GW1-2022-10164_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal lise Only:
1.Well Contractor Information:
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I FROM iTO DESCAIPTIO\
weli Contractor Name ft. 'L ft f '
NC Well Conmctor Certification Number 13;:flL"1ERCASFiG for:�alti'i9sed,." t3R'�1€R ��'�'EF�'-'r
FROM TO DIAMETER THICKNESS !MATERIAL
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Company Name166
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2.Well Construction Permit : j ` NZ W vi f�► t 50-1 fxov7 To DIAMETER THICKNESS MATERIAL
list all applicable well ronsirsctian permit'r o.LifC.C'ounn..Vtate.Y'arimtr:e.etr.i fL ft. in.
I
ft ft. is
3.Well Use(check well use): _
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS I`MATERIAL
Agricultural 13ti unicipalrPublic fL 20 ft. 1� iti Ot0 qd vC
Geothermal(Heating,,Cooling Supply) Residential water Supply(single) ft. R in
IndustriaVCommercial Residential water Supply(shared) a18 GRUITf- �. t
irrigation FROM I TO I
yMATERIAL I EMPLACEMENT METHOD&AMOU'NT
Von-Water Supply-Well: 0
fL
ft
Monitoring QRecovery fL fL
Injection Well: fL fL
Aquifer Recharge ©Groundwater Remediation _
19.SAND/GRAXWPAC&. f.i
Aquifer Storage and Recovery [3SalinirvBarne. FROM To MATERIAL I`EMPLACE!MENTMETHOD
Aquifer Test [3Stormwater Drainage ue
fL I ZQ fL Z LJtd oweA
Experimental Technolop 13Subsidence Control fL ft
Geothermal(Closed Loopl E3Tracer '20.I)MLI CLOG atmeL addli4bigAi6iti�t D"_`�-�
! hardne$,
Geothermal(Heatins%Cooiin Return) Other(explain under=2 i Remarks) FROM TO DESCRIPTION(oolor,
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4.Date Well(s)Completed: Well ID: fr- -O fL I �� LNOV
5a.Well Location: ) ft Si a<t
2 f 4 I,- Information Pf� t nk
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FacilityiownerName nn p0 Facility IDS(ifapplicable) f2- ft 44tD� AeffS
CC U cC i 10. 211 Zl ft. ft
J0.v1l�O itO�� 1\Ot
Physical.address.City.and Zip ft.
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Count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fieie one latilong is sufficient) 22.Certification:
6.Is(are)the well(s)(NP'ermauent or 13Temporary Signs etu oCe'riified WfI Connctor D
Be sign ng this form..1 hereby Teri f•that the well(sl was(were)ce n hurled in accordance
7.Is this a repair to an epsting well: [3Yes or [0<o with i5A A'CAC 02C.0100 ar/5.A NCAC 02C.02Cfi Nell Construction.Standards and that a
/Jthis is a repair,fill out knmvn:,el(cnnstraainn irjnrma inn and explain.the nature ot`!Ar ropy r f this record has been provided to the well nwner.
repair under#21 remarks sertior or nn the nark of this/arm.
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: SLBNIITTAL,INSTRUCTIONS
9.Total well depth below land surface: 9-6 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
I•nr multiple wells list all depths ijdii ferent(esamp!e-3Ca300 and 2r 100') construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Rel ttrces,Information Processing Unit,
if,vaier level is abnve casirg.:ae" II 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: t0 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6r construction to the following:
(i.e.auger,rotay.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: (Ft$ P Anf 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one cop) of this form within 30 days of
13b.Disinfection type: TL Amount: 1.$ d'L completion of well construction to the count' health department of the county
where constructed.
Form C V-I North Carolina Department of Environmental Quaiin-Division of water Resources Revised 2-22-2016

Top
Permit: 377842 Currituck J
PIN: 087AO020015000R
WELL PERMIT.`..
i
Owner:- Applicant:
AiSE161LARLCR '16NALHe.uTH SEPUfas Walter Joey Moore
Walter Joey Moore part„ers in ftUIk-frith
2162 Salmon Road 2162 Salmon Road
Corolla, NC 27927 Corona, NC 27927
=WEl.L`1EAU:�T>d}AItVT i +'�'tiONl BU D FQUNDATIGP /z)wA w,6
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Location: -WELL MUST PAAjNTAft -so*OwiWANY PART OF SEPTIC SY9TEM•
AND REPMR AREA
2174 Sandpiper Road
ScG t�jLK Z LoY J� '�L Nius7r BE iNs7ALLED SY A NC CEFMFIED WELL GRILLER•
4koVV* v �PERMIT MUST sit ON LOCA-n"ON DURING ALL AERIQDS `
OF WELL,INSTALLATIOPI
'- — - CALLAT LEAST 4 BUSINESS DAY PRIOR FOR REdUiRED
INSPECTIONS OF GROUP ANt WEL6.H Ao
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100.001 M.00,St.LON '1Ue ' v da '1v-1- Lv 'CG
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Permit By: Date: 0710712022.
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Certification By: Date:

Q 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
Walter J.Moore
2162 Salmon Rd.
Corolla,NC 27927
RE: Approval No.WWM1509
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2174 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 2174 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. 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.
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