GW1-2022-01694_Well Construction - GW1_20220131

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatiio�on: I_
_n m���•U FROM TO DESCRIPTION
( Well Contractor Nam
lot L
q^5 fL ft
NC Well Contractor Certification Number
25i:Z)CTI`EIt.CASIIrIG math ".' OR•
FROM TO DIAMETER I THICKNESS I MATERIAL
CGrs✓a Servile And 6pejouehm U4, ft10ft. r, t In. Sek to 1!G
Company Name 2 4 16.-D R CASIN&M..
2.Well Construction Permit#'V nS 6oO^(6 WW� `3O(/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits li.e.UIC.County.State.Variance,err.) ft fL to
3.Well Use(check well use): FL fL to
Water Supply Well: Td SC REEI+[ v: ::: � � ```'
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3M icipaltPublic 16 ft. III t. 1/ in- iO S� Q PVC,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) is
Industrial/Commercial 13 Residential water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft n oL Mred
Monitoring ©Recovery R ft.
Injection Well:
fL fL
Aquifer Recharge ©Groundwater Remediation
,19:SA1�D1GRrsY�t;P�►�&:af'-` = �;, = t �. :r -a-_"
Aquifer Storage and Recovery [3Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft w ft. ift
Experimental Technology 13Subsidence Control fL fL
Geothermal(Closed Loop) 13Tracer wevattaehaddlmsPa tc
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(mton hwdoes,soWU k Mm vulzi size,et,-)
0 7 fL ow" saftd
4.Date Wells)Completed: %z Well ID# fL 17, fL re a__ J
Sa.Well Location: ` Z fL I E'
fL J ft.
' (Mark Ztlr►b►, I�ett►cv �iswas
Facility/Owner Name Facility ID#(ifapplicable) tL ft-
105 OcrAk Pe"I Kk C.relL rZI&I fL fL
Physical Address,City.and Zip fL ft
"rl+tAtaG lelk ell to 23 0 Qe! z� R> Rxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one]at/long is sufficient) 22.Certification: t l
3l/6 V" W s' N �1 50 Is W
6.Is(are)the wells) Permanent or [3Temporary Signature of rtified 1 Con ror Date
)dv signing this form,I hereby certify-that the wells)war(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or OJNo with/5.A A'C.AC 02C.0100 or IS.A NCAC 02C.0200 Well Construction.Standards and that a
If this is a repair,fill out Mown well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under#21 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,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: 9 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferew(example-3@200'and 2C100') construction to the following:
10.Static water level below top of rasing: (o (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. V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one cope of this form within 30 days of completion of well
12.Well construction method: y e✓ 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) .3� Method of test: L t*kee, #§o 24c.For Water Suonly&Iniection Wells: In addition to sending the form to
TT the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount. j/ d�_ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit: 360026 Currituck �CLHt,1!'>J� Af**%G
WELL PERMIT
PIN: 101A011002300VP I .
Al6EMARLG REGIONAL HEALTH SERVICES
Partners in Public Health
Owner: Applicant:
ILLMAN MARK/THOMAS, NANCY CAROVA BEACH BUILDERS, INC.
1676 CARTERSVILLE ROAD 2162 SALMON ROAD
CARTERSVILLE,VA 23027 COROLLA, NC 27927
Location:
1645 OCEAN PEARL ROAD
�,tc. I OAK 3
-WELL MUST MAINTAIN��F Mlt�!lMUIN FROM ANY'
PART QF'SEPTIC SYSTbjI t&&kIR ARE
-WELL(VI LIST STAY AT LEAST 25 FEET FROM ANY BUILDING
FOUNDATION
-WELL MUST BE INSTALLED BY'A NC LICENSED WELL DRILLER S 16'52'�`E
-WELL PERMIT MUST BE ON LOCATION DURING ALLPERIODS r 40aw
OF WELL INSTALLATION PROPOSED SEP77C SYSTEM , - 1 ,
-CALL AT I.cAST 1 BUSINESS DAY PRIOR FOR REQUIRED (3) 54' LINES 0 9' O.C. , r — � �" (VACANT) I ,
INSRECTIONS OF GROUT AND WELLHEAD (480 CPO CAPACITY) I ,
Q �tL
$N ..q W iD 45.0 ut
okay
PROPOSED 111 2 Q�I y
4 BEDROOM DWELLING g' FUTURE
(480 GPD CAPACITY) " ,t25 43.0 POOL
,0' I ' AREA
N.• gg.5�4d51' ' (r �gg ..J '
E• 29T4H � � ,�'
100 0U'
PROPO ED N 16'42'46 If
CONCRETE PARKING
& DRIVE _
N ROAD
.:J,•.•+�- . : -:•� ., t i0p 6¢IC hYl�T-tlf'-WRY(�& 3,P� ?).::,.
u-u..��.._.."a4 r>:-�:: :Tom. '' •_tij�,•._ 7�..�� �'3�:-:'. __=~' r_i
Permit By: 1 Date: 06/21/2021
H oe
Certification By: Date:
Construction has been completed, a Residential Well Construction Record Form GWAa has been
submitted and inspections have been completed in accordance with 16A NCAC 02C.0300.

.rsX�rf y
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
Mark Illman&Nancy Thomas
1676 Cartersville Rd.
Cartersville,VA 23027
RE: Approval No.WWM1308
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1645 Ocean Pearl Rd.
Corolla,NC 27927
Dear Mr. Inman&Ms. Thomas,
On January 10,2022,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 1645 Ocean Pearl 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

THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR
A PERIOD OF 66 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.
i:.
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
Fil[ HEALTH DEPARTMENT; IF THE INFORMATION SUBMITTED 1NTHE APPLICATION FOR
DRTNkIN'G WATER WELL CONSTRUCTION IS POUND TO BE INCORRECT,CHANGED.,OR IF THE SITE
'IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL BECOME INVALID AND MAYBE
SUSPENDED OR REVOKED.
raVhen contacting the Environmental Health.office concerning this document,be sure to knave 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 Pasquatank. . ... ..... :. 338-4490
Chowan. . . . . :. . . ... 482-6023 Perquimans . .... . ..: . . 426-2100
Currituck. . . . .. . . .. . 232-6603 . • Bertie. . .. .... . .. . . 794-5303
Gates. ... . . . . . . . .. . 357-1380
Well Contractors are responsible for notifying the Environmental Health Offices-for grouting-,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspected and approved by a representative
of the Environmental Health staff b6fore 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 SET FORTH IN THE REGULATIONS,BUT SMALL IN
NO WAY BE TAKEN AS A GUARATEE THE QUALITY OF THE DRINKING WATER.
**Minimum Distances**
Private Drinking Water Wells to: '
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
-
(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 6r 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. . . .. . . .. . . . . . .... I . . . . . ..... .. .. . . . . I .. . 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
such as ponds,lakes and reservoirs . . ... . . . .. . . . ... . ... . . .. .. . . . . 50 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 . . . . . . . . . . . . . . . . . .. . .. . . . . . . . .. ... ... . . . . .. . .. . 1 100 ft