GW1-2022-01488_Well Construction - GW1_20220126

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
7 77 t 77'.1-:7., 7777777777,
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L .14::';'YA3�R7ANES
t1A 'S FRObt I TO I DESCRIPTION
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Well Contractor Name fit ld fit q re y f.-I f w-lr
4) 1,115 L o fL 20 fL c(ectr Ad S&C11
NC Well Contractor Certification Number 15;OUTER CASING
FROM I TO I DIAMETER I THICKNESS I MATERIAL
(40VA LLG -4 t I (-I ILI < Vq m. Jek yo FV(
Company Name J 16INI RCAS000RTi3MG: _ �s
2.Well Construction Permit#:347 3�l W W M/3o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fir.U1C.C-ouniy..1'tate.Variance.err.) ft ft is
fit in.
3.Well Use(check well use):
;17:SCREE�i'i" ;:-- s t:. .::_.:•`.°r;r..aa:;•��,,-�.•�.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/public '1 ft Zb Pt !1� i"• [O >s Gk�{0 ('VC
Geothermal(Heating Cooling Supply) Residential Water Supply(single) fL fl. in.
Industrial/Commercial Residential Water Supply(shared)
l _..
Irritation FROM TO 'MLATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL I fL - A Vw6 r tn�e�
Monitoring ©Recovery fL ft_
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drainage �(i fL Z( fL {i2 jp Ot,.rrt
Experimental Technology Subsidence Control tt ft
Geothermal(Closed Loop) Tracer 20 I3ItIILING:tOG`attk adiliflana€aheetgi
FROM TO DESCRIPTION(color.hardness,soiltroek am etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) tL
fit [C� ft bra wit %dja
4.Date Well(s)Completed: 11 %f tt Well ID# fL fL �e
5a.Well Location: ft. ft
gee+ ♦ DC K Ise 54rc i yick fit fit
i •a F
Facility/Owner Name Facility iD=(if applicable) ft. ft �'
.2033 SmK•trud we Rd, Care 11lA . ZZ4Z7 ft ft.
Physical Address.City,and Zip ft. ft
C. 087A0000ob0006q I;lRlc� '
County Parcel Identification No.(PIN) ^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one latAong is sufficient) 22.Certification:
3V 30' to N
Is' zazz
6.Is(are)the well(s)GYPermanent or Temporary Signature dfCoffified II CondEctor Date
13v stl;ning this form.i herehr rertifv that the wvell(.$)was(were)cwurrurted in accardanre
7.Is this a repair to an existing well: ©Yes or 13No with 15A NCAC 01C.0100 or/5A NCAC 02C.0206 Well Consrrurtion Standards and that a
If this is a repair,fill out known well ronstru riion information and explain the nuture of the ropy r rthis record has been provided to the well owner.
repair under#21 remarks section 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: '�tS (ft-) 24a• For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 5' (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 Iniection Wells: in addition to sending the form to the address in 24a
,A above,also submit one cope of this form within 30 days of completion of well
(i.e.auger.rotary.cable,l direct push.etc.)method: i►�tAC 12.Well construction construction to the following:
Division of Water Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ZV Method of test: 945 r�i? 24c_For Water Supply&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: kffL Amount: 1•S�Z. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qualit%-Division of Water Resources Revised 2-22-2016

5y� s
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
January 10,2022
Robert&Denise Stredrick
19061 Quiver Ridge Rd.
Leesburg,VA 20176
RE: Approval No.WWM1304
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2033 Sandfiddler Rd.
Corolla,NC 27927
Dear Mr.&Mrs. Stredrick,
On January 7,2022,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 2033 Sandfiddler 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.
W W W.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

Permit: 367384 Currituck rrn xvn 1 L K
WELL PERMIT
PIN: 087A00000600009 ��
ALaEMARLE KECIONAL HEALTH SERVICESPamtaa in Public i IOaltf,
Owner: Applicant:
STREDRICK ROBERT&DENISE ENGLISH TIMOTHY J
19061 QUIVER RIDGE RD 6470 KNOTTTS ISLAND RD
LEESBURG,VA 20176 VIRGINIA BEACH,VA 23457
Location:
2033 SANDFIDDLER RD ATLANTIC OCEAN
Silk. 9 i.a-' 6o
VMWMU8T MOATAIN 30PV+"UM 31LIltItNG FOUNDATION/ re—KVV6 ,I .
-WBLLTMUST MAIMt'i'0 0100 FROM'ANY. #A*+Ot=SEPTIC SYSTEM•' - `,fit,
,AND REPAIR AREA' .�
-WELL MUST SE INSTALLED BY A NO OERTIPiED WELL DRILLER. z
•W6NL PERMIT MUST 13E ON LOCATION DURING ALLPEFttQDS'' to ? f
4F WELL.INSTAGLATlQN U `
-CALL'AT LEAST 1 BUSINESS.DAY PFitQ RE�R t.itREr,
INSPECTIONS OF GROUT AND WELLHEAD
-- ran
-EXISTING WELLS)MUST BE PROPERLY A$Ak4DONEM AND•. 3 8@OkOOM/
PROPER FORM AU13MITTED INTO THIS OFFt�E
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SANOFICOLER ROAD
Permit By: , Date: 01/07/2022 a
e
Certification By: Date:
y Construction has been completed, a Residential Well Construction Record Form GW-1a has been
submitted and Inspections have been completed in accordance with 16A NCAC 02C.0300.

THE AUTHORIZATION FOR DRITNMG WATER WELL CONSTRUCTION SHALL BE VALM FOR
A PERIOD bF 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�T�;APPLICATION FOR• ;
.' DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE IN•CORREC•T;: HANGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHROR.IZ.ATION SHALL BECOME INVALID AND MAY BE
SUSPENDED OR REVOKED.
When contacting the Environinental-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. Ue office telephone numbers are:
Camden. . .. . . . . . .. . 338-4460 Pasquotank. . :...:.. . . . 338-4490
Chowan. . . . . . . . . . . . 482-6023 Perquimans. ..... . . . . . . 426-2-100
Curiituck. . ... . . . .. . . 232-6603 Berrie. . . . . . ..... . .. ... 794-5303
Gates. . . . . .. . . . . . ..... 357-1380
Wail Contractors are responsible,for notifying the Environmental Health Oftices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspe:&d and approved by a representative'
of the Environmental Health,staff before 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 8ET FORTIi IN THE REGULATIOVS,BUT SHALL IN
NO WAY BE TAKEN AS A GUARATEE THE QUALITY OF THE DRIN1WG-WATER.
**Minimum Distances**
Privata 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,drainfteld,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 U:iderground 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 . ... . .I. ,... . .... .I ... ... . . .. . .. . . . 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) Su4face water bodies which act as sources of groundwater recharge,
such as ponds,lakes and reservoirs .. . ... .. ... ... ... ... . . .. . .... . . 5D 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) Animal barns . . . . . . . . . . .. . . . . .•.. . . . . . . .. . . .. . . . .. . . ... . . . . ... . . 100 ft