GW1-2023-01013_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.well Connector Information:
Tinookk� J . English1 MWAMMZERROS
FROM I To I DESCRIM01
WelllWelCommctorName—f A m R OLXbrown/Sri sal/snei!
NIO-i B to R' 1b rRI1 nit SAIe ll
NC Well Cormvotor Cenlficaion\umber t��_L 11 is.OUTIM CASBPG Ir cog ORTAKERNilins �-
�AYIi{YMl+1't09 Ue� FROM TO DIAMETER THICKNCSS vtATER aL
raroya Smca .aA 1 R. I
ft
Company Name 31o5535 WWPA15xi 1s:.BV1�JtCA7g'o—a.aT18UM - -
2.Well CADStleCtiOn Permit#' FROM TO DUvfETE0. I THICKNESS MATERIAL
lint all applicab/ew itCOnstrurron permits his.UIC.Count.Nim Va"ure.el" + R 1-7 ft.
1t/ I. D VC-
ft ft n
3.Well Use(check well use):
jAquifer
er supply Well: FROM TO DIAME ER aLOTSIIE TXICA�$1E�$� MATERIAL
gricultural 13 rcipaLPublic Q', ft ft ( aI. �IQ 'IA-A VG
eothermal(HeatingiCooling Supply) Residrntiel Water Supply(single) ft ft in.
dustriaVCommercial DResiderltial Water Supply(shared) -_>{-
1 tion FROM TO yyNt.ATERIAL ENPLACE%IE]T/MECHOD&XM0
-Water Supply Well: O ft -� fr- 7Y {One I.ree1
onitoring Recovery tt fL
etiw Well: ft. a
Recharge OGroundwater Remediaion
19.SANQtGBAVBG.1tACS. ""'i�'T-3^'-.
quifer Storage and Recovery QSalinity Barrier FROM TO MA IAL EMMCU1GrtMEF80D
quifer Test OStormwsier Drainage (� ft L� ft Z R� oure
xperimenW Technology Subsidence Control ft rLeothermal(Closed Loop) OTractteothermal(Heain 'Cooling Return) 00ther( lain under=21 Remarks) Faom TO DESCRIPTION color.nwdae,mmmsa am
a.Date Well(s)Completed: l2 2 ZO2?Wen ID. TM Ib " e
Sa-WellLocation: f` t` Shad
.John MCN& h� ft. R
�— Facility/Owner Name Facility 100(ifiepplicable) EL R fL In. P�
"11 Oceah Pt1cr� , Cor°IIkE 21gZ7 ft. ft. �A
CE—
Physical Address,City.and Zip
651A 6t4 ably 6601
County Parcel Identification No.(PIN) k11OfFty�x
Sta.Latitude and longitude in degrsees/mioutes/seconds or decimal degrees:
(if well field one talons a sufficient) f f 22.Certification:
3� 31, 44 N 15' 52e 31 W T✓Z �� 12 7 Zo�Z
6.Is(are)the well(s)GParm m st or [3Temporerr Signature drCeoftd Well paean, Do
8v signing this fmm.I herabr cernfr that the we!lLrl twins fsven)amslruried mac w'darr.
7.Is this a repair m an esistl ag well: QYes or dNo with/5A SCAC 02C.0100 car 15.4 VCAC 02C 0200 Well Cansourimn Standards and iha a
your is a repair.fdl our brown well comwuri.zetrrma»n and erphun the aware ofthe ,pv nfrhr reward has been prnrided to the well nt xr.
repair under a21 remarks sertian w can the bark af1hu form.
23.Site diagram or additional well derails:
8.For Geoprehe/DPI or Closed-I-aop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,Only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SLBN=AL INSTRUCTIONS
9.Total well depth below land surface: A0 (ft-) 24a, For Ali Wells: Submit this form within 30 days of completion of will
I'nr ndlipineeli,lrt al depths ifdlfferem(example-3S200'and 2@100') construction to the following.
10.Static water level below top of casing: 31t (R) Division of Water Resources.Information Processing Unit,
/f rater level it above rasing.u e" 1617 Nail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. "' (in.) 24b.For In action Wells: In addition to sending the font to the address in 24a
/� above,also submit one cop) of this form within 30 days of completion of well
]2 Weltconstructiou method: 64 Cf construction to the following
(tc.auger.rotary.cable,direct push era.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: a 1636 Mail Senice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 Method of test: &*5 Pout e 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Lib.Disinfection type: µTA Amount: 1 e S 01- completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Enviromn ntal Qwlih�-Division of W'ucr Resources Revised 2-22-2016

F�,
CtKffttC.�Cil
!'� GH7.fDNN�-r:•
` 130GOOSELANDJNG "+art • Id9;f.1AlOMjjHN
*?�p�' .,�'° "-• ' VIRGIN+ABEACH.-VA 23k5i •1341 GOQt"SE ta1Pk[}INO � ..
,.. idINlABEA Bd5 r '�v
g
• ice''
pmt
y".; ,.tw�FouHo.,noc+l
a� n�,
uz.tu os •� s
'- � W�♦i NUbTI�ERJSt/St.1E^6Y/2`fitCr'Y"Fa-.�'R�-'E:53" . �t�1,�6R:,-'•,.•, ••-.,'a ya v {t....,.... n e a a}.
rr • '-I4fi:LP'�E3C7"36itKST EEOh3LdN$'1;iplrSLllJ�"�tNG AZL�EAtOIR'!*: ,mj � m �• ': � ,n Er ?e�
-gALLAT�1'f 6�iQ/'359 L§�lYi :F(7€�...REL�UIR
Y R.•
1'S d [. '4 d ♦ �a5 `' . 1 x .F.a � "A�«Mrx M` '.rt♦ � � S"i 4 1#,� rR.
fir. Y .r
_ o'7.n R. J+ ^g u ., r'H � "„ .ram ;x� i � L •�-4n � A Tx�
f 1 � ♦ i�
a
AQroOt
{a ;xt s'i r '!3+ Y �C� `3•Fi�.i.i'�$1.V r "'}. �
l
r,
pis s x ? ?,r; �' y x' *rzr ♦t ; �rs
�r x
�ltE• a { '�'U
Q COWth�S a R+ ierllbl U1�eD G
�dgndll}+ tiwtstm»b � iS �AGIC . .,,
p °w bbM
i ,t3
, v
r a-' ✓ 3'z+' "� � x ° rs r n4d"+ �� �'`*wp > w^v �ta�-�,�°*��°!r�".
x yl t h �d tM1.
f
4 b _ r tt L 4.Fp4^y^
�.�y7bi ��'�,x"'y »t��,�.r, y ,.�s '• { s 9 �-'�y x ' e � �'�� �„�'ry�� �� -
U
'" ,`rvw+� yr <i ep t. y S �i✓ tl t ���+�`� Y"w 4a': f�-`
g ^.

r ag6STAM a ' ROY COOPER•Governor
' ' O�n� NC DEPANTMENT OF
KODY H. KINSLEY•Secretary
HEALTH AND
HUMAN SERVICES HELEN WOLSTENHOLME• Inte(im Deputy Secretary for Health _
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
December 8,2022
John McNaught
1341 Goose Landing
Virginia Beach,VA 23451
RE: Approval No.WWM1522 _Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2377 Ocean Pearl Rd.
Carova Beach,NC 27950
On December 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 2304 Ocean Pearl Rd.,Caroba 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 stall,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. iA 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.
I
I
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.nodhhs.gov • TEL:[phone] • FAX:[phone]I
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER