GW1--03889_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tifto}ki J . Evtglish 14.WAM Z0'M
Well
�Con¢Qa�cttoorrNamme FROM TO DESCRIPTION .�
ft- fL E jk "e
.g fL 1 fL a roa I;f-F a 5Pt,e t!
NC Well Contractor Certification Number -
_ e OIIJTER--CAMG�fia:inniti'iased::.
C41,0ya Sawa aV4 / „Sy_ 'L 0 Q LL� IRON � TO � DIAMETER t� THICKNESS MATERIAL
Company Namery•Q0� jT�{AW►t + 3 / S-_ o^ (�•c
3�ggoJ yV��L� :F6:1NNERCASl3 $'�IIBII+IM MATERIAL
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC.County.State-Variance,err.) ft ft. In.
3.Well Use(check well rue): ft. ft. in.
WaterSnpply Well: 17.,8CRP,Y1+lz ;:�:w ,��' .. ::x ..�- >9�..�� �F•rsi,=,�r ,�-..z=F.�,:_
IFROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
N
gricultural [3 unicipal/public (�3 fL f. i t in. 'ickO � tlG
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. �
ndustrial/Commercial 13Residential Water Supply(shared) g'GRUG3=.. , .._•-:: ?. ".x
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: ft- 13 ft ? +w Po;A red
Monitoring ©Recovery ft. ft.
ection Well:
ft. ft
quifer Recharge Groundwater Remediation
1g;!3ANDIGBtSYIP=tIiCK if `r + w2 quifer Storage and Recovery Salinity'Barrier FROM TO MATERIAL EMPLACEMENT METHOquifer Test [3StormwaterDrainage °j ft I 54t�xperimental Technology Subsidence Control ft. fLeothermal(Closed Loop) Tracer '.:28:DI2III1tfGLOG attFROM TO DESCRIPTION(mlor.herdne$.soivrmk A=etc)eothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
(9 fL IL e-OWt'l
4.Date Well(s)Completed: ^3 2D 23 Well ID# ft 1 d ft •re i'I%Sam
Sa.Well Location: to ft ft 44
fL IL a�/ lv Sfe
Facility/Owner Name Facility lD:(if applicable) ft. ft.
2-13 3 Ocean Pearl ?A, Co ro 16, 2712,1 fc ft
Physical Address.City.and Zip ft. ft
GrAr>ri`} DFS"1 AQCibSvl ':< ::
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field.one latllong is sufficient) 22.Certification: to
3(cr• `� .�61V N 1 S 9io 5I 50 W aragon, rars*64
llAi
'�`l S Who 2
6.Is(are)the well(s)iirPermanent or Temporary Signature of Certified Tell Coprracror Date
13v.signing this form.1 hereby certify that the ivelks)was(were)coaviruried in accordance
7.Is this a repair to an existing well: ®Yes or EfNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the ropy ojthis record has been provided to the well owner.
repair tinder#21 remarks section or on the bark of this farm. 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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (ft.) 24a- For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2d@100� construction to the following:
10.Static water level below top of casing: `/ A) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"-" 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
AU
�1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method rrM4R� 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) 'z Method of test: (Fts PkMof 24c.For Water-Suimly&Injection 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: J7kTL Amount: I•S dt 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: 378885 f
Currituck
WELL PERMIT ate& "vim
PIN: 08ZA0000 2500013
i
Owner: AC68MA REG195NAL 1m ��'+1LTH SERA ICCS Applicant:
rant'
Health
Sicario Properties Sicario Properties
PO Box 1.76 PO Sox 176
Moyock, NC 27958 Moyock, NC 27958
Location: S!°45 i?0"E. 10Q 00,
2133 Ocean Pearl Rd
woo-
WRLOMUSt MAIN AIN�p"T+FROM BUILDING, PQUt4oA'i'I*/ve-A YU6
WELL MUST"NTAf,E+t` #PROKANY Pm+OF 92PTtC SYBTrzit :-
WELL 'MUST SS INSTALLED 8 Y A.NG calmF1ED WELL•'•DRILLER• �
WEt,PBRMi1'MUST BE ON LOCATION pURiNCti�CI.L.PEftIQOS'`
OMELL.INSTALLATION -
•GCALLAT LEAST 1 BUSINESS.OAY PRi109 FoiR RE(161RE0
POOL W/
INSFECTIONS OF GROUT AND WELLHEAD• 20540'CONC
SURROUNDle
a
c 0 0 0 0 O .C. 0000 40
I C 4 O - o PARKINO
PROPOSED
DWELLIlVfQ FLOOD-9
;N Ptx
ON PILINGS
SOIL DRIVE-'
Nt°45'00'W 'Imoo,
A4'PE LA
wwc r-rCj-&,,v
Permit By. Date:
08/29/2022
Pr
Certification By: Date:
i
Construction has been completed, a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed In accordance with 15A NCAC 02C.0300. J�

THE AUTHORIZATION FOR DRINXING WATER WELL CONSTRUCTION SHALL BE VALID FOR i.
