GW1--07411_Well Construction - GW1_20231117

i
i
iw2 k
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: , .
Ti+K o ln� J . En :FRw �
FROM TO DESCRIPTION
�.j Well Contractor Name • 5 ft. l l ft etarki b1,514i1 I s Ake((V
tit VI le swee(/
t( f` 20 ft r(e.ari ( 1"F __ _
NC Well Contractor Certification Number - S;:O1 FrER.C`/SING'(fo's: has d... [ j i,�.�,�tom-TA `° '
�nS{ o n �� FROM TO DIAMETER THICKNESS MATERIAL
Catrova Sevv z ate i' �- l!o ft 1 v4 . scbt qo 9vc
Company Name 1.&, .rASL ZIMBING lk , 'r. =; "rdf::
2 p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: q I ��O Z 11�vim3 R ft. ). , to
List all applicable well construction permits(i.e.WC.County.Stale.Variance.etr.)
ft ft l to
3.Well Use(check well use): .
17 ::rr;^ .1.g. .f:S ti..2:.t�k..-...:... ....,s�" •;f' CS .-,3.l2'.4.5
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public , ft- /9" ft j t�ci/ in- ad to SG.itgo PIT(
__ Geothermal(Heating/Cooling Supply) r v esidential Water Supply(single) ft. ft, in.
Industrial/Commercial °Residential Water Supply(shared) Itiw=GROIP£,. .:; : ;; r' 0 �rx ol
ln'isation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft (,(a ft-
1k-(xrrf-mr r co urea{
Monitoring ©Recovery fL fL
Injection Well: ft ft
Aquifer Recharge 0Groundwater Remediation �t h� �v a$j �;`
19.SANDl3RAV DPACI1'(iifapplicabte}
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage t( ft. zo ft feLSa,1 /eQ(wgskCef, pvure.c{
Experimental Technology 0SubsidenceControl ft. ft. I ,
1
Geothermal(Closed Loop) DTracer ;2WDRILLINGEOG attseht aFt ffi I'->no- i-I 'R- .kVfjg'
FROM TO DESCRIPTION(cobs hardness,soil/rock type,pram she,etc.)
Geothermal(Heating/Cooling Return) ()Other(explain under=21 Remarks) ft. l 44 f brown SastG{
4.Date Well(s)Completed: t if((/DZ3 Well ID# 5-- f(( f` t re.i l 7j4 //t-/'.
1( f. (2._ ft !r oe4' I-
5a.Well Location: / t-•ter r- (2 fL 20 ft 9 t'ey W/ ,r1•C�-V TT -',Fi'—s` .Cr,-,r--
KdY d �e►�n�/ 5 t Pt9° ft ft !( !! t '-r1 �.'z: V�lh'
`�' Facility/Owner Name Facility ID:(if applicable) .'
2 Lab Savictrcrer 1c244 i Core 1L 27927 ft ft. i. . NOV 1 s 2023
IPhysical Address.City.and Zip
-721V`.RL51ARKS- .. `. ;.t a ,, .f ; gA,ri{
Gurrl-1-IAcb- tit 7A6l 1oao'-/ooO2
County Parcel Identification No.(PIN) 1 t�" I~
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. rr one lat/long is sufficient) t fa:
22.Certification:
310� e��' ° N ° 5-1 Wrrl r Z 1
6.Is(are)the well(s) ermanent- or tiTemporary Signature of ed WeI on or Date
13y signing this form.I hereby certify,that the welr(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCA(.02C.0100 or/SA NCAC 02C.0200 1Vell Construction Standards and that a
If-this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided so the well owner.
repair under2/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 the same 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: 11 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30200'and 2 r@100') 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"-" 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 .
12.Well construction method: 41 eK
above,also submit one copy o this form within 30 days of completion of well
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) -l Method of test: �f Paw(' 24c.For Water Supply&Injection 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: 14TG Amount: 1.S dl- completion of well construction to the county health department of the county
— where constructed.
Form GW-1 North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 2-22-2016
.
i

