GW1-2022-10162_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information: C VE
- Well Contractor Name ' C 1 FRO O� ft DESCRY
T� o�k4 J . English IPTIO,
Aed
/� Q(� Q N O V l �0,�2022.i,.. � f
�l i O l ft ft
NC Well Contractor Certification Numbertty
L_ .�, �� ..15..01 ER CAMG for:�ti-issW
A Co►1S{YUG 'i FROM TO DIAMETER THICKNESS lU'T/ERIAL
r01/A S ttry�K OfYtO. n ft ft ( to s[j2 I PV G
Company Name q 1�q ,�/�
3CJ > 1 �jv�f`6 ' � FROM CASH R F3$IPiME
2.Well Construction Permit T: a�' FROM TO DIAMETER THICKNESS MATERIAL_
List ail applicable well Construction permits ti.e.UIC.COunrv..State.Variance.et�- ft ft
3.Well Use(check well Ilse): ft ft is
Water SnplyWell:
P FROM TO DIAMETER SLOT SIZE, THIChN'FSS J MATERIAL
Agncultural n. unicipzI.Public ft ft I/ in.
Geothermal(HeatinsCooling Supply; residential Water Supply'(single) fLft. is Cis I
Indus-rhallCommercial Residential Water Suppiy(shared) 18 ROiF1
Imeation FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
IcGeothermal
n-Water Supply Well: fL 7
Monitoring ©Recovey ft ; ft
ection Well:
quifer Recharge QGroundwater Remediation ft ft
19.SANDfGRSk
quifer Storage and Recovery oSalinin Barrie; FROMTo MATERIAL EMPLACEMEVT METHOD
quifer Test OStormwater Drainage ft. L61 It
i Z
xperimental Technology Subsidence Control ft ft
eothermal(Closed Loop) OTracer 20.D7 S12fGLt att�had
(Heating,'Cooiin Return) Other(ex lain under=21 Remarks) FROM To DESCRIPTION(eobnhardoe$soiVroek sia ec)}r
ft fL
hrgaq SQJ,,:f
4.Date Well(s)Completed: Well ID# I ft I ft
5a.Well Location: r) IL
[ 3 ft P4 L ft ft re w it
Fac m ry iliirvlov,ncrNae FaciliTD=(if applicable.) ft- ft
(ci`.7 ! N , Cero11.L, ZZ ( 7,1 ft fL
Physicai Address.City.and Zip ft. ft
Lt~rr(+uc-V- OYgA0011)0tY os
County ?arcel Identification No.(PIN) AddedAew we 1142 G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fieid.one latilong is sufficient) 22.Certification-
6 za` N �s° s� ` zr° W
- D zo22-
6.Is(are)the well(s)GYPermanent or 13Temporary Sienatwe of erin \'yell ncacror Date
liy signing this form..1 herelr:cer:f'that the lvell(s)was(were)raastrucled in arcordanre
7.Is this a repair to an existing well: [OrYes or MNo tvilh 15A A'CAC 02C.0/00 or 15A 'CAC 02C-.G2M,Well Construction Standards and that a
if this is a reoair.fill out known:veil rnnstru.ton information anti e.:plaui:he r lure r f the ror)of this rerorl lists been provided to the well mvner.
repair under#21 remarks senior,or on the bar.:of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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 ofweils construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: zo (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
P'or multiple wells list all depths if different(example-3g200'and 2�@L106') construction to the following:
10.Static water level below top of casing: Yi (ft.) Division of Water Resources,Information Processing tint,
If water level is above casing.:ae.. " 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: L (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
/� above, aiso submit one cop, of this form within 30 days of completion of well
12.Well cot method: �uGC{� construction to the following
(i.e.auger,rotaastruction ry.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) "� Method of test: C-9 Gt f kKf 24c-For Water Suppir&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: TL Amount: 1.$ dL completion of well construction to the county health department of the county
where constricted.
Form GW-1 North Carolina Department of Environmentai Quaiin-Division of Hater Resources Revised 2-22-2016

Permit: 382639 Currituck
PIN: 099A0010005000,5 WELL PERMIT
Atlantic Ocean�
AiHmA LE FLeGt6�nlxHe�h+seRvltes JKKN
�
Owner:
CORY, PHILIP MOTHY
2001 KILT DRIVE S ISLAND ROAD
FINKSBURG,MD 21048 ACH,VA23457
Location' F—L&N.V.Sy CWA
1957 SANDFIDDLER ROAD "a)
=WELL.MUST MAINTAIN OitFE&T MINIMUM FROM ANY
PART OF'SEPTIC SYVrEM/REPAIR AREA
. :. .�_ .,•,fit . . .: 'ri. _
-WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING
FOUNDATION at .. r .:�.s•
-WELL MUST BE INSTALLED BY•A NC LICENSED WELL ORILLER
_db fM_jV G1MA Setlrack j' '
-WELL PERMIT MUST BE ON LOCATION DURING ALLPERIODS p.
OF WELL INSTALLAPOW
Rebrtllf lfrade ._' �� ___
-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED
INSPECTIONS OF GETOUT AND WELLHEAD � +•_� _
1�01�0
-EXISTING VUELL(S) MUST BE PROPERLY ABtAMDONED.AND.
PROPER FORM SUBMITTED INTO-rHIS•OFFIGE W444-L
10'walkway !� m -.27.0' 1
Per M.B.3,Pg.54—\� ..13.R I �` �8.0 c Ic :.
t.O ! Dwafhag
�; 1 14.0 1;.t 10
8 t 93.0' T' '-` I �•
co
_ In
i'• �� __ 4.• c 1.� Ili ,., ___.
...... 30:Q` $
100
AL
0.8'eohwGam. ....3..- -.
Sar;:dEddler load
Send
Unimprovedved Sand Roadway
Permit By: Date: 10/19/2022
Hob - oe
Certification By: Date: _
Construction has been completed, a Residential Well Construction Record Form GWAa has been
submitted and inspections have been completed in accordance with 15 A NCAC 02C.0300.

ROY COOPER •Governor
NC DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTH AND
HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
MARK T. BENTON •Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
October 25,2022
Philip Cory
2001 Kilt Dr.
Finksburg,MD 21048
RE: Approval No.WWM1489
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1957 Sandfiddler Rd.
Corolla,NC 27927
On October 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 1957 Sandfiddler 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.
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH
LOCATION:5605 Six Forks Road, Raleigh, NC 27609
MAILING ADDRESS:1642 Mail Service Center, Raleigh, NC 27699-1642
www.ncdhhs.gov • TEL:[phone] • FAx:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER