GW1-2022-01142_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
FROM TO DESCRIPTION
Well Contractor Name
41 T9 R � � �2 ft n s;0
2 t` ZO ftI hr'►K�tk b�Otbs"I/
NC Well Contractor Certification Number _A11017M CASING fdr`midti J ' R
Carova SCfVC CC AAA C•011VfN44+ "41 FROM TO DIAMETER THICKNESS MATERIAL
is v pv C-
3625yZ WwM/Zgfo
Company Name ` _...._,
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits ti.e.UIC.County.State.Variance,err.) ft. ft to
3.Well Use(check well use): tt ft in.
WaterSn 1 Well:
Supply FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipaltPublic fL ley f_ ( 1 in- 01D $CpVC
Geothermal(HeatinglCooling Supply) 1Residential Water Supply(single) ft 0 ft in. e
Industrial/Commercial Residential water Supply(shared) —Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Vr ft ft � krCq
Monitoring ©Recovery ft ft
Injection Well:
ft ft.
Aquifer Recharge ©Groundwater Remediation
19'9ANDTtiRAY�:F-ilk:• __ . _ ...7-B'z:h��'?2�''sue=�_+`�=
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENTMEIFfOD
Aquifer Test [3StormwaterDrainage ( ft- Zd ft •u/rd
Experimental Technology' Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer %.28:1)RiI LINE:LGG blioels:R h ?v ?
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION(eabn iurdnesa soiUrock da ere
o f. ft
4.Date Well(s)Completed: Well ID# rL ft
Sa.Well Location: ft- 20 ft W
(� Joci Coppersm,A ft. n
Facility .7a
lity/�OwAr Name II e, Facility ID4'(if applicable) ft. ft
glo AdDikr �1�eI1R, 7i7lZI ft. ft
Phvsical Address,City-and Zip ft. ft
Cwrr,=4IAt:k 011A61106U 600 z =z1<R€ssalrxs
County Parcel Identification No.(PIN) DO SECT
04
Sb-Latitude and longitude in degrees/minutes/seconds or decimal degrees: UN
(if weell_field.one lat/bng is sufficient) 22.Certification:
Is lit I` N 15° SI` SDI f t W - �2 Ib
6.Is(are)the well(s)aPernianent or OTemporary Signature of trertifieo4Vell Co for Date
ay.signing this form,i hereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or GNo with/SA NC'AC 02C.0100 or/S.A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well ronstrurtion information and explain the nature of the ropy of this record has been provided to the well mvner.
repair under#2/remarks section or on the hark 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,oniv 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: I p (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Cx100'/a-nd 2]00') construction to the following:
10.Static water level below top of casing: G (ft.) Division of Water Resources,Information Processing Unit,
If water level is ahnve casing,use" V"//_� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) ?fib.For Iniection 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: A±ie( 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) Z'� !Method of test: 6ri 01 !4 24c.For Water SuoDly&Iniection 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: ram_ Amount: I A OL, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quatir-Division of Water Resources Revised 2-22-2016

Permit: s362542 Currituck
PIN: i R W I:L PERMIT
�.
Arrtwuc�
0wher: Applicant:
COOKE RICHARD REV TRUST COPPERSMITH jOEY
P 0,BOX 3037 . PG BOX 176
NORFOLK.VA 23514 MOYOCK,NC 27956
2204 SANDPIPER RD
vVeLl: � kry r, ff
LL tvnrsTat UN72FNsW*trp"•,,W P*f of softI.3YsTmm.'
ilvo REPAIR Mgx
AIM _
.L*USTBE liWAUX6 GY,A NC.CMIFIED WaL GRILLER• '""""""` ""�' -••�•�-M� •—e••».� ...r1..��m..
rr 14 u 8Q.4N LOGI1TfCN`E�tJKING i�.I.Pt�lt?Q9`'
OF WELL WAUATI t�{
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Permit By: Gate: Op/15/2021
Certification By. Date.. a
Constructlon has been compiated,a Residential Weft Construcbon,Record-Form G1N•1a has-been
'submitted and Inspeclict have.been completed in•accordance with 15 A MAC 02C,0300.
or

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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
December 16,2021
Joey Coppersmith
PO Box 176
Moyock,NC 27958
RE: Approval No.WWM1296
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2204 Sandpiper Rd.
Corolla,NC 27927
Dear Mr.Coppersmith,
On December 16,2021,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 2204 Sandpiper 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.
'Me-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 Iaws
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 t
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER