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Home My WebLink AboutGW1--04724_Well Construction - GW1_20230721 r. WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only: • 1.Well Contractor Information: i Tifto-Vi1y J . Eve lisp 9 ,:14-WA3'E17ANES ! . -.w FROM TO DESCRIPTION Well Contrra'aaorName i o " I Q fL Clear ii eS 1 Li { 81 B 1 ft. v ft. Cl V NC Well Contractor Certification Number i5;0it1`£It C1iSING(fiabiulhivvre'i�alCiE3N€Tt#i;;sg. 3'- " FROM TO DIAMETER THICKNESS MATERIAL Car°✓A 5erVCGC ova COI'stnAvrt0 Q L.I.C. 4 ' ft- Is fL I i!/ im scli i o (1-VL' Company Name gyae^.,.r u ,�iiL foie WW�llaZ3 :.16:-Ix Izca rsn ( - FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: ft. fL in. List all applicable well construction permits(i.e.WC.County.State.Variance.etr.) ft. fL in. 3.Well Use(check well use): :11 SCREEN;•2 :.r.:-,f, r : - $. ?m-C;Rnw.;, Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural In unicipal/Public IC ft- ' r ft- I IAe in. ,aid soh gD Pve Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL . ft. 1 in. i Industrial/Commercial Residential Water Supply(shared) _ ._ 1f; Irrigation FROM TO MATERIAL EMPLACEMEEN1T METHOD&AMOLT'lT Non-Water Supply Well: ® IL I 4beN 1-04 e pc re ` Monitoring ®Recovery ft fL Injection Well: fL ft. Aquifer Recharge 0 Groundwater Remediation r s H., w. k ::199SAND(GRAVELPACK#ifais� • ,cable) 8Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OStormwaterDrainage i ft- Ieif ft. (2;a lid 1001Arett Experimental Technology D Subsidence Control ft. fL . Geothermal(Closed Loop) DTracer 7.20:.DRI:LINGIi (attaehadditiiia=rei sitriacaaiti}: _%-.11-'' =ct= FROM TO DESCRIPTION(color.hardness.soil/rock type.pain size.etc.) • Geothermal(HeatinefCoolingg Rettu�rn) Other(explain under=21 Remarks) �w� Set4.Date Well(s)Completed: )i gsl itt a Well ID# `r ft- /Z fL grey $'cid • f�, Se.Well Location: 1 Z ft t O ft. q'reyl (,u f SY�i() s n -J.aaes t rq Elfin B&trlr ft. ft. / 6 Facility/Owner Narnel Facility IDS(if applicable) R ft �„'S Y— erS - 11 ,.D 14 q i .�i ler R , C; ro l La 21 q 27 ft. ft. - JUL�� Y V Physical Address.City,and Zip 1 ft. ft. J 9 'C.tierrti {C ocig4®®z®coBoao2 ` ,RIM ?0L3-.z 14s x x{h` rigifCounty Parcel Identification No.(PIN) iti`�R'G�,�p�f !dn'4 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' (if well field one latllong is sufficient) i f 22.Certification: (o'� Za Zg N iS° S! 2 Z w ,....l7 t (o l 50E5 6.Is(are)the wells) ermanent or DTemporaly Signature of ertifie 'ell C tra Dat 13y signing this form.1 hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or No with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a If 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 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. drilled: Q" SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: I V (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 2@100') construction to the following: 10.Static water Ievel below top of casing: 11) (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing.use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter. 1 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a �Al above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: /tj Vn 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 iCenter,Raleigh,NC 27699-1636 ir 1 13a.Yield(gpm) Method of test: ( S NAT 24c.For Water Supply&Injection 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: .4 1 L Amount: I•S 01.• 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 - � �... . i �vnKiRl 12^tMw Permit: •364106 Cur • rtucic WELL PERMIT PIN: 099A002000¢000:l - Ai.DEMARLEREGW&HEALTHSEIwICES Patintitin Public Health Owner: Applicant: - " BURKER JAMES&MARY ELLEN , , LONG&ASSOCIATES GENERAL CONTRACTOR 1260 8TH ST 207 W BLUEJAY CT N CATASUQUA, PA 18032 NAGS HEAD, NC 27959 Location: 1947 SANDFIDDLER RD • iitc 2. De. .. t,. Al"L.f* Sw c 4 *rRJ 13 -.- �' L. •WELL`MUST MAJNTAi. Z . 1 Dt G FOUNDATION/ P(l ?s. ' .. , LL1VUS MAINAI* S +FROA 1'PART OF SEPTIC SYSTEM . ' '; '-W I AND PAIR AREA,WELL MUST BE INSTALLED BY A NC CERTIFIED WELL DRILLER I. . -WELL PEIir ilt MUST BE ON LOCATION OUT ING..c11. I-.PERIODS OF WELL INSTALLATION • i • �; -CALL AT LEAST 1 BUSINESS --. r.'O ESS DAY. REQUIRED ..•.:' ° • 4. . ` It'tSP'ECTIONS.OFGROUT AND.WELLH D gr . r_ I Isla I 1.- r r I. a 1It - io"Is .i . ;,.' \P.; ,;(• MargiMI., i • i r•. , .3. • , . L- i . 1 ' 1.--7-ii • :" ', � r a _ 7--7‘-- ,. .. .. • Pi 1 : .. ___.; I• : " t �aa= . 1 j�,� 1 l • • %, - -. ou: i: . 0, • ,tr. 1 mil_ • P it By: r Date: 11/22/2021 SANG ao Row . Hobb e e Va9fa4 6YEp SMIO flQ.DN�Y 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. � I • ROY COOPER•Governor a l , NC DEPARTMENT,O •g, � KODY H. KINSLEY•Secretary HEALTH AND frq HUMAN SERVICES 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 James&Mary Ellen Burker 1260 8th St. N.Catasuqua,PA 18032 RE: Approval No.WWM1623 Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116 1947 Sandfiddler 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 1947 Sandfiddler 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 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.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER