GW1-2022-01141_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
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FROM I TO 1 DESCRIPTION
Well Contractor Name t�
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NC Well Contractor Certification Number U..0117=GASI1tIG forum" VOW"
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Company Name
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2.Well Construction Permit#:'281 J^^J^ '�2-O v'f VJ'A 12, FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U!C.County.State.Variance,rtr.)
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3.Well Use(check well rue):
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural [3MunicipaliPublic ft- 13 fL in. -O(p N O \/-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) UT
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Itrieation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft (L ft yt be, je Ourfd
Monitoring QRecovery R M
Injection Well: fL fL
Aquifer Recharge [3Groundwater Remediation
19 SANDtGRiIYEI.
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMnTMETHOD
Aquifer Test [3StormwaterDrainage ( ft Ar fL #I-r4pot K
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) Tracer 38.1)RIIL1itCsIAG ttitaeh"ataltee4Sl€ 3
Geothermal(HeatingiCooling Return) 130ther(explain under#21 Remarks) FROM To DESCRIPTION(color hardness will k sta eft)
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4.Date Well(s)Completed: b Zez Well ID# ft. I ft. 4�
Sa.Well Location: tt. IL G Si 14 -
ft. ft
JAW 14 Moors
Facility/Owner Name Facility ID0(ifapplicable) ft ft
2310 •Fdw C 12e Rol, Coblts . ZHU fL fL
Physical Address,City.and Zip r ft. ft.
CA.trri Boltz O V Ao tl 0008o00/
County Parcel Identification No.(PIN) 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
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6.Is(are)the well(S) Permanent or OTemporary Signature o#Certiffed Well onoactor Dar
13y.signing tha form.I hereby cert�-that the well(s)wav(were)comtrurted in accordance"
7.Is this a repair to an existing well: 13Yes or �O with 15A VCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well ronsirux-4on information and e.rplain the na/ure of the rnny e),rthis rer•ord has been provided to the well owner.
repair under#21 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 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: I`f (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example.3@300'and 2 J00') construction to the following:
10.Static water level below top of rasing: (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: `i (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
A_ _ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Iii G� construction to the following:
(i.e.auger.rotary,cable,direct push.etc.)
Division of Water Resotirces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
f4w tAq 24c.For Water Supply&Injection Wells: In addition to sending the form to
�(T t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t'7 V Z.. 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

Permit: 281220 Currituck
PIN: 087AO2100080001 WELL PERMIT
AtnE V,A,;u Rrc 1,(-)N rr HEAL:11 Sublets
ne PerTrs in Public Health
Owner: Applicant.
MOORE JOHN H MOORE JOHN H
820 TULLS CREEK RD 820 TULLS CREEK RD
MOYOCK, NC 27958 MOYOCK, NC 27958
Location:
2310 FALSE CAPE RD so
Z 8 1 v: 7# -73
-WELCMUSTMAINTAIN FIT+F1FtEK1A BUILDING FOUNDATION K,Y (�
-- ... -
-WELL MUST MAINTA-04*50*FROM'ANY P'Afk+OF SEPTIC SYSTEMAND REPAIR AREA _- -
_.. -
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-WELL MUST BE INSTALLED BY A NC CERTIFIED WELL DRILLER -
-WELL PERMIT MUST BE ON LOCATION DURING ALL PEAIQDS' -_ -
-- - —
OF WELL.INSTALLATION -..._-. _ - -
-CALL'AT LEAST 1 B•USINESS DAY PRIOR FOR REQUIRED
INSPECTIONS OF GROUT AMD WELLHEAD _-- - - -•_.--.-
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Permit By: !?a , Date: 08/23/2019
log
Hobbs,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.

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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
November 10,2021
John H.Moore
820 Tulls Creek Rd.
Moyock,NC 27958
RE: Approval No.WWM1280
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2310 False Cape Rd.
Corolla,NC 27927
Dear Mr.Moore,
On November 10,2021,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 2310 False Cape Rd.,Corolla,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