•
Permit: 392782 Currit pck ' www.arhs-hc.org
PIN: 087A0120b04000: ' ' • • . . (L PERt4111T
• ALMA/ALE LE REGil NAtHEAI.TH StcvJcti I 9
Pumas In Public Health • .
PERMIT TO CONSTRUCT PRIVATE ' •
• • _ DIUNIUNG WATER WELL;' .
Owner: Applicant: '
. Randy&Penny Singo ' • Sicario Properties •
2190 Sandpiper"Rd 1.1 1 „ • , • PO Box 17.6
. • '' Corolla, 2792 • . • ' ' Moyock,NC 2795E , •
Location: - 1 • ' { •
2190 Sandpiper Rd - r v'�
F`• ee we l; 6a - 4 " y
!° •
.ep 4- Sy. tli .
•
ff. 1(.•eer ueli 13.'4- -4-Pm . . _
Any s.f-rva . , . //1. .
* Coasd 14- w:1-h Wei Di-tiler- , •
1: Flow+
ZL,wC •
1
i �r,�,',,, ,,
1
./#'1/'# k Sovl er-i •.
*'The well pump must be installed by a Licensed Well Driller,a licensed pump installer Level C or D, ,
or a Licensed Plumber with approved education within the last 2 years'on pump Installation and well
disinfection.Only a Licensed Electrician or Licensed Well Driller can wire the Pumps'
SHALL MAINTAIN 25FT+FROM BUILDING PERIMETER •
SHALL MAINTAIN 50FT+FROM ANY PART OF SEPTICIREPAIR AREA -
MUST BE INSTALLED BY CERTIFIED WELL CONTRACTOR - ,• '
PERMIT MUST BE ON-SITE DURING ALL PARTS OF THE INSTALLATION
CALL AT LEAST 1 BUSINESS DAY PRIOR TO GROUT AND WELLHEAD INSPECTION ,
"WELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FOR AT LEAST 24HRS PRIOR TO USE" •
Permit By: Cr/VI,. bate: :04/12/2023
Melton,Tucker -
Certification By:. - Date' •
Construction has been completed,a Residential Well Construction Recnni Form;GW la has been
submitted and inspections have been completed in accordance with 15A NCAC 02C.0300.
1 .

•
THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR A PERIOD OF 60
MONTHS.AFTERTHE 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 far Well Construction in no way guarantees the quality of the drinldng water.
Wastewater systems and water supplies shall meet state and/or local regulation's.
NO CHANGES IN.THIS DOCUMENT ARE ALLOWED UNLESS PRIOR APPROVAL IS OBTAINED FROM THE HEALTH
DEPARTMENT. IF THE INFORMATION SUBMITTED IN THE APPLICATION FOR DRINKING WATER WELL CONSTRUCTION
IS FOUND TO BE INCORRECT,CHANGED,OR,IF THE"SITE IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALT.
BECOME INVALID AND MAY BE SUSPENDED OR REVOKED,
- When contacting the.Environmental Health office concerning this document,be sure to bow the application number. The number must be
used in all inquiries and inspection requests.
The Environmental Health Staf€ff can be located at the following telephone numbers between 8:00 a.m.and 3:30 a.m.,Monday through
Friday,except holidays. The office telephone numbers are;
•
•
Camden 338-4460 Pasquotank 338-4490
Clown 482-1199 Perquimans 426 2100'.
Currituek .. 232-6603 Bartle • 794-5303 . . •
Gates 357-1380
•
•
. Well Contractors are responsible for notifying the Environmental Heal h.Offices for grouting inspection,well head inspcchon,and required '.
"Water sampling. Drinking water well iuiis"t•6e inspected aud"approved by a representativd of the Enviroiumentai Seale sliffbefore any
portion of the installation is covered and/or used. •
•
•
•
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL HAS BEEN ; ,
CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIONS,BUr.SHALL IN NO WAY BE TAKEN AS A'
• GUARATEB THE QUALITY OF THE DRINKING 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 100 ft
•
(includes existing septic tank,d{ainfteld,repair area,
or.area permitted for an An site.wastewater system that has
not been installed,and a designated repair area for that system}
—
• 3) Industrial or miniciipal lute-s sludge-spreading or waas,ewer-Irri'ation sites • 100 ft
p P g g
•
4) Water-tight sewage or liquid-waste collection ortransfer•facilitr'• ' 50 ft
5) Chemical or Petroleum Underground Storage Tank. • J:..3...,., '100 ft
(does not provide secondary containment)
. 6) Chemical,or.PetroleuumUnderground Storage Tank _ 50 ft •
(does provide secondary containment).
7)• Spray or Drip Irrigation Site 1Q0 ft.•1
(or any other under 1SA 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) Anithal barn 100 ft

'.' `" ROY COOPER•Governor
,.` z,'... f+� NC DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTHAND.
HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
�, MARK T. BENTON••AssistantiSecretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 6,2023
Randy&Penny Singo
2190 Sandpiper Rd. 1
Corolla,NC 27927 •
RE: Approval No.WWM1739 - - - -
Well Casedto Less Than 20 Feet—Rule 15A NCAC 2C .0116
2190 Sandpiper Rd.,Corolla,NC 27927
On November 6,2023,the On-site Water Protection Section received your request to approve construction of a
private drinking water 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 2190 Sandpiper Rd.,Corolla,
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 abandor 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-,qualitv.._ : ..,_, -- .__-._ _._:-
If you have any questions regarding this variance,please contact Wilson Mize at(919)-270-9665
Sincerely,
11 ).0.._.e_,.c e am Try,,,--,..,..
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:,'919-707-5874 • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER