GW1--04725_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only:
1.Well Contractor Information:
Ti. o4lny . . English .14:WA1ERZONES _ ,, -a
?P FROM TO DESCRIPTION
Well Contractor Name y ft- 1� fL • TtvA sritell/ Of/ender I 8 1 a5 ol3-TER CASING(fda:.innl4 i
13 . ft. fL
NC Well Contractor Certification\umber � c-
1AYlSO A �� FROM TO DIAMETER THICKNESS 61ApT�E1RIAL
CekrO✓t Servc,c avid, + ft o ft L in. St, Lib PVC.
Company Name ` �i. Ki3
P Y• ��t/xt 21,E '�1{�� +,,{",��I :161NhI£IZGA51i9GA?H_ �ISIPFEs( otmal ''=r e
2.Well Construction Permit#: cJ V 3r/W V"W i4 0 lY 6 l FROM TO •DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.County.State.Variance.etc.)
ft. ft. in-
ft. it. in.
3.Well Use(check well use):
Water Supply Well: FROM ro DIAMETER SLOT SIZE ' THICKNESS MATERIAL
Agricultural unicipal/Public ft ft i in
!o I'L 1 �� rQto s�Gt�a plc
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) -1t£=GROIi'i.'.,. rvv
r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Sc AMOUNT
Non-Water Supply Well: 0 ft O it. $ }a.+tt�C �ur�0.
Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19'SAND7GR VELTACKCdilifti sbk)' .:...:,. r :: iget t_ g, g 5
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �StormwaterDsainage to ft- 15 ft ,4Z $ate rfierur�eC
Experimental Technology Subsidence Control ft ft U__
Geothermal(Closed Loop) ®'Tracer ':20:DRIi:LING'3s(3G(attiCh'sdditlaiiirs3 fE }::=:.-yam::--_'• :"' a"`
FROM TO DESCRIPTION(colon hardness,soil/rock thpe,grain size,etc.)
Geothermal(Heating/Cooling Return) Daher(explain under#21 Remarks)
JJ__ �j) b ft �' fL brow sRha(
4.Date Well(s)Completed:(4 0/�23 Well ID# S. ft- I .- ft Ci i'1C d fi/ sg.,¢[/SAei%
Sa.Well Location: I ft. fL ! l
r 11A6GNdilnere4 (lateral Coi1frac4vlS x'"% 1 tr'
d V 1Z LI Facility/Owner Name Facility iD: ft.(if applicable) ft. a�� y
I c 7100 Oc.eaw Peal-1 Rd/ Corolla r 2?q 27 ft.
ft
ft
JUL ill 1 2421
ft.Physical Address.City.and Zip
Cutryi t tot 6ODDocbT-0DOv `za`Rzrmtls. :. i ali to t :rr a t'ir v,&.;m .. shy'-o
County Parcel Identification No.(PI\) o a:9OG 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field one laUl�ng is sufficient) t 22.Certification:
�o Z �u �N 5�$-D q[ w • D23
6.Is(are)the well(s)Gfermanent or QTemporary Signature o C red Con or Dat
By 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/5A NCAC 02C.0100 or/5A 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 1/2/remarks section or on the back of this form. e
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: 12' (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 level below top of casing: Q (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: If (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
12.Well construction method: er 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 Sertiice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 l Method of test: (ems P u L f 24c.For Water Supply&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: 1-1TC Amount: 1.S o'L 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

4-- ...,%.-i'S ,,.. i •,•
Currituck.
Permit; 383310 .
WELt4,PERMIT
. .
PIN: 101E300000080000
At aEMARLE RiGtOMAt,HEALTH SERYKAS
TarrnObi Niiik-Hepith
•
• . , , ,
ISPYikl _...ant:
MACNAMERA GENERAL CONTRACTORS ,
Owner,
.
MACNAMERA GENERAL CONTRACTORS
PO BOX 833 PO BOX 833
moyocK,MC 27958 ' . MOYOCIS.NC 27958
. ,
Location:.
• 1545.0CEAN PEARL ROAO .
I-07 le OW15-10,0) oF Ltiotiv( . .
. ••
' 40'61.1?4.10.V . , core
.• ' pli1910,V0pLeileARK pRopER TY ..
