GW1-2022-08255_Well Construction - GW1_20220826 (2)

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'~ WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Y4_?IKATER;7
0
NE4
TI"D l FROM TO DESCRIPTION
Well ContractorName fL to fL yfG isrAd
(41 0 lct 8 ID IL to fL deaur Ij441C Sw►t 1t
NC Well Contractor Certification Number
I5:°OUTER:CASING`fo=3nalttaaaD.'
����, St�✓I��Q ��5*wc , FROVf TO DIAMETER THICKNESS MATERIAL
{1 IL t-1 fL 1 ll�, i° �►t,ia eye,
Company Name t 1 ..-
2.Well Construction Permit#: U5MqW W•f l�O FROM TO DIAMETER THICKNESS Y MATERIAL
L in.
List all applicable well construction permits(i.e.UIC.Counn..State.Variance.e1r.)
fL
fL ft. in.
3.Well Use(check well use):
Water Supply Well: I FROM I IAMETER SLOT SIZE' THICKNESS A MATERIAL
TO D
Agricultural nrcipal/Public ft_
fL t tJ in. �(O `(t o PvG
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL in.
Industrial/Commercial Residential water Supply(shared) 18GROi1F.
Irrigation FROM TO MATERIAL EMPLACEMEN-r METHOD&AMOUNT
fL ft.
Non-Water Supply Well: �011. /Nf R
Monitoring 3Recovery ft. fL
Injection Well: fL fL
Aquifer Recharge ©Groundwater Remediation
�19SeYNDTGRilk'EIEA�K'ifa" -able
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft Zv ft � 'S'L� Ared
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 20:-DRILLINGLOG attich`adtiflio
FROM TO DESCRIPTION(mler turdness.willrmk sia.etc)
Geothermal(Heating/CoolingReturn) Other(explain under=21 Remarks) 0 fL b fL ( kt L r0 wk YwLd
4.Date Well(s)Completed: ?/ Z Well ID# 4 ft L fL rC SI 14-'f it w0I
Sa.Well Location: 11, It.
10
ft ver 4Md wl Skit(( Rakes
Ghris+o�ht� �a'r�0�► r ft ft
Facility/Owner;vame Facility ID-(if applicable) ft fL
;X240 l W. 6lwc fl-s k C re3 . Co rot la. L 7?V? fL ft.
Physical Address.City,and Zip IT. ft
C rr�'kt�t�k- OY7 oog0olo6w3 `Zii:REMAit1S& y . {k
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) �� 22.Certification:
3g° 1 ' t" N 75'° 51 c t W G $
6.Is(are)the well(S)(Permanent or 13Temporary Signature of'CertRieff Wellp6ntracrgF Date
By signing this form.1 hereb}•certifi•that the well(s)was(were)constructed in arcordance
7.Is this a repair to an existing well: 13Yes or 6No with 15A NCAC 02C.0100 or 15.4,VCAC 02C.0200 Well Consirurrion Standards and that a
1f this is a repair,fill out known well ronsirurtion information and explain the nature of the ropy of this rer•ord has been provided to the well miner.
repair under#21 remarks section or on the bark of this form.
23.Site diagram or additional well details:
You ma} use the back of this page to vide ad-4�_l rill ails or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same s
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attaN""_'ra9bT,f(ite ss_!
drilled: SUBMITTAL INSTRUCTIONS ��I r /e 7F1
9.Total well depth below land surface: 20 (ft.) For All Wells: Submit this form with n 3�dayCs of02Z Ietion of well
For multiple wells list all depths if different(example-3 200'and 2 t@100') construction to the following:
10.Static water level below to of casing: ft lfes,Info 1w A'^:JD9iC.y ing n tii1
P g� ( ) Division of Water Resources,Informr33to�ing Unit,
If water level is above rasing.use"••' 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
Amerbove,also submit one copy of this form within 30 days of completion of well
1Z.Well construction method: /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) 27 Method of test: I7b5 Pw41D 24c.For Water Supply&Injection Wells: In addition to sending the form to
�y� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C'1 L Amount: •s 611 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: 366624 Currituck
t 1 WFELL PERMIT
PIN: 087600400'L00003
AtaE,mquRCG(U�'ALWALTH$ERVIC15 �!
P.atmm in Public Health ,
_ I
Owner: Applicant:
cant: rr
MARION CHRISTOPHER MARION CHRISTOPHER
PO BOX 21 PO BOX 21
MANQU IN,VA 23106 MANQUIN,VA 23106
Location: ; ti
2261 W BLUEFISH CRES
-WELOMUST MAu rrw�,4 2 '* i kk.t7 N<�FQLJf�lt7A71a�1/ �G, 2S
-WELL UST MAIKT-AlW5G+Fk0'1'A-A•'1Y PART OF SC. fSC SYSI�M
AND( PAIR AREA
.vVEU MUST BE INSTALLED 13Y A NC CERTIFiEIj.tNELL DRILLER N
LOCH 1 ION DURING AL4 PERinQS
_p��1;,L PEt�MtT MUST BF.,ON
OF WELL IN$TALLA71ON
\\ •Sy�o w
.CALL AT LEAST 1 5USINESS DAY,PRIOR-%OR REQUIRED \
NNISIVECTIONS OF GROUT AND WELLHEAD
-EXISTING WELL(5) MUS F PROPERLY AgA�IDOA{ED AND
PROPER FORM SUGM-ITTV)INTO THt$O—lCF_
5'MINglNrgfN
\ $U� &67,41
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• \ \ `�' Spa
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IV P
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EPr
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Permit By: 'T • - Date: 11115/2021
RAJ
Hoyof Joe
Certification.By: Date:
ConstrucBon 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 DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FURil
�.
A PERIOD OF 60 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.
Wastewater systems and water supplies shall meet state and/or local regulations.
..No CHANGES IN THIS DOCUMENT ARE.ALLOWED'UNLESS PRIOR APPROMAL IS OBTAINED FROM
.:THE HEALTH DEPARTMENT.' IF THE.INFORMATION SUBMITTED IN T APPLICATION FOR, r<
DRINKING WATER.WELL CON'STRUCUON IS FOUND TO BE INCORREC I°,'CIiANGED,4R IF THE SITE
IS ALTERED, THE CONSTRUCTION ATITHRORIZAT.ION SHALL BECOME INVALID AND MAY BE . .
SUSPENDED OR REVOKED.
When contacting the Erivironinental•Health office concerning this documcht,be:sarre to know 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: ;
Cainden.... . ... . ... . 338-446.0 Pasquotank. ..... :. . .. 338-4490
Chowan.... ... . ... . 482-6023 Perquimans...... .. . ... 426-2100
Curzituck. . . .. . .... . 232-6603 Berne. . . . ..... ... . 794-5343
Gates.. .. . ... . .... . 357-1380
Well'Contractors are responsible for notifying the Environmental Health Ofices for grouting inspection,well head
inspection,and required water sampling. Drinking water wells must be inspe fed and approved.by a represeiitative '
of the Environmental Health staff before any portioti of the installation is covered kind/or used.
r ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS gpT FORTIS IN THE REGULATIOtTS,BUT SHALL 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)
1) Ground Absorption Wastewater Systems.. .......... ... . ... . . . .... 100 ft
(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 PetroleumUnderground Storage Tank.... I.. .. .. . . . . .. too 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 structum.
housing the well head. .......... . ... .. . . .... 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 feedlgts or manure piles .. ... ....... . .... .. .. 100 ft
12) Animal banns . . .. . . . .. ... . . . . . . . 100 ft

-•7`�Va:n to i
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 27,2022
Christopher Marion
PO Box 21
Manquin,VA 23106
RE: Approval No.WWM1402
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2261 W.Bluefish Crescent
Carova Beach,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 2261 W.Bluefish Crescent,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