GW1-2022-10325_Well Construction - GW1_20221114

1'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ti+h,o�ln� :1q:_Fl(A3'ERZONES
FROM TO DESCRIPTION
Well Contractor Name
fL z ft ii 6WVl Srvte«
g� Z ft t'�K ft I tiWe, CoJat but- AD Sike1
NC Well Contractor Certification Number 15pu1EIt.CPISiNG`for.meth aIi'€ 4C'tf- ' : mot xr a>.
CoKs '►a Q �♦ FROM TO DIAMETER THICKNESS MATERIAL
fo{/A rjltfVltaC a ` $ I fL (l in. Va b P &
Company Name
2.Well Construction Permit#' FROM TO I DLIMETER I THICKNESS I MATERIAL
List all applicable well construrtion permits(i.e.UIC.County.State.Variance.err.) IL ft in.
3.Well Use(check well rise): ft ft is
Water Supply Well: -FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipallPublic ft ft (I(4 in 1010 t{() PVC
Geothermal(Heating,/Cooling Supply) NResidential Water Supply(single) fL ft. in,
IndustriallCommercial Residential Water Supply(shared) AKGROil9
Irrigation - FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL ft yr e'tfck�{L' bvt/Cd
Monitoring ©Recovery ft ft
Injection Well: ft ft
Aquifer Recharge ©Groundwater Remediatlon __
=,19.'SANDIGRkVEVPACS.�ii
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage [(( IL fL it-'ja ,J p )
Experimental Technology nSubsidence Control ft ft � �t
Geothermal(Closed Loop) Tracer ?A:1)RILLIIIG.LOG:attich`;rd d s3 sif
Geothermal(Heatin Coolin Retum) r3Other(explain under#21 Remarks) FROM I To DESCRIPTION(eobr,_t+„Jan�mivr—k tyim Vin slin,ems)
qy� 0 f f 6—vt S� K
4.Date Well(s)Completed: (D Well ID# 5- ft it ft
Sa.Well Location: 11 ft t 2- ft eaf (a e
Lor& f+arA�& 2 fL 1.6, It. skc(!s
Facility/Owner Name Facility lD,1(ifapplicable) ft. ft
9;$3 wean Pearl,Coralla ZZQ21 ft. ft
Physical Address,City-and Zip ft ft
C(A rrt.Ucy, 0*140 v S00l5'aao 3
County Parcel Identification No.(PIN) lull
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t 1D `-C
(if well field.one]at/long is sufficient) 22.Certification: DANQ/3 G
�5a �Zl c rr r
3( � �tl �' W
6.Is(are)the well(s)12rPermanent or OTemporary Signature of Ceiliffied XVell Co tractor Date
- - - By.signing this form.1 hereby vert f•that the well(s)was(were)constructed in arcordanre
7.Is this a repair to an existing well: ®Yes or eNNo with 15.4,VCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well ronstrurtion information and erplain the nWure of the ropy of this record has been provided to the well owner.
repair under 421 remarks sertion 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: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,yells list all depths if different(erample-3r200'and 2C1001 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,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: Ai e ey construction to the following:
(i.e.auger.rotary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W-E�LL�S/ ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: f'7Af PyIMC 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also,submit one copy of this form within 30 days of
13b.Disinfection type: 1 L Amount l•S O-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

Permit: 365914 --.--• Currituck
WELL PERMIT
PIN: 087LO05OQ15. QDZ
AwEMMALE R.CGItiuAL HEAUH SERVICES
P9Rtters in Pbblk Health
Owner: Applicant,
ipp cant,
HAMILTON SCOTT&LORA CAROVA BEACH BUILDERS
5221 N COURTHOUSE RD 2162 SALMON RD
NEW KENT,VA 23124 COROLLA,NC 27927
Location: r
2253 OCEAN PEARL RD a
�►�o x3N. sq
•WELL AAu,sT mAICITA;V 2,0"t PROM bUtLDW-0 FOUNDATION/ Wf 406
•t•VELL UST MAII�t r Aw'so+FP.��3+aAN.Y. P AFtR-T OF SEPTIC SYSTEM1. �•Ar
r• .(z.c.
kRD REPAIR AREA
WALL MUST BE INSTALLED BY A NC CERTIFIEd.WELL DRILLSR
YAdFs'LLPirR LOCATION L�UF'.ii�fGtl1LPR.t CfSr'�'' .r! ���fr:+�-:�'"at'i• iit� 's`i+�r,...:. .f
IVIIl'MUST BF 0 LOCt\TI J C a� . ✓_.
OF WELL iNSTALLATiOId
,GALL AT LEAST 1 QUSINESS DAY.PRIOR-FOR REQUIRED
BGTIONS OF GROUT AND WELLt \D
" Ur
40
�7a,717-
LU_
WT
4.• � .Fltli '�nr�Roeol�ie�.
Permit By: Date: 11/22/2021
,Joe
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.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COBEN,MD,MPH
GOVERNOR SECRETARY
MARK BENTON
DIRECTOR
Onsite Water Protection Branch
June 14,2022
Scott&Lora Hamilton
5221 N.Courthouse Rd.
New Kent,VA 23124
RE: Approval No.WWM1413
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2253 Ocean Pearl Rd.
Carova Beach,NC 27927
On June 14,2022,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 2253 Ocean Pearl 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.
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