GW1-2022-08725_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
T i A%o+k%t 3 . FV% i sh A,
-a4.-WAFER ZO'11ES . -:: :- ,' .: ..,:,:z,: .:. ,.• ..-..
FROM TO DESCRIPTION
Well Contractor Name 3 fL ['� fL t^ `+ color-
ft. ft.
NC Well Contractor Certification Number TjKUUIf CASING fbi.ini'm-:Z
A 11 FROM TO DIAMETER THICKNESS MATERIAL
LroVA Sawa P-V4 GAS{'tfLlLal'10 A LL(- -t l fL 14 ft. t 'a SCLt�� P Ve-
Company Name I6:-INNEIisC '10,
pp ps.p��q� ASI 'I•i1BL�IG., � ,_ .--^� ">"�-,
2.Well Construction Permit#: 310 319S7 w WVA H 3 FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(Le.UIC.Counn.State.Variance,err.)
ft. fL rn
ft. ft. in.
3.Well Use(check well use): r_
Water Supply Well: FROM TO DIAMETER SLOT S[ZE THICKNESS MATERIAL
Agricultural unici altpublic ft ft lr
P � [1 / in. a [® SC f� UL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) � 'r
-:.may:
PP ( &GROUT
Irrieation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. [ ft ��bul4dMle ut��!
Monitoring QRecovery ft. fL
Injection Well: ft. fL
Aquifer Recharge Groundwater Remediation
3fi SANDIGRAY€1::Pi1t K:lfs" F
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEN-r METHOD
Aquifer Test 13Stormwater Drainage ft 2p fL tf7- Sum r�u red
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 2(lE l)RILLING`ISDC:attseit' 'n�Fshif ...
Geothermal(Heatin 'Coolin Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(cobr hardoe$sarVtoek era eta)
p O fL ft.f i'YJWI'I.SGY�
4.Date Well(s)Completed: O 11012OZZ Well ID# ft [7 fL - grit!.{ S /5
Sa.Well Location: fL ft.
aeaL FCC yl+ .TV1de+ KfS uG fL ft.
3
F ft.acility/Owner Name Facility ID9(ifapplicable) ' tI
I-qZl- 5-K4Plper,C rAc,i 7-I.9 z-r
Physical Address.City.and Zip fL ft AUG.r 2 9
C Zvi-t�cY— OcIgA0=W0,V3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell f field.one lat/long iffi sufficient) o f 22.Certification:
3l0 3 Z 20 N '1 Tz `!it W �--
6.Is(—)the well(slar&rmanent or Temporary Signature of rtified Y ell Con ctor Date
By signing this form.I hereby rertyj*that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an wdsting well: E3Yes or E]<o with 15A.A.VAG 02C.0100 or l5.4,VCAC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the rapt'rI this record has been provided to the well owner.
repair under#11 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 details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3@200'and 2 t@1001 construction to the following:
10.Static water level below top of casing: 3 (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. b (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: AliG ex- 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) Z.� Method of test: (Ai Pk 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
T
13b.Disinfection type: �1 L Amount: 1•S d'L 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

i
Permit: 363195 Currituck
1�IELL PERMIT'. �AAl
PIN: 099A00000440093
ALWAARLE REGI9JNAL HEAVH SERIOCES
Pamiers in Pl;Ulk Heefth
Owner: Applicant:
BEACHFRONT INVESTMENTS LLC SANDBAR REALTY&CONSTRUCTION
5205 CANOE LANDING PO BOX 250
VIRGINIA BEACH,VA 23464 COROLLA,NC 27927
20' DRAINAGE (M.B 9, PG 54)
Location: N 03°4Z00"W 100.00'
1922 SANDPIPERffR//D
3� 3 iioT 77 10'AI CCESSORY SEMACK .
Ak-m sv*v �� . . �o PROPOSED
-WELL`MUST MAINTAkl( 21' 7!pF.t0i 1$UtLDt.NG.FOi.3f`IIOATiON/ WKJO& ` 4•-MIdFi FENCE �• ,~
-WELL
�;��i!EJST MAII TAPN'o*!'F.LoAR�AI�'Y PART OF SEPTIC SYSTEM Irp,q - '�,a PWOP�
ANs7( PAIR AFt>`A : to
12yt26'POOL A,0'
-WRLL MUST BE INSTALLED BY A NC CERTIFIED INELL DRILLER ~) � Sty stud. In PROP.CONC.,.
" 1 OWN Avon IR r_ ...
_Y4ZLL PERMIT MUST BE ON LOCA T IOIN D JRING ALL P.ER1009, o� � Ale$ 4 r
OF WELL INSTALLATION .I � 4, 6.
-GALL AT LEAST 1 BUSIN9S5 OAY.PRIOR-FOR R>_QUIRED
WSPECTIONS OF GROUT AND WEL!HEAD \ E SEPTIC
a TANK
.MSTING WELL(S)MUST SIf PROPERLY ABANDONED AND 10.7'1 ; h.- i' CHIMNEY
PROPER FORM SUBIVUTTED INTO THIS OFFICE I m
C! Z
I- 1 I
�4
I � I I
1 1
10 M�L• I I w
100.00' S °42'00"E
SANDPIPER` ?AD
(60 WIDE R/w)
Permit BY; Date: 09/1312021
'i Oe
Certification By: Datd:
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.

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
Beachfront Investments,LLC
5205 Canoe Landing
Virginia Beach,VA 23464
RE: Approval No.WWM1439
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1922 Sandpiper 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 1922 Sandpiper 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. j
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