GW1-2023-01012_Well Construction - GW1_20230125

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i.Well Contractor Information:
Tl tM,� l J . EV1 1 ra� -a4 wXTER
FROM TO DESCRIPTION ,
s� Well Contractor Name ft. ft. browvleo(or smell
q1O tor 1.! V fL 1,5 fL I,Me_ t"A�Gi (iMe
NC Well Contractor Certification\umber ISiOiIfERCASI1iGfdi:utalticssed- E)R' iR' °" '
FROM TO DIAMETER THICKNESS MATERIAL
Caroya Serv►tc ov+dl (.oNs{rvtt,�io n l.L� ft ft. It PSG -
Company Name 1 / -16 13MR
J f y�7S r w 1 W FROM TO DIAMETER THICKNESS MATERIAL
2.WeII Construction Permit#: I-V V V� N � ft. in.
List all applicable well construction permits(i.e.UIC'.County,State.Variance.etc.)
ft ft in
3.Well Use(check well use):
WaterSupplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MpATERIAL
lGeothermal
gricultural 6VResi
unicipall?ublic ft ft 7 rrL ,e la Ste[q, PVC
Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft in.
ndustrial/Commercial Residential Water Supply(shared) -
1€aGRO[I '-i x .e
FROM TO MATERIAL EMPLACEMEITMETHOD&AMOUNT
rdization
n-WaterSupplyWell: 0ft �l8 &IBred
Monitoring 13Recovery ft. fLection WeII: fL fLquifer Recharge Groundwater RemediationAquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENNT METHODAquifer Test [3StormwaterDrainage fL fL Z5;gg4xperimental Technology Subsidence Control ft ftGeothermal(Closed Loop) Tracer 20.XRMLING:LOG attach"eddbtliiis'B FROM TO DESCRIPTION(wlor.hardness,willruck situ,eta)
(Hearin Conlin Return) Other(explain under=21 Remarks) fL
4.Date Well(s)Completed:144 ZZ Well ID# ft. M �ttaC
Sa.Well Location:
fL ft
(�onc�ld Cusan
Facility/Owner Name Facility ID" ft' ft JAN 2 5 2023
ft. fL
230 I)Lea11 Pearl U , Corolla . Z7g 27 ,
Physical Address.City.and Zip 1' '
CtAIL D�I�02gdD!(t10L'1 N1111i��
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:
b 3 ° 32, tour N 15-a 5-Z( 26t( W fi �,� lz ZoLZ
6.Is(are)the well(s)�ermanent or [Temporary Signature Ceni Well naac[or Date
13y.signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [dNo with 15.4 A'C.AC 02C.0100 or 15A NCAC 02C.0200 Nell Construrtian Standards and that a
-1f this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair Larder#21 remarks section or on the barn 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `f (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200 and 2 r@100') construction to the following:
10.Static water level below top of casing: -3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use'•-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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
1-2.Well construction method: Awq a r 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� Method of test: C-&f PIAM f 24c.For Water Suably&Iniection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: TL Amount: '•$ dZ. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qualitv-Division of Water Resources Revised 2-22-2016

Permit: 374408 Currituck
PIN: D87AO290011000{ = KNELL PERMtT
AL3P.1ARLE IU,5w\!L HPAL:M SER110ES
Pamvn•R?cal'ie H¢dllh
Owner: Applicant:
Ronald Cason Ronald Cason
6476 Knotts Island Road 6476 Knotts Island Road
Virginia Beach,VA 23457 Virginia Beach,VA 23457
Location:
2304 Ocean Pearl Road
la R Lo-r t
WELL MUST htA1NTAIN 2PFT+FRAM BUILDING FOUNDATION f D�GK,YR]�j
WELL MUST MAINTAIt t'50+FRONI'ANY PART OF SEPTIC 3YSTEt61
AND REPAIR AREA
-WELL MUST BE INSTALLED BY AMC CERTIFIED WELL DRILLER- ,
-WELL PERmrr'iLIUST BE ON LOCATION DURING,ALL PERIODS"
OF 4VELL;NSTALLATION OCEAN PEARL ROAD
-CALL'AT LEAST 1 BUSINESS DAY PRIOR FOR RECIUIRED N00'00 00"W 100.00'
INSPECTIONS OF GROUTAND VVELL-HEAD
PROPOSED, .�
WELL AREA.-
PROPOSED 2 p
h i � BEDROOM
(56 x24)
L 20'J 24'
Ij,3 W
/7' O
O ' 50 69
O �
All
s� a
v ?
SOD-00.00 E 100.00'
Permit By: Date: 04/25/2022
Hob e l
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 A NCAC 02C.0300.
t.

ROY COOPER•Governor
HEALTHAND
W DEPARTMENT-OF KODY H. KINSLEY•Secretary HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
MARK T. BENTON o Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 30,2022
Ronald Cason
6476 Knotts Island Rd.
Virginia Beach,VA 23457
RE: Approval No.WWM1518
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116 ;
2304 Ocean Pearl Rd.
Carova Beach,NC 27950
On November 28,2022,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 2304 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 applicable law,rule,or regulation that
may be regulated by other agencies,nor does it-imply'sutfcient water quality.
If you have any questions regarding this variance,please contact Wilson Mize at(919)-270-9665
Sincerely, n(�
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