GW1-2021-03298_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I'tM otki VCR I i s h
14Witt3ER'7ATIE$;
. . FROM TO DESCRIPTION
Well Contract m Contractor Name�� � 3 ft- la fL c ear l'Wa sM,,eli
(D ft Zo fL ear 40 -Ckk a rl
NC Well Contractor Certification Number 5-
FROM TO DIAMETER THICKNESS MATERIAL
Cc.t-oyG� 5ervl�e avld CoHsfruc�-►on + ft I ft l :N la sck 4� C
Company Name
53 5 3 5� VJ k/P�i l `�
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well eonstrurtinn permits(iz.UIC'.County.State.Variance,etc.) fL fL j try
3.Well Use(check well use): ft fL to
JNo
aterSn I Well: �PP Y FROM TO DIAMEMR SLOTSIZE THICKNESS MATERIAL
Agricultural [3 unicipal/Public 0 I_ ft. r fr. l� uL JArto PGeothermal(Heating/Cooling Supply) IResidentia]Water Supply(single) t0 fL pL NTIndustrial/Commercial [3Residential Water Supply(shared) SGROLiTIrri tion FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNTn-Water Supply Well: ft fL 31 red
MonitoringRecovery fL fLjection WeU:
fL fL
Aquifer Recharge QGroundwater Remediation
-19'SiYNDt�RAYtYi4S. h:.-
Aquifer Storage and Recovery Salinity Barrier FROM TO I !MATERIAL / EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft z r IL it�_ $a t r
Experimental Technology Subsidence Control ft. ft. i
Geothermal(Closed Loop) Tracer 28 DAIILElYt:1AG 4whF ih f#
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,w!Vr ek type,cmin sbr,etc
q4L.� LZVj o ft' fL G f b n H
4.Date Well(s)Completed: 1 I� Well ID# ft. / Z ft. ✓a ad s-,r
t;
Sa.Well Location: I L f. 2 ft. ra w 2 l ,tkes
(�• ft fL
kifbV
Facility/04ner Name f Facility iD0(if applicable) ft. fL
V Ea
Sol Coro((a oe Corolla VNI-7 f. ft.
Physical Address.City.and Zip R fL
CtArlrC4v C 115A Woo(*Zoo► / M2 M
County Parcel Identification No.(PIN) information Prout,51
UV V IN `+'
51b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(if well field.one]at/long is sufficient) 22.Certification:
fie° r91 yr N fl �S yg` S' s/
l W U
6.Is(are)the well(s)dermanent or DTempot'ary Signature of Cealffied W'_ ontra r Date
11y signing this form.I hereby certify that the vveil(s),vas(were)concrrurted in accordance
7.Is this a repair to an e7dsting well: ®Yes or J3No with 15A 1'L'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the ropy of this rerord has been provided to the well owner.
repair tinder#21 remarks sertion or on the hark of this farm. 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-i 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: ta0 (ft.) 2 4a, For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths i(dii ferent(example-3@100'and 2C100') construction to the following:
10.Static water level below'top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is abnve casing,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
r above,also submit one cope of this form within 30 days of completion of well
12.Well construction method: �kgC�lr construction to the following: j.
(i.e.auger.rotary.cable,direct push etc.) '
Division of Water Resources,Underground Injection Control Program,
E13b.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l Yield(gpm) Method of test: CGS huh�� 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
Disinfection type: LTG Amount: I s D Z. 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

K'K13
Permit: 355354 Currituck:
i
PIN: 115A00000620014 WELL PERMIT
I ,
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n f-rl tl P\
ALBEKARLERCG16NALHEALTH SERVICES
Parmers in PCblic Heeia, Applicant:
Owner:
KIRBY MARY P TIMOTHY ENGLISH
26 CREST RD 6470 KNOTTS ISLAND RD
MIDDLETOWN, NJ 07748 VIRGINIA BEACH, VA23457
Location: j
COROLLA DR ' AR
802 C BEACH;MAR IV L.L.C. .
SItG 4 DB, - 405, PG.-.764
OS'
wujv-goo4w .pig N.16°51'46"W —*- +r/O.OD FENCE
'—WELL MUST MAINTAIN FE&-T MINIMUM FROM ANY' 100.00, -
PART OF SEPTIC SYSTEMMgPAtR AREA
-WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING _ --- -- - _
FOUNDATION I fl
-WELL MUST BE INSTALLED BY-A NO LICENSED WELL DRILLER lay I s
-WELL PERMIT MUST BE ON LOCATION DURING ALL-PERIODS It
OF WELL INSTALLATIONZa
y
-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED {
INSPEC-rIONS OF GROUT AND WELLHEAD , }` 3
EXISTING WELL(S) MUST BE PROPERLY ABANDONED.AND. '-4: c> ;.--! ^ 4 r
PROPER =0R1V1 SUBMITTED INTO THIS QFFICE
0 0
T .
5Z
D 0` h1.h3k, - -
•,,-S 16' 1kWE
COROLLA DRIVE 6:Q' R./W
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Permit By: / l / /® Date: 04/05/2021
/Fkbbs, 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 NGAC 02C.0300.
i

THE AUTHORIZATION FOR DRINKING 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.
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 THE APPLICATION FOR• - • .
DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT,:CHA�tGED,OR 1F THE SITE
IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME INVALID AND MAY BE
SUSPENDED OR REVOKED.
When contacting the Environmental 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 numbers between 8:00 a.m.and 8:30 a.m,
Monday through Friday,except holidays. The office telephone numbers are:
Camden. . . . . . . . . . . . 338-4460 Pasquotank. . . . . . .... . . . 338-4490
Chowan. .. . . . : . . . . . . 482-6023 Perquimans . . . . . . . . . . . 426-2-100
Curritack. . . . . . . . . . . 232-6603 Bertie. . . . :. . . . . :. . . . 794-5303
Gates. . . . . . . . . . . . . 357-1380
Well Contractors are responsible for notifying the Environmental Health Oftices for grouting•inspection,well head
inspection,and required water sampling. Drinking water wells must be insp;&d and approved by a representative
of the Environmental Health staff before any portion of the installation is covered and/or used.
f
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIOI TS,-BUT SHALL IN
,TO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRINKING WATER.
"Minimum Distances"
Private Thinking 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,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 liquid-waste collection or 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 . . . . . . . . . . . .. . . . . .. . . . . . . . ... . .
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 . . . . . . . . . . . . . . . . .. . .. . A. . . . . . . . . 100 ft
12) Animal bams . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . :. . . . . . . . . 100 ft

�$v
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COHEN,MD,MPH
GOVERNOR SECRETARY
MARK BENTON
DIRECTOR
Onsite Water Protection Branch
April 13,2021
Mary P.Kirby
26 Crest Rd.
Middleton,NJ 07748
RE: Approval No.WWM1174
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
802 Corolla Dr.
Carova Beach,NC 27927
Dear Ms.Kirby,
On April 13,2021,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 802 Corolla Dr.,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,
j
{
Wilson Mize R.E.H.S.
i
r
6
WWW.NCDHHS.GOV
TEL [phone]•FAx [phone] I
LOCATION:5605 SIX FORKS RD•RALEIGH,NC 27609
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER