GW1-2022-08249_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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� LDESCRIPTION
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Well Contractor Name W 1:
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NC Well Contractor Certification Number 1$;:Olr'mv r1 SING '
FROM TO DIAMETER THICKNESS;L';,ATER1AL
ya .Serve a►rtd Co K��Fri�c.'h 6h LC_G_ t 20 �( $�k `(0 t►c
Company Name `pDk-.f.�� il�./� . .:. :��.
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r wM g FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3� � W 1 01 fL � Iry
List all applicable well construction permits(i.e.U1C.Counn..State.Variance.err.)
fL fL is
3.Well Use(check well use):
Jater supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural WR
unicipaI/Public q ft. to fit. t t! in ,Ol S(h Ito G
eothermal(Heating/Cooling Supply) esidential Water Supply(single) fL fL in.
ndustrial/Commercial Residential Water Supply(shared) SifiAOiFF
lTisaLlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL Ito fL 3� w*a OLA
Monitoring D Recovery fL ft-
Well; ft. fL
Aquifer Recharge ®Groundwater Remediation _
::19iSAItiD7GRA3!€L:PA£K
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD11
Aquifer Test [3StormwaterDrainage �Q fL �.� ft t�`aQl�d 01(f��
Experimental Technology' Subsidence Control ft fL
Geothermal(Closed Loop) Tracer 28:DRiILIl1Ks`iit)G attaeh`sdffiEFs `' ;,
r sia,eta)
Geothermal(HeatinPJCoolin Return) Other(explain under=21 Remarks)
ks) ft. TO fL DESCRIPTION(color hardness,wiltz—k
4.Date Well(s)Completed: t62z Well ID# Io ft. ft re
5a.Well Location: 15 fL fL 6I1AI f(GalCeS
i� RYAn MCC14116M ft fL
Facility/OwwnerName e, Facility lD,1(ifapplicable) fL ft.
160 Ocean PpAr CarO��R Z 7le27 ft. fL
Physical Address,City.and Zip tL ft.
Cwrri fw�K I olAOlaool4o00l 21:I txs r t
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certiflcation:
3(,° vp I 5731/ N 7s0 Sd A &111/ W 77� (� Zo22
6.Is(are)the well(s) permanent or Memporary Signature of Cerri ed W9VContraMr Daze
Bti signing this form,i hereby vert f'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or E�No with 15A NCAC 02C.0100 or
I5A NCAC 02C.0200 Well Construction.Standards and that a
if this is a repair,fill out known well consirurtion information and erplain the nature of the ropy'of this record has been provided to the well owner.
repair under#2I remarks section or on the hark of this form.
23.Site diagram or additional well details:
You may use the back of this page to pr er-additigpakw�1.si a or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same " f
construction,only I GW-i is needed. indicate TOTAL NUMBER of wells construction details. You may also attach dOin��p� ee —T e�es�y.
drilled: SUBMITTAL INSTRUCTIONS AAII''�77 22 �
9.Total well depth below land surface: � A) �, For All Wells: Submit this form within 3D Ayso f?oompletion of well
For multiple wells list all depths if different(example-3@200'and 2 ttri`.100') construction to the following: s
{ih'3iift sw31 Pi* ,,�.G l:ng Unh
10.Static water level below'top of rasing: (ft.) Division of Water Resources,Iuformaia&VR1.o6eQag Unit,
If water level is above rasing,use'••" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. to (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/ above,also submit one cop; of this form within 30 days of completion of well
12.Well construction method: e r construction to the followine:
(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) IT Method of test:�s+4S �tf_ K►Q 24c•For Water Supply&Injection Wells: In addition to sending the form to
�- e the address(es) above, also submit one copy of this form within 30 days of
i"13b.Disinfection type: V, Amount: oZ. completion of well construction to the county health department of the county
where constructed.
