GW1--04789_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only:
1.Well Contractor Information: i
`" ) Ti. o4ln j J . En9l►sh •14r:WATER=wIv�s .,. :.
FROM TO DESCRIPTION y
Well Contractor Namme 5 f- GD ft. ./_- j Or 5jkeIlY ,'/
N1or F/ jt ft- 1 1 ft- t i tier1eek)r, ♦!i iron,tc!TC$nett
NC Well Contactor Certification Number .4 r
FROM TO DIAMETER THICKNESS
iS O[f1I;R:Cl►SII'IG(for'ntulh vFe1t>Ri (R. 3-54
MATERIAL
(.&vogA r5trV000 01469, C P Sh C'bO A .1.1,C. ` ft i ft 1(4 :in. SGLI qd — PVC---Company Name r�� !,' f -1S INI+iEIZCl1S B'; JBINGf ott l 4ti- �" -
11n_11"13 +pt,AJWi , 3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V`V 666 V F V V_v- s ft. ft. in.
List all applicable well construction permits(i.e.UIC.County.State.Variance.etc.)
ft. ft. in.
3.Well Use(check well use): ;:-
17:.SCREEI+i. ; .:,. _i6z g.> P 4N . ii• .,.'-:-
r,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Dunicipal/Public ®loft ft. riff in. -018 5,d4110 piC.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) T ft ft. in. .
Industrial/Commercial DIResidential Water Supply(shared) dB-GiUlff -.... :< .._- ., -< ,ti; . . .: :�. _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ► ft. ft 3, bed •%ule nolXred
Monitoring ©Recov -r j"'�EIS/ ft- ft
Injection Well: ! ' ft ft.
Aquifer Recharge 0Groundwater Remediation
—
`` 2, 1 ZOZ3 -:°14.'SANDIGRrYF-�1':Plif'K:diBlrplicable) ...ri;:'�-z �-,.`r_ :wr•a•-.s4":�7
Aquifer Storage and Recovery Salinity Barth L .a FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater DriirgieproviesirisOrek ft- Pi ft 0-1 5-akcif pbute<e
Experimental Technology E2SubskNeTtiitc*CkiSOG ft. ft.
pGeothermal(Closed Loop) OTracer ::20i•DRILLIltGLOG(attach"edditioiit<Fsl i f!'see ;>-� "7a,=+-s
FROM TO DESCRIPTION(color hardness,soil rock type,gram size.eta)
Geothermal(Heatine�Cooling Return) Other(explain under#21 Remarks)
I- n� rr�� o ft 5- ft brown ..and /L
4.Date Well(s)Completed: (91 a 2023 Well ID# f ft (0 ft i re(( t..( So Otte S%(7
Sa.Well Location: (D f(( ft. pe,t1/arcr
6ar'at1 6rowfl 1 ft.
I !q ft yt' y t/ snot(sl<els
Facilityr/Owner Name ]],,rr11 /� Facilityl ID#(if
applicable) ft. ft
t(ol�Z 5 i4(D1pert CdroY4LL/ 2-G9z7 ft.ft. ft
ft.
Physical Address,City,and Zip1 t
CAA(r1-1-ACk 1o[4010060boo/ `21:rREMAICK3 ,.::;.;. .::..!Z.,; r w+a: -:.,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
! o 2. S�rl N 7J �0 � ���t w
6.Is(are)b the wells) ermanent or Temporary Signature of a ell Co,�ctor Dar ��
By signing this form.I hereby certify that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or DNo with I5A A'CAC 02C.0100 or I5A NCAC 02C.0200 lVell 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 back of this farm.
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-I 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: 1 (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 a l00') 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 rasing,use"• ))" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. t0 (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: ��� 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
iTh
13a.Yield(gpm) '( Method of test: 610 PUl.*I 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: i4TC Amount: 1.5 DZ 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

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Re emit;:: 36961"3, C:umrttack:
PIN; 101A010600600;;N:
WELL PERMIT
,_4,--,:., , ,
Owner:," ACk@ainFLGRCt,o.?.$ALHe�ITH SEgyle.S: Applicant .
7,at t m.in"640e.Heaith. ..
Sarah BrQWn Sarah Stow
1662 Sandpiper Road. '1662 Sandpiper'Road
Corolla;NC,27927 . ' Corolla; NC 27927
• Locations f• ,
06°35'0t}"Vtf ! T00 00' ��
1662 SANDRtP.ER_RC7 c7:_ -
..
tELf at0.usT'MAINTAii�2 "�+PROM 3UU,34.91 G:rOUN A` lO / *f �s "
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fELL'MU•ST MAfl4TMN SO+FROM;AMY PART OP SEPTIC SYSTEittl >' • .z, `,-,
Np REPAIR„A,REA3 _ . ,;_ :-- ,agr r
ELL I tUST SE INSSTALLEI 8Y A NIC CERTIPtE0 VEJ.L 9R1LLER ,
`P.I L tMRivtiT MUST8EFO LPCt TION ttt tNG A..LP 141?S:: {. i;. b• • i 4. ..
r WELL fititSTACLA7t4N .s` 1 ,, ,i, vs.or. • oas •o . '
t'1.4,4,T LEAST' $k3Sillt§$L AY Polo I=C}R�FtEQUtRE) +n Vrolk c iaOAjc"•°o ."0"s `
tSP;ECTIONS O 'GROUT�;AND LLHEtiD T TALL" ..40.....4-` ® 4,<..-'a.�.���
EEAPCE •
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Permit�y: ,-►''i_ `` a-' .r Dale":e 02 18%120 22�
.a. ;Joe.; A.
Gerttftcat on By Date
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Onstwction has:been comptet d, a;Residential Welt Constructi�.n Record Forrri,GW 1a has been
. .submitted and ins• pections have been,oompteted iti accordance:wit 15A NCP C 02.C._03po
.

c ORTH CAROL44A DEPART IR.NT'OF EN v IRONMENT'AND NATU AL RESOURCES:'
•YARIA,NCE A.PPLICATION,-FOR ZC,.010(i"4 ELY,CONSTRUCTIO 'STAIYI)4, DS,
PRIVATE"DPJ NKINN`G WATER WELLS UNDER 1SA NCAC 0: 03 00
,
' 'WATER SUL?PLY)rVELLSUNDER X5A NCAC O2 U1Q7
Al7 tvatersupply ellr net considered `Pri-vate llrinkzng Water Weds"and tnelucttt g irrigation,induslrtal andtecmmerc ctl wetly
WELLS 4TT ER THANWATER SLIPPLY`'UNDEIR;ZSA NC kC 02C 0108 -
:lrrctudtngtnolzttorzn aril recbve Netts;
Print clearly er type itiforrr atiori,Illgtblesubmittals will'L a returned=as uz omgtete
'DATE: "1 "41, II` 2� ~
PEIYIIT.N�? `,�" (to.be campteted, yD�VCt1DPT)
A,: WELL OWNER For$ingle fariuly•rsg1ences list the Property owners) For ali';athers, list Siam,ofithe.'busrrtess,
orgartzct on,or government agencyand:persori delegated signature autl ority" . .. ,
id
:ivfatling;Address. 4 2 / 'r S i„- ''t' .
5,Fr�G:State A/c- Zi Coder Coup
City t$"F P '
:lay Tele o. No: -
':EMAIL Address:. ` • Fax NQ, "
'8 l?I=IYSICAL.LOICATION }t'.ELL rr.:
P:ant tifica"tion umber(PIN)of well.site: `I D( PI? DDQ k,i' 1> ;
(I): rcel Identification
I
co;, unty: 40`4414 7rie: , - .„
(2) ;Physical Address i(f different than mailing address) 4 ' � '' O 7 C , tc ,
0 -
.4-44-.-.....4.. f.., -.:-- -::,„:.!./:.;.,. ,:,7....
— - a —--
City:. . ►'or4t ! ,aj s� ; 'Sate NBC ,,cp Code ... 1
C L URILLE)2.INFORK87.TON(if lard r*
t?'Tell Dulling Contraetar's NamZ„• Tt'^' Y � '" ll _
NC WQlt Drilling Contractor Certification No;. ( is: .
kCoinpatiyN'ame.�Caytrowei 7 ervice'd'C,�.L �c suc}ion (r am Gontaet`Person 14 E tS 4...
City::"Colo t k State:;,NC,., Zip Code Z`FJZ? County;- Oteri Ick. ..
l ay iele No; .:Cell Not:,-: (22).6(Q C.L 5— '
~IVIAIL:kci ess; `fiJ Carovo,snc.4vvx, Fa Nb .•
Farm U wv-22 NO- ' ;Revised FebnFa 2.?t

ROY COOPER•Governor
111 " ° ��� 'Nit: DEPARTMENT:OF
�.a KODY H. KINSLEY•Secretary
I$
' HEALTH AND
° ,x HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
A 4` � � HUMAN SERVICES
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
June 2,2023
Sarah Brown
1662 Sandpiper Rd.
Corolla,NC 27927
RE: Approval No.WWM1633
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1662 Sandpiper Rd.,Corolla,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 1662 Sandpiper Rd.,Corolla,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