDEMARLE FLEGiIl\4L HrAL-i$ERV!C5
Farm=h PCdGc Health
Ovmer: Applicant:
VILLARDI MICHAEL&VALERIE VILLARDI MICHAEL&VALERIE
130 MARLAS WAY 130 MARLAS WAY
CAMDEN, NC 27923 CAMDEN,NC 27923
Location:
2364 CAROVA RD
WELL`AAIJST N1Ali+4TAI pMW*Uj m6 FOUNDAl1GN� WK04
WELL��i U5T MAlF�1T,AFf'SO PI�A{lA�t�R�tY F:�Rf OF ScFT1C S`(.Sl>=U4
AND Ft PAIrZ AREA , _ N os'53'23' W
WILL MUST.BE INSTALLED BY A NC CERTIFIED.WELL DRILLER I00.0o'
LOT 6
WELL PSWAit MUST BE ON LOCATIION DUFJNG ALL PERiFJOS 14600 SQFT,
OF WELL INSTALLA TIOrt
r - -•-
-�L.E AT LEAST 1 BUSINESS DAY.FRIaR'rQR REQUIRED I nC
IN-Spp-CTIONS OF GROUT Al`M WELLHEAD 3 I ( TJ t0 w
sa
o ) I of
s,w Ste" SB
0
PROPOSED
'/STORY QY PILES,;
?BEDROCIWS '
b FFE- a 0'
� I 1
\ too.00' 1 1
• -
S o., S3'23"E
we-r.. t.�itTior+/ �4
.--z --, Y: V
b 'O CAROVA- ROAD —
I Z (60,PU&IC R/W)(N8. ?, PG. MY)
(UN/MP40tE0 SAND ROAD)
Permit By; t. ` �/ - Date: 11/10/2021
Ho s, Joe .9 hovl$" 11•Zz-2�,
i
Certification By: bate:
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•.
`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
July 29,2022
Michael&-Valerie Villardi
130 Marla's Way
Camden,NC 27923
RE: Approval No.,WWM1433
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2364 Carova 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 2364 Carova 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 27641 1.642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
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