Form GW-) North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Permit: 363866 Currituck
PIN: _10•A010001900 WELL PERMIT
At6EMARLERNI!5N IHEALTHSEPUICes
Owner:
Famisrs inftoc 1•teelth Applicant:
MCCULLOM RYAN MCCULLOM RYAN
1305 ROANOKE ARCH 1305 ROANOKE ARCH
CHESAPEAKE,VA 23322 CHESAPEAKE,VA 23322
Loci
1663 OCEAN PEARL RD ou soy 3 es,�£•scs _
Sec. l k.to larr I q
'5 W*'W fi*V-Jf"
1 .
•WrxLL-'MU8T MAiWAiN•W"+Fatlmiw 4:@ItitG FCUPIDAT qk! _ .65'M
-V4ML k1U3'F'NUtlNTAeMI;BOrr i Ftf A�tY PA4R OF SEPTIGMT-4*
AND•RF{PAJRAREA • ^� `
u;
•W1ALL MUST BE WsTkLiMW A NO 0I#ttlF(E15 WELL,ORI 0 tw
'•Z 'v,r•r ,y. i
WELL�Et iiAt l'MM��iiST am QN LOCxdoN DURING ALL t� IFia&k Barg �j
t�F WELL:iN$'F'M;U8tl "'' -"°t CS
-C6l.I..AT.LdA8T.1 RUS1 S PAY PRiQk-POR REQUIRED. t
040l;C,TIOI�3
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GE OF sow WwAo
OCEAN PEARL ROAD
foolUNIMPRO VED R/W)
Permit By: Date: 09/27/2021
obb ,
Certification By: Date:
Construction has been completed, a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15A NCAC 02W-00.

i
THE AUTAORIZATION FOR DRL IIfIl+iG WATER WELL CONSTRUCTION SHALL BE VALID FOR
A PERIOD OF 60 NIONTHS AFTER THE DATE OF ISSUANCE,
The issuance of the Certification of Completion wino 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 AR. -LOWED PRIOR A.PPRO-'y,AL IS OBTAINED FROM
THE HEALTH DEPARTMENT.'.IF THRINFORMATION SUBMITTEDIN'T R'APPLICATION FOR,
DRINKING WATER WELL CONSTR-MON IS FOUND TO BE INCORRECT,:CHANGED,OR IF THE SITE
IS AI;TERED,'THE CONSTRUCTION AUTHRORIZATION SHALL BECOME R VALID AND MAY BE
SUSPENDED OR REVOKED. �.
When contacting the Environmental Health office concerning this document,be-.sure to-1 now 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 am,
Monday through Friday,except holidays. The office telephone numbers are:
Camden. . ... .. . . . .. 339 4460 Pasquotank.. .... ; 3384490• ,
Chowan.: . . ... . 482-6023 Perquimans......... . .. 426-2100
Currituck...... . ... . 232-6603 Bextie.... :. .. .. . .. 794-5303
Gates... . . ..... . .. .'. 357-1380
Well"Contractors are responsible for notifying the Environmental Health OfTim for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspZ&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-M DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS!%T FORTH IN THE REGULATIOVS,BUT SHALL IN
NO WAY BE TAKEN AS A.GUARATEE THE EQUALITY 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)
1) Ground Absorption Wastewater Systems. ........... ...... .. . .. .. . 100 ft
(includes existing septic tank,drainfield,repair area,
Q
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 or 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. ..... .. ........ ................ ... . .. . ... 25 ft
Surface water bodies which act as sources of oundwater recharge, "
9} Surf groundwater
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 . . . . .. .. . ... . . .. ... ............ ..... .. . . . . . .. .. 100 ft

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
May 25,2022
Ryan McCullum
1305 Roanoke Arch
Chesapeake,VA 23322
RE: Approval No.WWM1401
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
1663 Ocean Pearl Rd.
Corolla,NC 27927
On May 25,2022,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 1663 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 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 applica>le law;rule,or regulation that maybe 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