A PERIOD OF 66 MONTHS AFTER THE DATE OF ISSUANCE.
The issuance of the Certification of Completion in no way guarantees the issuance of other local,state or federal
permits.
The issuance of a Permit for Well Construction in no way guarantees the quality of the drinking water.
Wastewater systems and water supplies shall meet state and/or local regulations.
NO CHANGES IN THIS DOCUMENT ARE ALLOWED UNLESS PRIOR:APPROVAL IS OBTAINED FROM
THE HEALTH DEPARTMENT.' IF THE.iNFORMATION SUBMITTED..IN•TW.A1 FL-ICATION FOR• 7
DRINKING WATTIM WELL,CONSTRUCTION IS FOUND TO 13E NCORRECT,'a_ NGED,OR IF THE SITE
IS ALTERED,THE CONSTRUCTION AUTHR.ORIZATION SHALL BECOME 1�,TVALID AND MAY BE ,
SUSPENDED OR REVOKED.
When contacting the Environmental Health office concerning this document,;be.sure to.know the application -
munber. The number must be-used in all ingdnes and inspection requests—
'The
.
'The Environmental Health Staff can be located at the following telephone numbers between 8:00 a.sn.and 8:30 am.,
Monday through Friday,except holidays. The office telephone numbers are:
Camden. ... . .. . ... . 3384460 Pasquotank. . . ... 338-4490
Cho' . . . . . .. . .. . . 482-6023 Perquimans. . ..-. . . . . 426-2100
Curzituck. . . . . . . ... . 232-6603 Berrie.. .. :. ....... 794-5303
Gates. .. . . . .. . . ... . 357-1380
Well'Contractors are responsible for notifying the Environmental Health Offices for grouting,inspection,well head
inspection,and required water sampling. Drinking water wells must be inspZ - d and approved by a representative '
}
of the Environmental HealtU staff before any portioxi of the installation is covered and/or used.
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE-M DRINKING WATER WELL
HAS BEEN CONSTRUCTED TO THE STANDARDS 8PT FORTH IN THE REGMATIOVS;BUT SHALL IN
NO WAY BE TAKEN AS A•GUARATEE THE QUALITY OF THE DRIl XIN(3 WATER.
**Minimum Distances"
Private Drinking Water Wells to:
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
1) Ground Absorption Wastewater Systems.. . ... ... ... ... . . . . . . . . . . . 100 ft
(includes existing septic tank,drainfFeld,.repair area, Q
_ or area permitted for an on-site wastewater system that has
not been in�falled,and a designated repaii ar-�o�hat system) -��_—�- ---- - ---
2) Other Subsurface Ground Absorption Waste Disposal Systems .. . . .. . . 100 ft.
3) Industrial or minicipal sludge-spreading or wastewater-imgation sites . . 100 ft
4) Water-tight sewage or liquid-waste collection or transfer facility.. . . . . . 50 ft
5) Chemical or Petroleum Underground Storage Tank... . ... . . .. . . .. . . 100 ft
(does not provide secondary containment)
6). chemical or Petroleum Underground Storage Tank.... ... . . . . . . .. . . 50 ft
(does provide secondary containment)
7) Spray or Drip Irrigation Site . .. . . ... .. ... ... ... .. ... . . . . . .. . . . 100 ft
(or any other under 15A NCAC 02T)
8) Building Foundations,excluding the foundation of the structure
housing the well head. .. . . .. . ... .. ... .. ..... .... .... .. .. .. . .. . 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
such as ponds,lakes and reservoirs .. .. . ... .............. .. ._. . . . 50 ft '
10) All other surface water bodies,such as brooks,creeks,streams,rivers,
sounds,bays and tidal estuaries. 25 ft
11) Animal feedlots or manure piles . . . . . .. .... . .... ... ... . . . . . . . .. 100 ft +
12) Animal bains . . . . . . . .. ... . . . . . .. .. .. ... . . ...... ... .. .. . . . . . .. too ft

u
ROY COOPER•Governor
DEPARTMENT.,C?.F KODY H. KINSLEY•Secretary
HEALTH AND
HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
May 23,2023
Sicario Properties
PO Box 176
Moyock,NC 27958
RE: Approval No.WWM1624
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2133 Ocean Pearl Rd.,Carova Beach,NC 27927 -
On May 23,2023,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 2133 Ocean Pearl 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.
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 Wfls6n 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