''WE4:14USir*M:INTAirft.Ofr+FROtit"' OW-FdtiNDATIgN .
.
-*144-144.07:PAINViOr.51:1-t'.FRO-NtANir44:!*0:0,F SEP710 tywrrygyv
AND RVAIR AREA-. ' :-....-4... i:....... ' '• ' • -.,....„.1. ;:: ' . , 0 •' -4.-1
• ,*t • --,..1 !,-. , '.. • „.2. , - 01.4.26.10 .„..5-1- , 0, , , ,, ,,s,\,n.. .
WELL MUST SE INstgiAD13Y A NC.0d'alvitt wEuctivti.,tign, . . ie-tifi,Tr--- -,.:_,.,, .-7-- - .,1 .7 41. - ,,•
. 4. -, • • : • -.4,:%„:.!.... 1 3,,-4,,:,„1,.. ,. .. -- 0 d, , ,,-, •:,;„4 . itr,..,.:.- .....- •----: ‘. 4 k- •
wEa,PEramEr mdst as.cmi.pc-AtioN otitd.Nel\i..t.pgsteg*..„:„ ..
oF'wa.1....iNtlAa.TAittcyk• ,. • , , ,, . . . • : , • .. - - le;,.• -'...,-.:-• :yr'.• ),..'!..•,,a_04.:••-n--.0.-. , •-•-•:% „.0),
••,- .:" -_.4,ii---7.. ,-. .......:;-•--r i cr
.tALI,AT.-11.A.TE-1 ellsV4410a PAY:PRi.G.RiFPR RECiAREt), -
.."-tR§PEd,1:10N 1:05.:R.ogrie,440:, wo4.14$AD rrA700R '' .../J----,
. /am • 1, -." -.,, 4 '• s.7 r
i - ,x1F7
* L"4004- wg- grooffAr-r . --' ON % Ave.
13114r I i I t-7,-0,,, .DI•vadasiG „it, • 74, • i f :.
if** niP6t titest Or 1-irr
2 maw . ,:, • • , Lorm
tompfilartiED . kv la.4„... ., ..: •4. , - 4711,1,5702N prawARK
<91Rfaivo , I , . . A-01, ncitr • :. , i 1 i •PROpEMY
, . ..r i: , Os .. Ptc.484.0.Os ••
Lor 0 '1. . / ,, 4,,:, 1,4 ,
ortistON OF ixviARK "7: -, ' ' '• I .i .'‘` 4.
I 4-
,,,c,A,,,,,„, ..., car a,. , ' • i , 1
,
i / ,
.. . . I. '.. . : 17 .i.e5', ' i .,.,, . •
, .
• el'ilI / ' ,, , I ...
,.. , , . •
CV: / I -'4 i
. , Vi.,,,A, 1 i • i c / i 411: . - •
i
; ;I' I
. ' .
,
7 / , 4,
I / .,..,,,,./.-.' , .4? 1-•.....-r. ....F.'''.
, I / ' 1 . . ' --. ...••••,^^7'• •
10 WIYORpROVEDiva. : ' ,f I /I ,t:/ii;e./... S-6:11'-'''EAS!'. eilro.'P.C...l'‘-'11H5 106' - O. ----'-
...
---*,...--•-- .,. - ,..,,,,- tiff, ,
.. • ---`" .. ., : i4VOCIB::::.,..„,
' ...,.._ _ 0 EWNIIN:FoLor to .
. , pilaStoN or LEWARA7030FIERTy •
. , P4 4 412.Ice • f
• P.C.0440.98 I <
. I
I .
. ,
permit By: • r- ;:' . .1 . .Date: 1 9/3112022 .
11. l'
Certification By: • . Date:
, I
- i
i -
1
Construction has been completed,a-Residential Well Construction Record Forro.GVV-1,a has ben
submitted and inspections have been completed in accordance with 15?''NCAd.02C.0390..
!
. • .. . .
• .
• .
• . .

.. - .
. ,
• i •,----•
Permit: .383310 . Currituc*
WELL PERMIT
PIN: 101E306000080000
AL DENLARLE FtWIt5NAL HEALTH$ERN,:ICES
Esamersin Ptibti Keen
. .
