GW1--04788_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only: ,, ,
1.Well Contractor Information:
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r TI IM O'4'�lt� J . En9 FROM zovEs _.:,. ,:,.
FROM TO DESCRIPTIO\
Well
Contractor�a Name w ft- 1VD ft. i rey .ra;Jer croivt, sat'
'` I 81 1.r t,0 H 6® fL torcooK0SPi fi'vt� lava s(iiiell `Irc1
NC Well Contractor Certification Number // ��__----LL 15 OUTER CASING(far multi vre'lls)OR INEtf ' .-*.' 3-
_ [A� 1AYISTr�f,G Q �� FROM TO I
DIAMETER THICKNESS MATERIAL
CarovA Servca GttA0. 1 ft. t3 ft. 1 1l to 5chLib lox _-_.
Company Name I, ��(1J�I + n ;.16: ItCASIiiIt:'ORT$IAiE )FX ?""
2.Well Construction Permit#: .-3
1`D 353 _ "_ l'��` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.Stale.Variance,etc.)
ft. fL I fn.
ft. 1 in.3.Well Use(check well use):
11 SCRP .,. :— . .,. -Tr ,. asrz;_,v ;'f'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public fL ft.
l
13 �� j /� in'
,Ol© . Sck�� PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. is
Industrial/Commercial Residential Water Supply(shared) � =
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft- I j ft- 3k6eivitA�rfe PO4 nd
Monitoring �RecoverS,,, .�.sv"! tZ ft
Injection Well: Mt., e� ft ft.
Aquifer Recharge QGroundwater Remediation � p�,y�
2 i 2023 l SAI'lD1GRA :P rifiim ble) - �:...,w_..
8 Aquifer Storage and Recovery Salinity Barriel,JL J FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stotmwater Drainage ft f 2 Jake( e0-tArecl
idd�+ ter>:fl rr' re a
Experimental Technology OSubside� ft ft
Geothermal(Closed Loop) OTracer `.20:.73IiII:LINGLiIt (attrifih-auklitlwitsFsif>siiiiissti•1'}: .:::_,,..;i :VmA3 5
FROM TO DESCRIPTION(color hardness,soil/rock type.pain sin,etc.)
jGeothermal(Heating/Cooling Return) InOther(explain under#21 Remarks)
1_ 22 d ft. if f broom. saw
4.Date Well(s)Completed:tPr/Zl0ZJ Well ID# it fL to ft. .trey land
5a.Well Location:: da ft it ft. /0 d 14ter
P BrOW Y1 I/ ft. // ft salty 7rer 6,((trey h7<e.C6tiCrek)
Facility/Owner Name Facility IDA(if applicable) - ! 1 ILj 7 ft. I r`e y wl W3 .I— site I t.CO4_Ntstc0
2 S''' ocean P IS Coroti t.l 1/127 ft. ft. 1 7 L
Physical Address.City.and Zip ft. ft.
CAA.7-V-V .....O.ZZ..Odq 3111/tF,/MI'ARISS.1�:.-"..J�.. / ` .Q;-.../_�: ;... ;..::<,r ..
County Parcel Identification No.(PIN) f15S'1ST'GGC 6y t�l� Parker CaWrekte
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tray-61416r
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s)ar ermanent or Temporary Signature ofCe fled Con for Da
13y signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with/SA NCAC 02C.0/00 or ISA NCAC 02C.02(X)1Vell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or nn 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: SUBMITTAL INSTRUCTIONS
9.Total well depth belowland surface: !t '2 (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 @100') construction to the following:
10.Static water level below top of casing: LI (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: CI (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
G f 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
("----) ^ Q
D 13a,Yield(gpm) IU Method of test: 6111: PkuM f) 24c.For Water Supply&Ioiection 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: 4TL Amount: 1.5 dru completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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V RIANCE :PPLICkTIO I`FOR 2.E. 0 00 A LL Ct NS'IRUCTION ST D RD i
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.. `WELL OWNER or§t_g1 434- r-esii ez ces lac kti prort o� .errs):;F`ox'? 1•6`rbers„i?9,t sGazxe of tie btiV.0e# _---
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ROY COOPER•Governor
44'4 >�& >� , NC DEPARTMENT;OF KODY H. KINSLEY•Secretary
x' HEALTH:AND
HUMAN-SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
IN SERi/ICE
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
June 2,2023
Andrew Brown
1363 Brampton Rd.
Los Angeles,CA 90041
RE: Approval No.WWM1632
Well Cased to Less Than 20'Feet—Rule 15A NCAC 2C.0116
2135 Ocean Pearl Rd.,Carova 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 2135 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 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