GW1-2022-09263_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'~� Ti r►�o�ln� J . Ev,g I i sh
t � .14.. tA'i'ER`7.d3VE,S
Well Contractor Name DESCRIPTION
g9 10 ArArkci6r a s ill
NC WellContactorCertification\'umber �Q f. U fL le 14t tp(Gr �,-�-{,(C so ef(
IS:.OUTER C8 G for s uN-casie 1 'OR%€ A: -`
Caroya SCry1K m4 / „Siy_ b 4 LLI FROM TO DIAMETER
THICKNESS MATERIAL
�.0 jTMVfI ` }1 fL 1 1f fL Company Name ?l �
{ 1 ra s 0 A/L
_-..
�, + 16:1NI+tER�CASiNG�3E'}'tJBING•��. '� -:x,�,�-:r .:��r�:,•;
2.Well Construction Permit#: v`,-W�� W WK Y J L T(j l FROM TO DIAMETER THICKNESS MATERIAL
n
List all applicable well construction permits tie.UIC.Coun ,.Stare.Variance,etr.) fLfL tn.
3.Well Use(check well use): fL M to
Water Supply Well: O DIAMETER SLOT SIZE y THICKNESS MATERIAL
Agricultural VResidential
unicipal/Public Q7 fL 20 ft. 1/ in. .010 PVC
Geothermal(HeatingiCooling Supply) Water Supply(single) fL ft. irL
Industrial/Commercial Residential Water Supply(shared)
48 GRO[ff
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d fL (p 17 V; f
Monitoring ©Recover fL fL
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
19:SAittDiGRAY€I:PK£�if a" ;s:..-x
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage IIp fL Z( fL fFZ oL,red
Experimental Technolog} Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20:DMLINGLOG attseli'adillf[tmiFafieetsi
FROM TO DESCRIPTION(color hardness,sorUrxk n am etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
0 ' 7 f` 6- WrI attdl
4.Date Well(s)Completed: Z 2022 Well ID# fL F fL PC.,c- l 1 Q elm
Sa.Well Location: ft. 26 fL lre 5-and W igw(5
(�\ LLC fL ft
S FortlnAlC �nvES�wtCVltS 'r"a• a t�i r
Facility)tDwntt Name Facility tD-(if applicable) fL ft 9
513 Cavta!�4 LIJ �Conila , Z1127 fL fL Physical Address.City.and Zip fL fft. -, _
Cu.rrik_("V 101Q600 003 000 0 2 rr��/f
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
36 2�CI t-131 f N -7 50 5-61 9-61 W
6.Is(are)the well(s)(ErPermanent or Temporary SignanisAf Ce. ed WrlfConractor Date
By signing this form.i hereby certif%that the well(s)wuv(were)constructed in accordance
7.Is this a repair to an eadsting well: [3Yes or Vi�io with 15A N'CAC 02C.0100 or)5.A NCAC 02C.02fi0 Well Construction Standards and that a
/f this is a repair.fill out known well cnnstruction information and ecplain the nature of the ropy of this record has been provided to the well owner.
repair under x21 remarks section or on the hack 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 1 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: 20 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells h5t all depths if different(example-3Ca200'and 2[L100') 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 Senice Center,Raleigh,NC 27699.1617
11.Borehole diameter. (1P (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one cope of this form within 30 days of completion of well
12.Well construction method: tcA4 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) Method of test: W15 NMV 24c.For Water Supply &Iniection Wells: In addition to sending the form to
1 l the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: HT� Amount: •S oZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 Nonh Carolina Department of Environmental Qualiry•Division of Water Resources Revised 2-22-2016

en ores r
Permit: 366361 Currituck
WELL°PERMIT"
PIN: 1419QQJ4jL
AL50KARUREG1d\AL HEALTH SERIMCES
Fa mars M Ptl6k Hestib -
Owner; Applicant:_
FORMAX INVESTMENTS LLC FORMAX INVESTMENTS LLC
PO BOX 10 PO BOX 10
ELKWOOD,VA 22718 ELKWOOD,VA 22718
-WELL MUST MAINTAIN '1*FED i MINIMUM FROM ANY
Location: PART OF•SEPTIC SYS'f'EM/RE'P►AIR AREA
513 CANARY LN -WELL MUST BE LOCATED AT LEAST 25 FEET FROM BjI 3&VNO
trs 3a - r=LJNDATIONTAY AT LEAST 25 FEET FROM ANY BUILDING
-WELL MUST BE INSTALLED BY A NC LIOENSED WELL DRILLER
-WELL PERMIT MUST BE ON LOCATION DURING ALLPERIODS
OF WELL'INSTALLATION
-CALL AT LEAST I-BUSINESS DAY PRIOR FOR REQUIRED
INSPECTIONS OF C-kOUT AND WELLHEAD
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t... . "
' gib � - • . .yam -.
I E$:IAT d r
AAE - 5 zer
r
Permit By: s Date: 12/03/2021
Hob oe
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 15A NCAC 02C.0300.

THE AUTHORIZATION FOR DPX41 V'G WATER WELL CONSTRUCTION SHALL BE VALM FOR
A PERIOD OF 66 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,
w
The issuance of a Permit for Well Construction in no way guarantees the quality of the drinking water.
Wastewater systems and water supplies shalt meet state and/or local regulations.
NO CHANGES IN THIS DOCUMENT ARRALLOWED'UNLESS PRIOR APPROVAL IS OBTAINED FROM + .'
THE HEALTH DEPARTMENT. IF THE INFORMATION SUBMITTED 1N TM. .APPLICATION FOR,
:. DRINKING WATER WELL CONSTRUC UON IS FOUND TO BE INCORRECT`,:CHANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AunMORIZATION SHALL BECOME INWALID AND MAYBE
SUSPENDED OR REVOKED. "�•
When contacting the Euvironrnental.Health office concerning this document,be.sure to know the application . .
number. 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. .. . .. . .. . .. 3384460 Pasquotank. . :.. . 338-4490
Chowan. ... ... .. . .. 482-6023 Perquimans....'.. 42.6-2100
Curhtuck. . . .. . ... . . 232-6603 Bettie. ... :... ... ... 794-5303
Gates.. .. . ... . . ... ." 357-1380
. Well Contractors are responsible for notifying the Environmental Health Offices for grouting inspection,wellhead
inspection,and required water sampling. Drinking water wells must be insp'eeled and approvedby a representative
of the Environmental Healt� 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 SET FORTH.IN THE REGULATIO19S,BUT SHALL IN
NO WAY BE TAKEN AS A,GUARATEE THE QUALITY OF THE DRINKING'WATER.
"Minimum,Distances"
Private Drinking Water Fells to:
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
1) Ground Absorption Wastewater Systems. . ....I..... ... . . .. . . . ... . too ft
(includes existing septic tank,drainfield,repair area;
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-imgatiou sites . . 100 ft•
4) Water-tight sewage or liquid-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 well head. .. .... ..... ........... .......... .. .. .. . ... 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 .. .. ... ..... . ...... 100 ft
12) Animal barns.. . . . . . ... . . .. . . . ..... ... ... .... .. . .. .. .. . . . . . .. 100 ft

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
March 22,2022
Formax Investments
PO Box 10
Elkwood,VA 22718
RE: Approval No.WWM1347
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
513 Canary Ln.
Corolla,NC 27927
On March 22,2022,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 513 Canary Ln.,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 6om 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 f
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,INC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER