GW1--06141_Well Construction - GW1_20230922

CW_1 For Internal Use Onl.
WELL CONSTRUCTION RECORD
c P
l
1 Well Contractor lnformatio`n: �� d S� Y4t1ERik3i DESCRIPTION
l `114(2: 4A �+ • FROM Iru
1 i �1
,
10 ft. CD . 10W Slue,
Well Contractor Name � ._.
® :ec:
Aixam :
c:isolrr�'casn�G fdr:mnlh
NC Well Contractor Certification Number • FRO TO DIAMETER PVC
allainlinall
nay„-p n C.(.arya Scrrv�uc a
Company Name• 2 l-,,_/ 16gC DIAMETER
2. t Well Construction Permit it:
0OI i ) fly W M I1�� FROM T�®_
List all applicable well construction permits(i.e.U1C.Counts.Stale.Variance.err.} ft ft. i in.
3.Well Use(check well use): I ;> _i...W.AP ';-t:s M_44i
r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MAATERiAL
Agricultural Q unicipalfPublic (5 ft. [er fL !tit !in. ,O(o 5(,�1.-W 1 vC-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL cc ft. in.
i in.
Industrial/Commercial OResi enttap6_Ji.(are.Su ly(shared)r�` ' gitROU' i St?::: 47. ,,,,-_ r .s; aiIII., t' =
Irrigation E:i, F 1,i R^ =am TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: .. d n IC fL tilP.AVD114e6 pvcAfea
• Monitoring 0RecoverySFp d . 2e23 fL ft
Injection Well: • fL ft.
Aquifer Recharge ®G)0btl S ifRCiNN�dieFio UI Y _h;—� xti?
'� 19 SANDIGRA :P-At;'KTiiagpi
Aquifer Storage and Recovery Salinity Bar r ` Oa FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage . IS" ft- LR fL (lt Vtei t. 4 poured
-
• Experimental Technology °Subsidence Control ft. ft.
•
Geothermal(Closed Loop) Tracer �'.2D:DRII;LINGL`OG(attachadditfonlI811ebffi> +r r < " rr-�?'•._tc�
FROM I TO DESCRIPTION(color hardness,soWVrvck type.grain size,eta)
Geothermal(HeatingtCooling Return) °Other(explain under#21 Remarks)
//�� pp.P O ft- (a f- Iprown. 5-4
4.Date Well(s)Completed: —11F`f 1 Well ID# to ft. C( ft q rey s.4yi/
Sze,Well Location: I ( fL / , fL new.barern. RObef4' �lcttvelI (2re of ft. i.yre ' sic F.(sGel(S
Facility/Owner Name Facility!DO(if applicable) ft' fL
D.DU3 S netriper R.d Corolla e 2l''V1 ff. ft. i.
Physical Address.City.and Zip i
Carry fuck Obgatoo I S( cool =2):RFMAitS3 •: ;; :r, : _:.L•..: ..4 - , , ::*7-:�3<
County Parcel Identification No.(PIN) 14s5 isk A t,tk'rew C_ 6—a "'4er- a•
144
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r er y I Par/Cer
(if well field.one IaUlong is sufficient) t tt 22.Certification: I I p , -
3(° ,oP 2(" 75°
N f 4z W LlI-L12023
6.Is(are)the well(s) ermlanent or E3Temporary . Signature of 'fled iI Contrac , Date
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: Yes or:EDNo with 15A NCAC 02C.0100 or/5A NCAC 02C D200 IVeil Construction Standards and that a
If this is a repair,ftil out known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under 2/remarks section or on the buck 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 1 OW-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: I I
(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@l00') construction to the following:!
10.Static water level below'top of casing: to, (ft.) Division of Water Resources,Information Processing Unit,
' /f water level is above casing.use"••' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. L9 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: M.ujt ' 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�\
1 Method of test: �S PK 24c.For Water Supply l&ilniection Wells: In addition to sending the form to
/ 13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1.4T(.0 Amount: I.5 el- completion of well construction to the county health department of the county
where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1
I f

