GW1-2022-03227_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Infotm1ation:
^`� V lit Ill
FROM TO DESCRIPTION
Well Contractor Name ft �2 1 era G I- lrf0►I
cICAr- li-me— --mllt�lr s
NC Well Contractor Certification Number 45'.OUTER CASING fora
_f / 1O �J / FROM TO DIAMETER THICKNESS MATERIAL
Car-bv& Servt� avtp� CdrtS C�' liU ( fL ft in-- -�' l Z doh qv i PUL
Company Name �( 2 16 1NId£it GA� '[(3B -y r.F 3r .;
2,Well Construction Permit#: 3 3 5 02$ " W W Rt 3 J-(�L FROM ro DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(i e.UIC.Clo .State.Variance,err.}
R ft in.
fL fL in. -.
3.Well Use(check well use):
�..�
Water Supply Well: I FROM I TO DIAMETER SLOT SIZE I THIC6NESS� MATERIAL .' !
Agricultural 13M nicipaltPublic , ft
Geothermal(HeatingiCooling Supply) Residential Water Supply(single) 'L fL in
Industrial/Commercial [3Residential Water Supply(shared) SGROLFIN..
Irrigation FROM TO MATERIAL I'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It Z IL rbr/ffdN.t�
Monitoring ©Recovery ft fL
Injection Well: fL fL
Aquifer Recharge ©Groundwater Remediation _
-19.SANDlGRAi f. ..... ry
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEtvTMVMOD
Aquifer Test [3Stormwater Drainage 1 7 h- Z/ 0-
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20:D1tB Id1VG:LOG attar ndddiiiiffAi e4s if
Geothermal(Heatin Coolin Retum) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION(ol harilnesill wil/rock t1M triftsta eta)
't o fL Z fL Wr
4.Date Well(s)Completed: a Well ID# ft. 3 tt pet
Sa.Well Location: C.
i A'u�iP� �urOhY u ft.
- 1 S-1 _
Facility/Owner Name p—� Facility lD_-(ifapplicable) - ft - 1
��5 J �CP,un ►Cfi'r� � �'Wa , 2"Yq,7J1 fL fL 1
Physical Address.City.and Zip fL ft
Currl`�uvk, 09'lAb14061g060 REifFA1t1C5 _ _
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lav1ong is sufficient) t t� 22.Certification:
0 3 r 30 ii N 7 S° 3Z Z8 ' W ��/ ��
Z�Z2
6.Is(are)the well(S) Permanent -or [3Temporary Signature oKenifiveWell,00ritractor Dar
t All
By signing this form.l hereby rertify that the wrll(.$)was(were)construrted in accordance
7.Is this a repair to an existing well: ❑Yes or [!�No with 15A NC'.4C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and char a
If this is a repair,fill out known well construction information and arplain Me nature nj the rope of this record has been provided to the well nwner.
repair under#21 remarks section or on the hark of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/l 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: SLBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aD —(ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifjerenr(example-3@200'and 2 t�u'100') construction to the following:
10.Static water level below top of casing: v3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise" 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
above,also submit one cope of this form within 30 days of completion of well
12.Well construction method: At-)U✓ construction to the following:
(i.e.auger,rotal cable,direct print etc.) V
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: 6_0 � �•For Water SuDnly g Injection Wells: In addition to sending the form to
yW the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: + Amount: �`li �.1 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
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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
a... February.25,2022:,
Angie Murphy
1929 Pleasant Ridge Rd.
Virginia Beach,VA 23457
RE: Approval No.WWM1329
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2353 Ocean Pearl Rd.
Carova Beach,NC 27927
Dear Ms.Murphy,
On February 24,2022,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 2353 Ocean Pearl Rd.,Carova Beach,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 of to`your responsibility to comply withanyother''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