GW1-2022-10163_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only
1.Well Contractor Information:
Ti n�o�h J . Eh t i s h 14 WAR ZONES
_ FROM TO DESCRII'TIO'
Well Contractor Name 5 fit- 1't ft �dfl e_ ce k( 1 l° 5011
q I M ft. 6 _
NC well Contractor Certification Number I&ODTER l AS1NG{dr:�ialfitased:` ' t9A3
e �� FROM TO DIAMETER THICKNESS MATERIAL
CAlro✓A SefwLx avidl ConStrvlyF►04 �C �f fit fit , is - VG
Company Name 16 1NIQ£R CA$13stG8;LT3$iTtCs =`t_' a>-:rr: F f r",
3��/04 H/W�C�� O FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit T: n V f ft fL in.
lis:all applicabie well construction permits(i.e.LOC.Counn..Stare-Variance.pr.i
I fL ft in.
3.Well Use(check well use): -
Water Supply Well: II FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3municipal,Public �l� ft fit 111 in ,Div 1 yc VC
Geothermal(Heating-Cooling Supply) Residential water Supply(single) fit fc itL
[3Residentiai water Sucoly(shared)
IndrismaUCommerctal �B;GitUL�''::. : - '�` `�;'•�`^'`��'FROM TO MATERIAL{ EMPLACEMnT METHOD&AMOU'NT
Irrigation fit fc S�
Non-Water Supply Well:
Monitoring E3Recovery fL ft
Injection Well: fc f1
Aquifer Recharge 13Ground%vater Remediation
19 SANDIGRAVt:P-A-CK ' "
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterDrainage �[l fi j �( fitZsr
Experimental Technolo, nSubsidence Control fit R
Geothermal(Closed Loop) �T acer 24.DRILLING LOG art ilalft3f
FROM ' TO DESCRIPTION(colon hudoes.sciUrxk sia.eta
Geothermal(Heating%Coolin Retum) Other(explain under'-21 Remarks) fL fit 5<e11f� eov.
4.Date Wel(s)Completed: i 102Z Well ID: fit ft ,,, �re CI(5
P I ft.Sa.Well Location:
(L �(� ft ft.Joph CEl'Poei7�t I tL fL
�-- Facility/Owner Name Facility ID=(if applicable)
_lob. S-VJ1 ,oT� 7_1 v ft. fL C��o!la ,
Physical.Address.City-and Zip •at Prx _
IAtri�ttrlG D$1R0J16D(&V,12
County Parcel ldenrification No.(?IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if.ell field-one latlong is sufficient) 22.Certification:
3(&" 3 t' t8" N _V: ' 51' 56" W
6.Is(are)the well(s)135%rmanent or Temporary
Sienzture ol-ortified WFII Conficlor Date'
13v sigr-ing tMis form.1 herebv aertT'that the well(si ryas!were)ranstrurted in arcardame
7.Is this a repair to an e3dsting well: ®Yes or E f o with 15.4.1'C.AC 02C.0100 nr/5A NCAC 02C.02r.G Ivell Construrtion Standards and that a
lfihis is a repair,fill our known well construclion information and rrplain ire nulure of the ropy of Mu record has been provided to the well owner.
repair under#21 remarks senior,or on the hark rf this farm. 23.Site diagram or additional well details:
S.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: P (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
1•'or mulapie rvelis list all depths ifdifferent/esa hole-3Cai00'and 2(c100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing.e<se" " 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: �6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
^—,f above, aiso submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 CtW�( constructi
(i.e.auger.rotary,cable,direct push etc.) on to the following:
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: (pus par-le 24c.For Water Suopiv&Iniection Wells: In addition to sending the form to
C the address(es) above, also submit one copy of this form within 30 days of
T
13b.Disinfection type: t , Amount: 1.7 02 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 Rater Resources Revised 2-22-2016

'. ROY COOPER•Governor
NC DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTH AND % HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
HUMAN SERVICES
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 4.2022
Joseph Coppersmith
17 Sylvias Chase
Moyock,NC 27958
RE: Approval No.WWM1510
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2206 Sandpiper Rd.
Carova Beach,NC 27927
On November 4,2022,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 2206 Sandpiper Rd., Carova Beach,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. iA 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.
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH
LOCATION:5605 Six Forks Road,Raleigh,NC 27609
MAILING ADDRESS:1642 Mail Service Center, Raleigh,NC 27699-1642
www.ncdhhs.gov • TEL:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

Permit: 378QM Currituck
f'1NE!LL PERMIT.
PIN: 087AO110010000�
ALBEMARLEREG16NIALI MUM$EVICH
Owner: Pamirs m PL*bk HeeithApplicant:
Joseph Coppersmith Joseph Coppersmith
107 Sylvias Chase 107 Sylvias Chase
Moyock, NC 27958 Moyock,NC 27958
i
2206 Sandpiper Rd 2r1' I—E48BNt=NT
2- C SC 1{ VT t O p c.2,stv 138
66c
Nf°4St?A.°w idotw'
.V,eLL'L4US't°iwtQNTAtM e+ .t$�FOUM ATloi�J>ti C 6. 1�
-ALL'tfa!USr IwAn�1 s�<t�«t*I�tQitA'11t►l PAi#fi OF SEPTIC sY81"8M S S' !tfl�
AND REPAIR,a _
WQ,L§W4" 'n INSTALLED 8Y A NC CERTIIFtED WELL GRILLER t
We!= PERMIT MUST BE ON LOCA110N OUR NG ALL PE1�fOD�'
OF WELL iN5TAL•LATION
-CALLA'T LEAST 1 EIUSINESS DAY PRIOR FOR R.trd ORED f I I +
INSPECTIONS OF GROUT AND VVELtzHEAD {�
DWX
!8 tJtl' HIVAC I
a
PROPOSED
< DWEUM I
34.00,
2-IftIVSM
PARKING t
SANDPIPER READ (60`
Permit By4: Date: 06/29/2022
H h /
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.