1;:, • www.arhs-nc.org
-Periit: 400193 71. Currituck
ALSEMAttLE REGIONAL HEALTH SERVICES WELL PERMIT '
PIN:- 087A00001510001 • Partners in Public Health
. PERMIT TO CONSTRUCT PRIVATE
. DRINKING WATER WELL
•
Owner: Applicant:
Robert Caldwell Robert Caldwell
. 215 Apollo Dr 215 Apollo Dr 1
Seneca,SC 29672 • Seneca,SC 29672
• Location:
•
2063 Sandpiper Rd
•
•
S4A* l am
. r
•
. VI '
. .1. ..._ 0 /
c.4- 1[_______Ag)r"‘CL' .
' •
v
q V I
*"The well pump must be installed by a Licensed Well Driller,a licensed pump Installer Level C or D,
or a Licensed Plumber with approved education within the last 2 years on pump Installation and well
disinfection.Only a Licensed Electrician or Licensed Well.Driller can wire the Pump*" •
SHALL MAINTAIN 25FT+FROM BUILDING PERIMETER
SHALL MAINTAIN 50FT+FROM ANY PART OF SEPTIC/REPAIR AREA
MUST BE INSTALLED BY CERTIFIED WELL CONTRACTOR
PERMIT MUST BE ON-SITE DURING ALL PARTS OF THE INSTALLATION
CALL AT LEAST 1 BUSINESS DAY PRIOR TO GROUT AND WELLHEAD INSPECTION •
"WELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FOR AT LEAST 24HRS PRIOR TO USE"
`. : ,•.
Permit By: .. ::.:..:.:: ;...,:::: �° -..:..:::::;...: -:: - ..,:.:il:,:.:: ,.._.:.. Date; . 9114/2023 •
Carver,Kevin
Certification By: • Date: •
Construction has been completed, a Residential Well Construction Record Form GW-la has been
submitted and Inspections have been completed In accordance with 15A NCAC 02C.0300.

•
•
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AP NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DR1NXING WATER WELLS UNDER VA NCAC 02C.0300
WATER SUPPLY WEL11,S UNDER,I5A NCAC 02 C•.0107
All water supply wells not considered"Private Drinking Water Wells"and includingmgatio industrial,and commercial walls.
• WELLS OTHER THAN' A.TER SUPPLY UNDER ISA NCAC 02C.0108
Including monitoring and recovery walls. •
•
•
Print dearly or typeIlaformation. illegible sribmiitals will Ntaturrned as incomple
. DATE: • , 20 PERMIT NO.: a© I (to be-completed by DNQIDPH)
•
A. WELL,OWPIER--For single family residences'list the property owne(s). For all others, list name of the business, "
organization,or government agency And person delegated signature authority:
• t2ober
•
. Mailing Address: 2 L S Apoi10 On lie
• City; 5 P.rl"e-ciZ _ State: SC Zip Code:467Z.Ceuuty: • • •
• Day Tele No.: Cell No.: .
- EMAILAddress: Fax No.:
•
•
E. PEP SICAL LOCATION OF WELL SITE. •
(l) Parcel Identification Number(PIN)of well site: Orlift000 l"SJt36oq . •
County: . Ca,rri r(•
• (2) Physical Address(if different than mailing address): 20.6 3 ' P,)oer'Rol •
•
•
City: Corolla State;ivC . Zap Code.: ' 2 7 qZ7
C. WELL DRILLER 1NFORIVIATION(if known)
Well Drilling Contractor's Name: • , r j to'thy QEktf
lc�h
NC Well Drilling Contractor Certification No.: '1( 6 ~
Company Name: Crotrrz Brice 444 t .91-4 4,1 UC Contact Person: 6 JElijah
. City: &ro(k State:NC Zip Code:ZMMMO County:_ Caro'•rack
Day Tele No.: Cell No.: C lg!t Zrr:. •
EMAIL Address: ,mac) rovo-srt .,ce M - Fax No.:
•
•
•
•
Form C -22V Page 1 • Revised February ZO17

