GW1--03885_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ti 1.o+kv J • Ev►A i(b{l1 'dT R` T7.O1V�S DESCRI
FROM PTION
Well Contractor Name 2 ft. 12 ft
{ V 1 V 115 fL ?,.W fL [ift caice61°w4 low
NC Well Contractor Certification Number CASAiiG fia�
SSi'i9L�:S nreltittisedd.' 13R,.
,'FROM TO DIAMETER THICKNESS MATERIAL
CaC01(A 5,erVC(A py4 „S 0 Q ` 1 t it. 9 fL i Ij in. S L� f V
Company Name Y 6 F p
2.Well Construction Permit#: FROM To I DIAMETER I THICKNESS I MATERIAL
ft List all applicable well construction permits(ir.U1C'.Cbunre.State.Variance.etc.j ft in.
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3.Well Use(check well use): ft _ ft in.
W8terSupplyWell: FROM TO DIAMETER SLOTSIZB THICKNESS MATERIAL
Agricultural 611eltice'ntial
unipallPublic fL ft 11 in- ,0(0 � YG
Geothermal(Heatine1Cooling Supply) Water Supply(single) ft fL in.
Industrial/Commercial r n W ter pp � shared) �fl�,..- .. .. ;_r-,.<. _. -:.::-
Irri tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOU'NT
Non-WaterSnpplyWeII: ff11 O fL S fL ?✓f'�0?11'f6iu 5Af2d
Monitoring ® 44- 9 U 3 M ft
Injection Well: ft ft
Aquifer Recharge C�Pig� lt�E�foe4t�c + - -n.>s
Lc��� ��g ��11 SeYNDtGRiSYIs1:R.k€:K:£ii`
Aquifer Storage and Recovery 13Sai t r FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage t S IL W fL it&; 4� O4-ad
Experimental Technology Subsidence Control fL I ft
7.R
Geothermal(Closed Loop) Tracer `W..#)RMI.II4(s:Lt3C: _r^
FROM , TO DESCRIPTION(-[-hardness,soil/tock - sin-eta)
Geothermal(Heatin 'Coolin Return) Other(explain under=21 Remarks) fL ft. WYI.
SQ
4.Date Well(s)Completed: U 2-3 Well ID# ft ft re-
ft
5a.Well Location. ft e-
'� e fL ft- 3 ft Zo fL l�
Facility/Owner'Name Facility ID (if applicable)
/'� 7 ft ft
ig g 5 d � r co ro lta 27q�1 ft fL
Physical Address,City.and Zip
asl6000020&3 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one IzVong is sufficient) ( t 22.Certification:
<3GO 31 SS f, N 75-0�,5Z 2r W
6.Is(are)the weli(s)epermanent or 13TemporaU
Si�iature ofCe fled We ce r te on Da
1 y signing this form.1 hereby certy�-that the well(s).vas(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or do with 15A.VC.AC 02C.0100 or 15A NCAC 02C.020 Well Consrrurtion.Standards and that a
1f this is a repair,fill out known well construction information and erplain ih.:nwure of the ropy of this record has been provided t t the well Owner.
repair under»21 remarks section or on the hack 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.
i
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _f (ft•) 24y, For All Wells: Submit,this form within 30 days of completion of well
For multiple wells list all depths if different(esain{ple-3@200'and 2@1001 construction to the following: '
10.Static water level below top of rasing: 3 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above rasing.use" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. lD (ia) 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
12.Well construction method: construction to the following:
(i.e.auger.rotary_cable,direct push.etc.)r
Division of Water Resources,Underground Injection Control program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l 13a.Yield(gpm) 0 Method of test: "S Pk� 24c•For Water Supply g Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b Disinfection type: I L Amount: •S dz- completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016
Form OW-1North Carolina Department of Environmental Qualir%-Division of Water Resources i
I

ROY COOPER • Governor
NC DEPARTMENT OF KODY H. KINSLEY•secretary
HEALTH AND
HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
HUMAN SERVICES
P1 MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
May 22,2023
David&Kristen Lodge
6049 Walking Path Ln.
Midlothian,VA 23112
RE: Approval No. WWM1616
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2278 Sandpiper Rd., Carova Beach,NC 27927
On May 22,2023,the On-site Water Protection Section received your request to approve construction of an
irrigation 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 2278 Sandpiper Rd.,Carova Beach,NC.
In your request,you indicated that due to 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.
I
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.nodhhs.gov • TEL:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER