GW1-2022-08255_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
_ri N.0+h,[ �t ���� Ye.wa ltzolrEs =. ..FROM I TO DESCRIPTION '1
6
Well Contractor Nome fL 0 fL d(fft ato✓ Sike l! Suf�v
LO fL Zo fL Clea✓ 1,MC SJkC116Yett
NC Well Contractor Certification Number L.I15;0VrER.CASING f*i
FROM TO DL►METL•it THICKNESS MATERIAL
(Rrova serv�'ce cKol CeKspruc�'ieK LI.G lit 'Ll17 fL t0 I-
soh PAC
Company Name �// Z�f �J't, 1y' 1SIlHH£R.GA$INGS6BIAI(f - -- „
2.Well Construction Permit#: t 1 �✓`�1 �"•—A4 Y `® FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e,U1C.County.Stare.Variance.eir.)
ft. fL in.
I, fL is
3.Well Use(check well rise):
JIarrigationter Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESSAgricultural qyunicipallPublic fLZufL1/4t"• � 010 O((0eothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
ndustrial/Commercial [3Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL frI fL jtf O Re red
Monitoring aRecovery fL fL
Injection Well: fL fL
Aquifer Recharge ❑Groundwater Remediation
=19.SAND7GRAVELFktiS ofa'
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
Aquifer Test 13StormwaterDrainage fL ZU ft. yo OtAred
Experimental Technology [3Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILIMI -,LOG atiffihstt�tloatFslieeisi '^
FROM
Geothermal(Heating/Cooling Return) M Other(explain under=21 Remark,) TO DESCRIPTION(colon hnrdoess,soil/rmk MM givin sin,ern)
0 r' fL roNM. swP4
4.Date Well(s)Completed: 4 T ZDZZ Well ID# fL fL /"t! n/W Sot
Sa.Well Location: Z fL M zo IL t w Its
�/ ,L fL fL
I` ;LlY-fie '1171 W �Qers
v Facility/Owner Name T— Facility ID,'(if applicable) ft fL
;X3$4 0ctaa SaKds Rcl, (,orolla, 7114L7 fL f.
Physical Address, ft.
CC4f r1• ss&z O 1 1 O i W / --2DRM1�11t1{CF
Countv 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° ?I' SUN N le 5l� Sg�� W
irk
6.Is(are)the wells) Permanent or [3Temporary Signature ofterfied WeIFContraeor Date
13v.signing this farm,1 hereby rert�4-that the wells)was(were)constructed in accordanre
7.Is this a repair to an existing well: ®Yes or SNo with 15A,N'C:AC 02C.0100 or/5.4,VC.4C•02C•.0200 Well Construction 57andards and that a
ropy o this rerord has been rewided to the well owner.
:1Jthis is a repair,fill out known well ronstrurtion information and erplain the nature of the n-' j p
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to prow a a(ldito al avel pit detai r well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same s o
construction details. You may also attach drroal�abe�fr(eqq�,_�
construction,only 1 GNAT-1 is needed. Indicate TOTAL NUMBER of wells v ��
drilled: SUBMITTAL INSTRUCTIONS n )
9.Total well depth below land surface: ( ) h' r 202 Z
�0 fit• 24a. For All Wells: Submit this form w'ithi days o completion of well
Far multiple wells list all depths if different(example-3 00'and 2@100') construction to the followin
g- ,J,;7',+anan ;dim'+;-,44 na un"
10.Static water level below to ��^-p of casing: 3 (ft.) Division of WaterResottrces,Inforrnatibit`.1yib¢Et3sr�'unit,
/f+vaier level is above rasing,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
12.Well construction method: prw6 C/
above,also submit one copy of this form within 30 days of completion of well
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) 2 W► Method of test: 6s p0k"O 24c.For Water SuDDIv&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: Amount: ot-• 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

permit:. 376324 Currituck
01700 b WELL PERMIT
PIN: b87 A 07 Obi
ALaEMMLEILWIPMALHEALTH SERVICES
PStmeB is Ptaviic Health
Owner: Applicant:
Sam&Kristin Rogers Sam&Kristin Rogers
112 Lighthouse View 112-Lighthouse View
Aydlett, NC 27916 Aydlett,NC 27916
Location:
2386 Ocean Sands Road
SrG 1 134K 17 LOT ?
443,0MUStlthAiINTA" iftK swmWe FOUNDATION/101110-K?V4
WELL>ftlU.ST MAN. Vj%Vj0 e'�tWM.Aw PAfk+OF Sa' ric 8Y8Tmm NOW52I7 J --r 100.00'
AND REPAIR ARON
AVELL MUST BE INSTALLED SY A NC CERTIFIED WtIL MILLER-
ANE, PERmrr mue BE ON LOCATION dURWO ALLi'MR C)S"
011-WELL,INSTALLATtON -- y�
-CALL'A'f'LEAST 1 ALSINESS DAY FR[OR FOR PledtJIRE5P
INSPECTIONS OF GROUT ANO,� €iwEO 9
l� 9.9 _... Iry
QS
'1 O
0 o ac.
(BENT ]
i
S09°W!rE -- 100.
S0145100"£(P)
_ SR —OCEAN SANDS ROAD~ r
(60 WADE R/W)
SR
Permit By: Date: 06/06/2022,
Aftbk
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 02C.0300.

THE AUTHORIZATION FOR DRINL EING WATER WELL CON8TRU'CTION SHALL BE VALID FOR
APERIOD OF 66 MONTHS AFTER THE DATE OF ISSUANCE. W
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 APPRO Y,A,L IS OBTAINED FROM
THE HEALTH DEPARTMENT.' IF TH&WORMATION SUBMITTED,IN T. -APPLICATION FOR, . ►� ; ...
.' DRINKING WATER WELL CONSTRUC'L•T0N IS FOUND TO BE INCORRECT,'C>IANGED,OR IF.THE SITE
IS A'L.TERED,THE CONSTRUCTION AAUTHRORI;ZATION SHALT:BECOME INVALID AND MAYBE
SUSPENDED OR REVOKED. "
ealth office concerning this document be.sme;to know the application
. When contacting the Erivironinental H g ,.
g
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..... .. . ... . 338-4460 Pasquotank. . ... .:.. . .. 338-4490
Chowan.: . . ... . . ... 482-6023 Perquimans. ..... ... .. . 426-2100
Curiituck.. ... . . .. . . 232-6603 Bertie. . ..:.... . .. . 794-5303
Gates... . ..... . ...: . 357-1380
We1 Contractors are responsible for notifying the Environmental Health Ofln-ces for grouting,inspection,well head
inspection,and required water sarApling. Drinking water wells 3 iust be inspe&d and approvedby a representative '
of the Environmental Healty staff before any portion of the installation is covered and/or used.
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL 11,1DICATE'THl3 DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIOVS;BUT SHALL IN
NO WAY BETAKEN AS A.GUARATEE THE QUALITY OF THE DRINK1NG'WATER.
"Minimum Distances"
Private Thinking 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, e
or area permitted for an on-site wastewater system that lias
not been installed,and a designated repair area for that system)
2) Other Subsurface Ground Absorption Waste Disposal.Systems.. .. :. . . 100 ft.
3) Industrial or municipal 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 yveli head. .... ..... .. 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
such as ponds,lakes and reservoirs... . ....... .......... . .. .... . . 50 ft r
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

3..
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
June 7,2022
Sam&Kristin Rogers
112 Lighthouse View
Aydlett,NC 27916
RE: Approval No.WWM1405
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2386 Ocean Sands Rd.
Carova Beach,NC 27927
On June 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 2386 Ocean Sands 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 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