. ,
Owner: Applicant:
•
MACNAMERA GENERAL CONTRACTORS MACNAMERA GENERAL CONTRACTORS
. PO BOX 833 PO BOX 833
• MOYOCK, NC 27958 ,. fvlOYOCK,.NC 27958 .
. ,
• '
. ,
Location: '
- 1546 OCEAN PEARL ROAD
1.01- ft Osinsi,41110F
(..d.40 d.c.4.-- _ - — •
tor s
_ _,. • ...- OMSYMIOFLEWArtKPMPERty
Watj..74MWST IviAINTAK.ZOT4.pg*T040140.1t49 FOUNDAiftpk!
. ,
ANELI;..'igtf.S7 MiNI tir VON.''6'e+PROktAft*'PART.OF SEPTIC Sr . . '
AND R4PAIR AREA ' -,.--e. ..:.:, ' 2'
cds—ri rio.3, . • k4. : ,
,
WELL MUST SE INiiAilt6i;?i NO-0ErifiFtebws-4.604th • r4411--5, 4k jc2;,;-r...., iii„li
• ....,... ..: ,,,...„ .. • . , .,:...e.cr- ......,,,,....., --- ,04 • ti sl 'i' . '
WELLPERMIt MUST Bac1N 1.ocATiotil riu06 i1.z.:pokicki,*„: .-- ° 4,4J :, 4.''.,.:.'.'•. -7:.`..• '-- ' '_ ,_,, ,,,/.- x 'i .4 4 F. -
OF wEl...t,itl$tikeiSAI.i'lcik "'.: .. • ' 1 ' ; ' - • •• .' ' 1,;!„!--‘' `:-.:1•' - Mr-.:):S';iMPY4111114-1:".• ZZ`4 „9
a EA,a,D.,.04 ailif,..—:.
..:tALLAT,LdAst.1 g•r* .i.Elsky-tafifp.tRiTcDR.Eiqc14r.Etl. _l '- ''' '-'' --....- -,,,('' .. ii0111111 -,:,•-•,-;.,
tO§P-!•CTIONS 9F%-..q se (4.Oitart WE:W.-HEAP • ---
. ,
. .
ii- LaPeitVirif.- 1011144. 0 di.i/sir'r .,,,.,:. 'PF9.- th„ 4,,,
. well -. pRoposa,
14r ; ;DWELLING ... •ff .,
1-1*4- poiot. ofide or 1,01— 1 .....,,,..- 4,t
I" t. ,,,4: 407-x4
UN/APRoter, At 4 '4,t. ,. ...... h ,1 .' DivisipicrorawARK
PARKING I
• . :'.'4- 41' V - .P I* kJ,1 • Fka A,;La:10$
Long P, /
. 0,1'1PN OP L E WA RK It :Ifi* ' /. PROPERTY C• - k 0 OW SF 1 1 , 1 I
f, / i .,?' - 'I ,•:...
/ , 14 4:
. 'tt. '. 4•;.• I / / ..e,
,.
/ /
1 1 i ,.,..• a
_.
_ ,f. i —
/ i , 4Y---=-,-"'• •---- .
-....4.- . ,L.'..., c A—gr,b7.105
'
tor/mar/mow, . , r, -,--arts„ i1:50r o '
. ' ...,..i*••• i ..
•
.-- 1 • „, '
-,
. --- , ..,,,,•• ,., 941160!„,,,_-.
PASTERN Plit.F Cp[or 11)
. conSICW 0FLEWARICPRopEpry.
. - Pc.A,21,13,:vd • -
. .
. P.c.4 Su).08 ,
. ,
. .
. . .
Permit By: • , : ir- --', /. . Date: 10/3112022
/ - ,':-., Itt- ..,
•
•
CertificatiOn_By: •. - Date:
.. .
Construction has been completed, a Residential Well Construction Record Record'Form.GW-1 a has bp.pri,
submitted and inspedtichs have been completed in accordance with 15A NCAC 62C.6300.
. .
•

1
44,51. "'„t,
° ROY COOPER•Governor
a`, ' NC DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTH :AND.
� t HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
"' etc: MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
June 9,2023
MacNamera General Contractors
PO Box 833
Moyock,NC 27958
RE: Approval No.WWM1641
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1546 Ocean Pearl Rd.,Carova Beach,NC 27927
On June 9,2023,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 1546 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 owl ner 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:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER