GW1-2022-10322_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J . Eng ia:W. wNFs .♦ : ,:,
FROM TO DESCRIPTION
Well Contractor Name ft ft
q f g9 S [Z ft 'IV ft you+ ode( law coioe
NC Well Contractor Certification Number ay;Q(IIlrR CASIIIIG.ra;:m�h aai pg£
/' l.0lASTsiwfrO A ✓�` FROM TO DIAMETER THICKNESS MATERIAL
I-Ova sefy t e a + ft. i- ft L ` in PVC,
Company Name 1 - _-.
��,a��3 �w M l�,oZ 1ti:Il�N£RCAS11i}G�R'IIISING:(.__t - I-
2.Well Construction Permit a: FROM To DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits ti.e.UIC.Counn.State.Variance.etc.) ft ft in
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM TO r 'D AI METER SLOTSIZE i THICKNESS I L W rrye MATERIAL
Agricultural 193unicipall'Public -7 ft. •90ft G` S'i. in- ,e 6o q6- pVC
Geothermal(HeatinglCooling Supply) esidential Water Supply(single) ft I� f
Industrial/Commercial 12Residential water Supply(shared)
Irrigation FROM I TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft ? "}L el
Monitoring ORecovery ft. ft
Injection Well:
ft ft
Aquifer Recharge ©Groundwater Remediation
14:Se1NDIGRAVU7T 1CK.if.'
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMIOTME I101)
Aquifer Test 13Stormwater Drainage to ft Za ft ayL �7
Experimental Technology' Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20::DRIL1MG:LOG attachaddld6nuFalis�
Geothermal(Heating/Cooling Return) r3Other(explain under=21 Remarks) FROM I To DESCRIPTION(color,hardness wiVrmk siv etc)
�` qq © ft s— ft • r sz
4.Date Well(s)Completed: �I c u2V Well ID# ft ft r rr 511
Sa...Well Location�: h £t 1 f
ben pie. V"i nSlow ft ft
Facility/Ow�nnerNaame A _1 /�� Facility ID-1(ifapplicable) ft. ft
Zito d,LoAeiper PUL.WYO[ &, rt rl ft. ft a va 1)f1
Physical Address.City,and Zip ft ft
Lurtr��uclL 0$1 AOcpO?-�4��ey`t
County 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:
p" Sot L1,31t N -75G,5-1/ 5-6'r W Ig v2
6.Is(are)the well(s)mlp�rmanent or [3Temporary Signature ofCertificPell Contractor Date
By.signing this form.1 herehr cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an erdsting well: ®Yes or allo with I5A NGAC 02C.0100 or 15A NCAC 02C.02Gf)Well Construction.Standards and that a
If this is a repair•fill out known Weil construction information and explain the nature of the ropy r f I&Y record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
y SUBMITTAL INSTRUCTIONS
9.Total well depth below land e: � ! (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd Brentsiren(example-3v100'and 2C/00') con st ction to the following:
10.Static water level below top of casing: FL (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 copy of this form within 30 days of completion of well
12.Well construction method: __ LUG Gib 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
4 13a.Yield(gpm) 1 Method of test: �Af P-At,.p 24c.For Water Supply&Infection Wells: In addition to sending the form to
• , e the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection TL Amount: •7 O-L 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: 364173 Currituck J
ALoexmRlERfGitiv;.lHc;ti!?H$tRvICLS WELL PERMIT
PIN: 067A0000206000� pamlBte tt Puulk Fleelth•
Owner: Applicant-
WINSLOW BENNIE CAROVA BEACH BUILDERS
4724 SCHOONER BLVD 2162 SALMON RD .
SUFFOLK,VA 23435 COROLLA,NC 27927
Location:
2118 SANDPIPER RD
S! 9 1.0r 2aG
•►�E.t,L,iVIf.fST MAtf�Ft'A�N•�'SPT+F1�dM:>>�tj�.ltxplLtljG FQUNdAT1A,N
•WEL.L.idVaT MAINT'AFN•'Sc+FROJUt,4?aWr PART.OF SEPTEC S'YS Gl r>
AND R41PAIR AREA ;•..•,• :,4
WELL MUST SE INSTALL-k613Y A NO OdlR CIE() U WGL ,+DR1"L
WEL',L'PEPMrr MUST r3.9 qM L4GA T iON DU,c�ilAiQ l\LL is RtQt<I — N 9'53 9'W lgap0
O WELL'Wb-fiA&TAtldg- ;-Q, ,L!-YAT.LEAST I EI ��N0S-
4 • $MAY PRW'R' Ft iCo
�Nsn crcoNs QF �' `f: §410?-WeLk 'SADCIS
a t
�d
se 28.a'
61
Ll
H ✓J H 1at�s�z s9'
SB E. 2921tS53.20'
x 6.8
— N 09'W,49"W
100.00' 5�9"f 100.00'Me)-
-SANDPIPER ROAD —.." ".',.. .1;,:;'' •r':
eS0'PUB(/C R/iftd[9. a P6 45)
Permit By: / !f! Date: 10/06/2021
b ,Joe
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 15 AACAC 02C.0300.

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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
June 9,2022
Bennie Winslow
4724 Schooner Blvd.
Suffolk,VA 23435
RE: Approval No.WWM1407
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2118 Sandpiper Rd.
Carova Beach,NC 27927
On June 8,2022,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 2118 Sandpiper 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