GW1-2021-02787_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:r
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FROM TO DESCRIPTION
�. well Contrsctpor�Name ! !_ I
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NC Well Contractor Certification Number I 15:OUTER CAMXG az:iaraiti
FROM TO DfADIAMETERTHICKNESS MATERIAL
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Company Name (� H�r tk yo F y(,
FROM TO DIAMETER .._.,.. _,_ _ '•- z a
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2.Well Construction Permit#: �J � w WrA`�� ETER THICKNESS ' MATERIAL
List all applicable well construction permits(ix.UIC.County.State.Variance.err.) It, It. to
3.Well Use(check well use): ft' fL in.
JNn
r Supply Well: FROM TO v DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
icultural C3Municipal/Public fL 7rJ tL i�j uL • T ��� f
thermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
ustrial/Commercial 13Residential Water Supply(shared(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water Supply Well: (� ft- 10 fL fi +u eeA
nitoring Recovery ft fL
tion Well: fL fLuifer Rechazge ©Groundwater Remediation
uifer Storage and Recovers �Salinrty BarrierFROM TO MATERIAL EMPLACEMENTMETHOD
uifer Test 13Stormwater Drainage "L I S�tglJ[ Nrerimental Technology Subsidence Control fL fL
thermal(Closed Loop) Tracer(Heating/Coolingothermal Return) Other(explain under=21 Remarks) FROM TO DESCR[FCION rnbnhoranas,sosltrock ern
o �E 0 lord s
4.Date Well(s)Completed: ? 4 Well ID# ft. it �kwr►kS
sa.Well Location: 10 tL 20 fL liqkf 4rev. w c6t/t
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Facility/Owner Name �^ Facility iD,(ifapplicable) D- fL o„
q65 Scoter Rd. Gorotik 2' 1?"1 fL ft.
Physical Address.City,and Zip It. ft. *�tl
Gu,rtrf4%cK ©iri7rA f+'t7ayto .. :_:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field.one lat/long is sufficient) 22.Certification:
36' 1.!� 21" N �S" S!+
6.Is(are)the well(s)�r nanent or 13Tempomry Signature o errifie 'ell CAFtractor Daze
By signing Mis form.I herein.certo-that the well(s)was(were)constructed in actaardance
7.Is this a repair to an existing well: 13Yes or No with 15A NCAC'02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a.
Ifthis is a repair,fell out known well construction information and erplain 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:
&.For GeoprobetDPT 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 OW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled' �yy� SLBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: et4i (ft.) 24a, Far All Wells:, Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example.3L200'and 2@,100`) construction to the followin
g'I
10.Static water level below top of rasing: 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,uve" 1617 Mail Service Center,Raleigh,NC 27699-1611
13r Borehole diameter. (in.) 24b.For Injection Wells: lit addition to sending the form to the address in 24a
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above,also submit one cop\ of,this form within 30 days of completion of well
1Z.`WeII construction method:_ Awter 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: /e 1636 Mail Se y'ice Center,Raleigh,NC 2-16"-16M
tTw t } 23a.Yield(gpm) Method of test: a F16�!�_ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, alsoRsubmit one copy of this form within 30 days of
136:Disinfection type: 147C Amount: t•S OZ completion of well construction to the county health.department of the county
where constructed,
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Form GW-i North Carolina Department of Environmental Quality-DiNision of Water Resources Revised 2-22-2016

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MILLER GREG MILLER GREG
131 CIQLDCREST DR
131 GOLDCREST Dft
ChESAPEAKE,VA 23325 CHESAPEAKE,VA 2
2021'MIDLAND RD
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COHEN,MD,MPH
GOVERNOR SECRETARY
BETH LOVETT
ACTING DIRECTOR
Onsite Water Protection Branch
January 23,2019
Greg Miller
131 Goldcrest Dr.
Chesapeake,VA 23325
RE: Approval No.WWM846
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2021 Midland Rd.
Corolla,NC 27927
On January 22,2019,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 2021 Midland 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 27609r
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER