GW1-2022-09265_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onlv:
1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number tr I1iE'L6�oi" t1 51"tC��
! is.:t)UTERCASIhr, fdr. tiased. t3lti "-�
IX(.OVa StWca 00A Gnsfr__ v) ' ! / FROM R TO fL DIAMETER THICKNESS MATERIAL
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Company Name
3(.630 wWM 131R .,.�. .� .
2.Well Construction Permit#: FROM 70 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits tie.UIC.County.State.Varimvx.eir.) ft ft In.
3.Well Use(check well use): ft. ft. in.
-17:,SCREEN';
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal,,Public W-I ft rZo ft ( in. �(0 6 VC
Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) fL ft
I
Industrial/Commercial 13Residential Water Supply(shared) $ _ - ;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft- ? tAre d
Monitoring ©Recover ft fL
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage j f. 7— ft ,�Z S4kd ttrGCr
Experimental Technology Subsidence Control fL I ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG adschaddltlnueTalcxisl#
Geothermal(HeatingVCooling Return) E30ther(explain under=21 Remarks) FROM I TO DESCRIPTION(color hardness,smurock type,yerW
R ? fL r wv1 rile
4.Date Well(s)Completed: '7 27 202L Well ID# fL g fL Plc l4 C✓
Sa.Well Location: ft 20 fL
fL fL
Form4 TaveSfw ,%IS �-�-�
Facility/OwnerName Facility ID�(ifapplicable) ft fL
.
Physical Address.City.and Zip fL ft Iflt1 i
GArrt r.k
_ la ltl o0 0 003 zoo o Z
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:
er
It 1j N 7S0 549r to W ; 9 28 Z
6.Is(are)the well(s)Ej5ermanent or Temporary Signature of Ceriffied W511 C ctor Date
By signing this form../hereby rrertT-that the wells).vac(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or GNo with 15.4 NCAC 02C.0/00 or 15.A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction information and explain the nature of the ropy of dtis record has been prat ided to the well owner.
repair under#21 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 1 GW-1 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- w (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 7dii ferew(example-3@200'and�12^.100') 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 casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. �_(in.) 24b.For Injection 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) Method of test: 1;f PIA 24c.For Water Supply R IRIM92n Wells: In addition to sending the Pormays to
` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: TL Amount- 1•$ tv't. 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: 366363 Currituck
-WELL PERilll&
-PIN: 101A0000 'i *2
Auemmu Rtc113w L HEALM SEPNIees
Partners in PtiwL-Hesitt,
Owner: Applicant:
FORMAX INVESTMENTS LLC FORMAX INVESTMENTS LLC
PO BOX 10 PO BOX 10
ELKWOOD,VA 22718 . ELKWOOD,VA 22718
Location:
517 CANARY LN
5cc. 2 trc 34Z
V*LL-MUsrWi AWN +FMW wit FOUNDATION f VZAKA*
WgLL}MUST VAit+i°PA*4Vq#I'rnogAW Pqt k+C)F sgTIC SYSTEM
AND RE!!'eA R ArREA
WELL MUST SE INSTALLED ELY A NC CERTiEtED WELL 0PJL ER
WEIr'L PERMIT Mt1sT 8E ON LOCATION DUR1N43 ALL.PERIQtOS''
OF WELL.INSTALLATION
-CALL'AT LEAST 1 EIUMt4E8S.DAY PWOR FOR tiE(tAREV
INSPECTIONS OF GROUT AND WELLHEAD• ` �
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Permit By: . Date: 12/03/2021
. HobyFrtlr
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 DRINKING RATER WELL CONSTRUCTION SHALL BE VALID FOR .
A PFRIOD OF 60 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.
The issuance of a Permit for Well Construction in no way guarantees the quality of the drinking water.
Wastewater systems and water supplies shall meet state and/or local regulations.
NO CHANGES IN THIS DOCUMENT ARE.ALLOWED UNLESS PRIOR APPROVAL IS OBTAINED FROM `. .
THE HEALTH DEPARTMENT. IF�THE.INFORMATION SUBMITTED IN Tom.APPLICATION FOR ; .
:. DRINKING WATER WELL CONSTRUCZ`ION IS FOUND TO BE INCORRECT,.CHANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME IN.VALID AND MAY BE
SUSPENDED OR REVOKED. -!
When contacting the Environinental-Health office concerning this document,be.sure tv•lmow 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,exceptholidays. The office telephone numbers are:
Camden. .. . . .. .... . 338-4460 Pasquotank. ... ...'.. .. 338-4490
Chowan... ... . ... . . 482-6023 Perquimans.... .. .. . 426-2100
Curnituck.. .... . ... . 232-6603 Bertie. . . . :... . .. . . . .794-5303
Gates .. . . . .. .. . . .. ." 357-1380
Well Contractors are responsible for notifying the Environmental Health Offices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspeed and approved by a representative
of the Environmental Healt) staff before any portiori of the installation is covered and/or used. .
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATEMM DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO.THE STANDARDS nT FORTH IN THE REGULATIOVS,BUT SHALL IN
NO WAY BE TAKEN AS A GUARATEE THE EQUALITY OF THE DRINMG-WATER.
**Minimum Distances**
Private Drinking Water Wells to:
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
1) Ground Absorption Wastewater Systems. . ... ..I .. .. ... . .. . . . . . .. . 100 ft
(includes existing septic tank,drainfiold,repair area,
e
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-irrigation sites . . 100 ft
4) Water-tight sewage or liquid-waste collection or transfer facility.. . . . ... 50 ft
5) Chemical or Petroleum UAderground Storage Tank....... .. .. . . . . .. 100 ft
(does not provide secondary containment)
.6) Chemical or PetroleumUnderground 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. .. . .. . . ...I. .. . 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
suchas.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
El wood,VA 22718
RE: Approval No.WWM1349
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
517 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 517 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 abandonjany 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