WI0700031_Inspection_20210311

North Carolina Department of Environment and Natural Resources
Division of Water Quality — Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700031
DATE OF INSPECTION: 3/8/21
INSPECTOR: R. Sipe
NAME OF PERMITTEE(S) Anthony and Denise Canino
MAILING ADDRESS OF PERMITTEE 101 Channel Run, Washington, NC 27889
PHYSICAL ADDRESS OF SITE (if different than above) Same as above
PERSON MET WITH ON -SITE Anthony Canino; TELE NO. [phone]
WELL(S) STATUS:
XExisting and operating Class V Well
Existing well proposed to be converted to Class V well
Proposed/not constructed
LAT/LONG OF WELL(S) 35.494167N, 76.953056W (Inj. Well)
Appx. distance of well to property boundaries: 15 feet (Inj. Well)
Appx. distance of well from foundation of house/structure: _50 feet (Inj. Well)
Appx. distance of well from septic tank/field (if present): _84 feet (Inj. Well)
Appx. distance of well to other well(s) (if present): 150 feet to supply well
Appx. distance to other sources of pollution: None
Flooding Potential of Site: high moderate Xlow
Comments: Both inj., and supply wells appear to be in good condition consistent with findings of prior inspection
and operating adequately.
Injection Facility Insp. Report (Rev. Sept 2009) Page 1 of 4 Pages

Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of 4 Pages

See Attached Map
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanks/drain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
N/A (not determined during this permit renewal inspection)
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 4 Pages

Well Construction Information
Date Constructed: 10/27/2000
Well Contracting Company: _Taylor Well Systems
Well Driller Name: John Taylor
NC Well Cert. No.: _2435-A
Address:_2030 Taylor Rd., Chocowinity, NC 27889
Telephone No.: ; Cell No.:
Email Address:
Proposed Depth of Well(s):
Total Depth: _90 feet Total Depth of Source Well, if present:_80 feet
Casing:
Depth: 53 feet; Diameter: 4 inches ; Type (gay. steel, PVC, etc.): PVC ; Stick Up: 12+ inches ft
Grout:
Depth: Unk. (not determined during this permit renewal inspection); Type (cement, bentonite, etc.):_Unk. ;
Placement (pumping, press. etc.): _Unk.
Well ID Plate Present (Y or N): Y ; Heat Pump ID plate present (Y or N): N
Influent spigot (Y or N): Y
Effluent spigot (Y or N): Y
Well Sampled? (Y or N): N ; If Yes, Lab Sample ID numbers: N/A
Static Water Level: Not Measured
Injection Information (if applicable):
Injection Rate: GPM
Injection Pressure: PSI
Injection Volume: GPD
Temperature- Summer: F°
Temperature- Winter: F°
Comments/Notes: Both inj., and supply wells appear to be in good condition consistent with findings of prior
inspection and operating
adequately.
Injection Facility Insp. Report (Rev. Sept 2009) Page 4 of 4 Pages

Injection Facility Insp. Report (Rev. Sept 2009) Page 5 of 5 Pages