GW1--04786_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-` Ti o-tifty J . Eh9tish
•:Y4::i,TERzoNES :_:.. k..: - M.;:�..
FROM TO DESCRIPTION
Well Contractor Name
�( i W9 B A. ft. I® ft blwn.d elir
•i 0 it lei ft c:.k rer wa+t- litilesevell
NC Well Contractor Certification Number
IS:flLY!`EI[.CitSI11IG(fiaiitnilOR: figt :.Wi -_
CohS{hKi�►o Q �/ FROM TO DIAMETER THICKNESS MATERIAL
Car®va 5erv►lc a • I ft. >J,19 ft. l % in. st„rib pve
Company Name 4 ..
�x7I y�p�M T��y '•;lti:=INI+IEIt�:C'A.�'llgfs`=DRi�#IBIHIE:,(Rt�=„rR a�..,—. -q-?t,�r?u.-..gY`.,
2.Well Construction Permit#: 3 V 1 5 oS V--• `1 6 V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(VIC.County.State.Variance.etc.) ft. ft in
fL ft i in.
3.Well Use(check well use):
r
Water Sn I Well: •
'�z�sCRl�l+I:s; :, -- ;: -:::.- ..:m.�,�,r-..:.^�,,_,_-�+;.-, !�
PPY
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL D unicipal/Public Pit ft l q IL l i/ in. ,0(O $ch i{o Pee..
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
0Residential Water Supply(shared) ;GAD , - ti ': R , ti
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- ((o ft- frbk nto i k. Puled -
Monitoring ©Recovery ft. ft
Injection Well: ft- ft.
Aquifer Recharge ®Groundwater Remediation -$ IGRA ,P4Cm:fif ) v O,, n' ai :
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 1(Q ft. Ze. ft- Pt.krttil Poured)
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20:•DRIIiLINGLtG(attse6addltkiiiiiiLeetsilrs ty},=_ --,;: " '.:>
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,tmrdae�soil/rock type.(train sia eta)
� I t� (e. ft 15n)w tl Se l
' 4.Date Wells)Completed: v/]c/2.0Z3 Well ID# 6 ft' is it Gi ye gilt
Sa.Well Location: 10 ft i' ft put _layer
Ange(ct dl•'elly 4 Quid 6eit es 1 i f lei ft e�rey sr I f
-�• Faci /Owner Name Facility!DO(if applicable) I l ft- l 9 ft I Ii V S.vi4 W f she//r
2oSc S4nd�iperl Corolla. Z CK7 ft. ft r /r L
Physical Address,City.an Zip ft. ft
Lu r r•1 i- . 3L REist FKss.--. . :` . ; ; p.A.,:,-z-v
County Parcel Identification No.(PIN) tlZk./ �Vt,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J U L a 4 2023 _
(if well fold.one lit/long sufficient) O r p J t, 22.Certification:
No So It N 1 a •6` _L 2 w 1 v . i t1/ 3
#1 PfP.e toz
tiQ
•., 4G
6.Is(are)the well(s)r ermanent or`- Temporary - Signature of C nified ' Con ._for Dat
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Ero - with ISA NCAC 02C.0/00 or ISA 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 copy of this record has been provided to the well owner.
repair under#2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having_thesame You may use the back of this page to provide additional well site details or well
construction,only I 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: /� (ft-) • For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths if different(example-3@200'an/dr 2�@l00') 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 casing,use ' "1 _ 1617 Mail Servvice:Center,Raleigh,NC 27699-1617
11.Borehole diameter: kit (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: 1 er • 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(gym) VI Method of test: f Pk 24c-For Water Sunoly&Injection Wells: In addition to sending the form to
..„, -- T - the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4 1 L Amount: 1•S ei-- 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
i

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:Permit 381505 Currituck / /
WELL PERMIT
PIN: 087A00001780009
.74
AL Be WWI 11.105:Int.HE 311 S&RinCES
Painters in PUblic Health
Owner: Applicant: •
Angela dkelly& David Games Carova Beach Builders
PO Box 175 2162 Salmon Road
Groveport, OH 43125 Corolla, NC 27927
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PO b
Location: •
Sao`
2050 Sandpiper Road
5 ! Ld r II 71 sae
viee ms I ...... ......... .... . •
"—WELL MUST MAINTAIf�t FE SE'MINIMUM FROM ANY * {r' �'°` �-
• PART OF'SEPTIC EilDAIR AREA'• • .
-WELL hAUST STAY AT LEAST 25 FEET FROM ANY BUILDING I �- 14.4_
FOUNDATION 4.
-WELL MUST BE INSTALLED BY-A NC LI9ENSED WELL DRILLER p b
T I
-WELL PERMIT MUST BE ON LOCATION DURING ALLPER!ODS 1103 i a 2 . _ 1 �.
OF WELL'INSTALLATION . . • 111111 `�! ,-. ,
_ I-CALL AT LEAST 1 BUSINESS DAY PRtOR FOR REQUIRED % �,
INSPECTIONS OF GROUT AND WELLHEAD w �< , r— � , O�
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Permit 13y: ',Ail. p': ;%' i. / ' Date:
• p" Hob- o
Certification By: Date:
Construction has been completed, a Residential Well Construction Record Form GW-la has been
submitted and inspections have been completed In accordance with 15A NCAC 02C.0300.

•
s .
THE AUTHORIZATION FOR DRINING WATER WELL CONSTRUCTION SHALL BE VALID FOR
A PERIOD 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. .
M1 •
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•TRE.APPLICATION FOR. . •• ,r ;; ;• ...~,
•.•:. DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT,:CHANGED,OR IF THE SITE :° : ' ',i. •.
. • ' • '•IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME VALID AND MAY BE ..".:, ;' • .
. SUSPENDED OR REVOKED. '• : ! :
- . -•Wheircontacting the Erivixonhtental•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 rinmbers between 8:00 a.m.and 8:30 a.m., , •
. ' Monday through Friday,except holidays. The office telephone numbers are: • •
Camden 338-4460 Pasquatank, . ....... . , 338-4490 •
. • Chowan • i . 482-6023 Pergni srts • 426-2100 . •
Curiituek 232-6603 • • Bertie .• • ' , 794-5303 '
Gates '•' 357-1380
• . Well'Contractors are responsible for notifying the Environmental Health O ices for grouting,inspection,well head .
inspection,and required water sarcipling. Drinking water wells must be inspeed and approved by a representative ' , •
of the Environmental Health staff before any portion of the installation is covered and/or used. •
i •
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE'THE DRINKING WAi•klt.WELL
. HAS BEEN CONSTRUCTED TO LEE STANDARDS 8.81'FORTH IN'THE REGULATIO tS,BUT SHALL IN
NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRIl KUNG WATER. . .
•
' , **Minimum Distances** • •
• •
Private Drinking Water Wells to: . • • '
(This listing is not all inclusive,please see 15A.NCAC.02C..0107 for complete listing)
• ,
I) Ground Absorption Wastewater Systems • 100 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-irrigation sites, . 100 ft• '
4) Water-tight sewage or Iieuid-waste collection of 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 bains 100 ft

. 4 ROY COOPER•Governor
, �= NC DEPARTMENT.OF i KODY H. KINSLEY•Secretary
1�#EALTHi�h
HUMAN HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
H �V SESERVICES,
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
June 2,2023
Angela Okelly&David Gomes
PO Box 175
Groveport,OH 43125
RE: Approval No.WWM1634
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2050 Sandpiper Rd.,Carova Beach,NC 27927
On June 2,2023,the On-site Water Protection Section received your request to approve construction of an irrigation .
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 2050 Sandpiper Rd.,Carova Beach,NC. In
your request,you indicated that due to 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