. M. "wdt w ow" r' utri4.1;$Jt1 U,&ST-Include type of wells)t•t e ao is1r ctod; Me for which the variance is.
being regtzeetedf ikacriptiod of how the alternate construodonwill cat wt+dauger hwnau health and welttie and the
environment;and ria,son.why construodon audlor operation in aocordta a With the standards is not technically feasible
{" - andlcr provides equal or hatter protecdoe.of the groundwater.
•
• Z. � rier ii.: w 6A "off. rrf 12 •at .. P. /PAIf$
• ni 04cst. o .. ' ,.,c�rrr,+',.. .
•
• _
E. ATTACHMENTS—Provide the following information as attachments to this Whelan:
• II
{ w•• (1) A map showing general location of the property(Inoluding toad names;NC State Route Number,distances, •
' ' any key molts,etc.)Meat for finding the weltlocati t. .
(2) Detailed•site map•with scale showing location of propotod well relevant to septic systom(s), building •
•
foundations,property lines;water bodies;potential sources of contamination,other wells,etc. • '
(3) . Submit a copy of the local welt permit application and site emulation map of applicable).
(4) Any other infOrgiad011 relevant to the variance reguest such as a well construction diagram showing proposed -
well liner or atypical construction materials/Methods. -
. ' F. OTHER lidINHVIOM CONSTRUCTION REQUMBUDITS . .
•
• For water'supply walls, approval of a variance will require that•atlt ltrwal coral'
o istruotion reguirem+ is beyond these
• speeif ed in 154 NCAC'02C .0147 be met Wiliam additional oemtruotion requirements for Coastal Plain and
• i ?' Piedmont'and Mountain region wells.are raced on Attachments A and B�,o pages a�5 of this application.
• Approval of a crarianbe••will not be owmatdered in cases where the specified.minimum additional construction
• xegairements cannot be met.' • 1 '
` I
i G. SIGNATURE£; • • .
i • Stgnainre of Pusan. a faf PFeu Coaste •
al the well driller)
► k' J lth ,
Tr .
Print or die FaNa ne ee atm*.li Imo la) Well Cenitr ietlon •
(typically driller) •,. t
• . ::r><--..f. 3 ' . .
I . •
•
SignatureofCeuat ransmentalHealthSpacie�4at
( Print we Type Vail Name ar Cduatylinvironmentalfhalth!SVecialtat .
. } C •
Per ISA NC4C 02C.0118 the Secretary of the Division of Water Quality or the.division of Pi blia Health may require
• sub;utittal of information deemed necessary to make a decision on the variance,may impose conditions as part of the
' decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance
. •applicant:who is dissatisfied with the decision of the Director may commence a contested case by Ai a petition a�
described iiii G.S, 15013-23 within 50 days after receipt of the decision. I
•
Bator OW-22V Page 2 Revised,Febceari 2013
•

ir
,i 1 ) Z7° It 445'•.usiarea4'1Of lltlfi 1'17 •
•
nt vtnot" k/tt . rent 4"+ 3 1 1' •
•
• TN Y.° .1.
• v Q.( i $ •
• Gr v. A•ez.141h `5Tv-CA-.li .
A R H 5/Ct+rr►' �v.4C (2.5'9 2'3 epte. •
Good morning everyone,
Attached is the updated well territory map with revised contact IhforMation that Includes my new work number as well
as my current mail address.'shank(ou.
•
• • Wilson wills R.E.H.S. •
Regional Environmental Health Specialist
Division of Pubfic.Heaith,On-site Water'Protecttort •
Mirth Carolina Department of Health and Human Services
•
, 27O 66 Vttork fiell •
219-4 -2015 Fax • •
Wilson.MixeiDdhhs, c gov •
Vat Sot Fortis Road •
. 1642 Maid Service Center .
a NC 76 9-uax _ • •
•
•
ttu://ells.ng
tybltdtgaltlj.con}4oswtal • • •
Ematt•correspondence.to and from this address Is subject to the •
North Carolina Public Records Law and may be disclosed to third parties. •
•
•
V911Dbe . • •
Unauthorized disclosure of luventte,health,legally privileged,or otherwise confidential Information,Including
confidential information relating to an'ongoing Stag'proqurement effort,is prohibited by law.If you have received this •
a stall in.error,please notify the•seender Immediately and delete all records of this s-math. • •
•
Roe carespaadence to.and tram No address to aubieatto me Nord cantina Fubuo Norms tan and sisal be dtsctosed•to third gaga by an authcrt ed State
dotal.Unauthorized dt*down of luvenite,health,tagatty ptivneaad,or otherwise con5derdial Ufionriattan,tdeUcdt�eartitdadd lnivm*ll n AMR)to an(MOM
State procurement effort,to prohibited by law.if you have recei!ted tills email to error,pte tee act*the ender Immediately and*tete all recoils dads ill.
•
•
•
•
•
•
•
•
•
•
•
•
•
•

•
N0 ROY COOPER•Governor
git=' 4 NC DEPARTMENT OF KODY H. KINSLEY•Secretary i
HEALTH AND
. HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
_.' , 1 F#UMAMER�/10E
� * MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
September 20,2023
Robert Caldwell
215 Apollo Dr.
Seneca,SC 29627
RE: Approval No.WWM1704
Well Cased to Less Than 20 Feet--Rule 15A NCAC 2C .0116
2063 Sandpiper Rd.,Corolla,NC,27927
On September 19,2023,the On-site Water Protection Section received your request to approve construction of a
private drinking water 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 2963 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 I AFFIRMATIVE ACTION EMPLOYER