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Home My WebLink AboutGW1--04787_Well Construction - GW1_20230721 A J '15A• 4r k WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 1.Well Contractor Information: , • . TI M,o FROM TO DESCRIPTION 6 ft I1 ft &lea . 6' s Ul Well Contractor NameQ ,�}� ut� ��J ,,,] q ( Q t P �t ft- b ft {%,eGY wi (l4'1&9feivt lli"fl+ A I.. NC Well Contractor Certification Number 1.r+U1F1`$RCASING(fai' + '> R`L fe r _ BB �� "� FROM TO DIAMETER THICKNESS MATERIAL rov t erll�a 00 COSilnil o q LLC- A ft. O ft t14 in. f 5G1�. ES Pv1'......_ Ca 5 l 1 I 1 Company Name +� �,y y�p� r_ ?�: ns .4 '� 6�y�, W 1I•'1`\`�il� ��6�INNEit:GAS1NG;�''£{1BIPi�_CReotSet'�Ielaee�'ioei3}- FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit�: ft, fL in. List all applicable well construction permits(i.e.UIC.County.State.Variance.etc.) I ft fL in. 3.Well Use(check well use): 17i:SCRWAqti:.: . .... >_:s a-itF s-.-,g;i.y.ne Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural Ivjunicipal/Public I7 fL 20 fL i yp in. .010 $a(f a ex Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, 1 '( in. Industrial/Commercial Residential Water Supply(shared) iF!' :;` Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft- (il it 1181)zafn -k. eekrcf.4 Monitoring 0Recovery ft- ft- Injection Well: it. ft Aquifer Recharge Groundwater Remediation ,19.'SAND/GRAYEI P.AGK if a ble} - , ..:, =r Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 01 Storm wE.,5 Mal ag ft- .y h ft tf p „on� �•V � ft, �6! ft. 1 eural Experimental Technology Subside-c t Geothermal(Closed Loop) 13Tracer '� A t 2023 20:•III G- (attach'additFouireli sitribe iti* ?'4 -=t•%� FROM TO DESCRIPTION(color.hardness,soitlrock type,grain sim,eta) Geothermal(Heating/Cooling Return) Other(explat n er-21 emaks) jr.� ft. /� ft. Set ad r aft P J SJ .brcv:t 4.Date Well(s)Completed: LIj Well .,nn jay i* 5' ft. i I ft Trey r /i- /� 5a.Well Location: (1 ft 12 fL f L'C�.� 1,,Yer '. ! • Tovv.e SZ. 5c,1 SLow5 Zft ze ft jrey scfo w( 5 15 Facility/Owner Name Facility IDg(if applicable) ft ft J 11,40 Se.afiref at Corona, 1.-/t vi ft ft Physical Address.City.and Zip CtArri+itc>k 1o140I1o0o{.o66I AyREit3Ait$S r. ;.,.: .:u;W' rwaic. : County Parcel Identification No.(PIN) ,`_•—s{J^lt by eery re •_'. 4- Lw,tt'cc • 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lsca�' `�iYl�r a (if well field.one lat/long is sufficient) 22.Certification: gib° go t sot., N 7 ' 51 Pitt W • . 7 EDE 6.Is(are)the well(s)iPermanent or DTemporary Signature of C 'fie ell C ,tractor Dat By signing this form.I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or 12 No with ISA NC.AC 02C.0100 or ISA:VC.AC 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#2I remarks section or on the hack of this form. 23.Site diagram or additional well details: 8.For Geoprobe/DPTor 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 1'GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: CoSUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: Z Co (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@i00') construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing.ase:: 7 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter. ' :'`r✓ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: tA�cr above,also submit one copy of this form within 30 days of completion of well construction to the following: (i.e.auger.rotary.cable,direct push.etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY aW�ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 _ 13a.Yield(gpm) v( Method of test: �f P. - 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. 1 Disinfection type: 14TC Amount: •S er!- completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Qualiy-Division of Water Resources Revised 2-22-2016 I 1 ?~`Permit: 376201 _ • Currituck 1/74110116 jZ,./ 4 PIN: 101A0110004000i WELL PERMIT . •. ALBEMARL REGION ALbikes p SEtLliKEs Penal Owner: Applicant: Tomasz Scislowski Tomasz Scislowski • 64 Foley Road 64 Foley Road . • Warwick', NY 10990 Warwick, NY 10990 • Location: . I 1640 Sandpiper Road • ' , p.K' ,� L,,T 4$I( ' . . • • -fr 1344 tIAust M MAibi +i iI ,G FOUNDAT1011 j1p+�i(ri)6 ` 0. t f 6181-itiUST Raittrr'1kit4 itli ii.A& PAR+OF th-P1'IC SY TEM: - 4ND REPAIR AREA • . - . • ff NELL t 41JST BE INSTALLED BY A NC CERTIFIED WELL DRILLER• . • #: INEIA.FERMI''MUST BE ON LOCATION OlJRiNC AL.¢'EI UQQS ... ; t 01,?•WELL lwsmLiATION t .OAL..M'LEAST'I l$IJSINESS DAY PRIOR FOR RECtIJIRED ;. 1 INSPECTIONS OF GROUT AND WELL- 10AD �8£. ill •i • 1. t ,t d ` 14 ; . . :v1r ',1. 1 i• ' • eOO OL -a.00.z s • Sandpiper Road •. • •_ • .fog . vravoi ubd idletry Permit By: f , :./ n..f/ Date: 05/27/2022 , . . o.bs,Joe r� 1 ,. Certification By • Date: e e.:4.41,to, ti 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 • THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR _ , - A PERIOD OF 60 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•TR3APPLICATION FOR. • ••• ; 7 • •:. . ; DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORRECT,:CHANGED,OR IF THE SITE ` '.i. -. • - • IS ALTERED,THF CONSTRUCTION AUTHRORIZATION SHALL BECOME I WALID AND MAYBE , . ..... ', :..'.':::. - • • ' • SUSPENDED OR REVOKED. • . .`/ : When contacting the Erivirotunental•Health.office concerning this document,be.sure to•Know the application . .• •. .. • - . number. The number mist be•used in all inquiries and inspection requests,.•. . •" . : • '.`` The Environmental Health Staff can be located at the following telephone numbers between 8:00 a.m.and 8:30 a.m, . • Monday through Friday,except holidays. The office telephone numbers are: . . ' Camden 338-4460 . Pasquotank. . ... .:.. .,. 338-4490 ' . •. Chowan 482-6023 Perquimans • 426-2100 . ' Curiituck • 232-6603 . Bertie • • , 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 insieded and approved by a representative • • • of the Environmental Health staff before any portion of the installation is covered and/or used. . 4 ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL " HAS BEEN CONSTRUCTED TO THE STANDARDS ter FORTH IN THE REGULATIU*S;BUT SHALL lfd` . .NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE D` a ' I GWA1'EE ' - • • •• , **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, • s • or area permitted for an on-site wastewater system that has - , - . not been installed, and a designated repair area for that system) • 2) Other Subsurface Ground Absorption Waste Disposal Systems . 100.ft. • . 3) Industrial or minicipal sludge-spreading or wastewater-irrigation sites . . 100 ft• . 4) Water-tight sewage or liquid-waste colleotion or transfer facility 50 ft • 5) Chemical or Petroleum Underground Storage Tank 100 ft • ' .x • ' (does not provide.secondary containment) . " " • 6) Chemical,or Petroleum Underground Storage Tank 50 ft (does provide secondary containment) 7) Spray orDrip 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 r 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 barns 100 ft J • ROY COOPER•Governor NC DEPARTMENT OF KODY H. KINSLEY•Secretary (! f ) HEALTH AND HELEN WOLSTENHOLME• Interim Deputy Secretary for Health HUMAN SERVICES ,; MARK T. BENTON•Assistant Secretary for Public Health I Division of Public Health Onsite Water Protection Branch June 2,2023 Tomasz Scisiowski 64 Foley Rd. Warwick,NY 10990 RE: Approval No.WWM1635 Well Cased.to Less Than 20 Feet—Rule 15A NCAC 2C .0116 1640 Sandpiper Rd., Swan Beach,NC 27927 On June 2,2023,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 1640 Sandpiper Rd., Swan 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:919-707-5874 • FAX 919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER