GW1--06142_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: '
1.Well Contractor Information:
Ti# o4ity J . Evt9lish .?i4:.W(t')E&•ZONES : . .., . .:.�-. .:n> .f-titi.;.:.a
.� l , •FROM TO DESCRIPTION
--7'-'''' Well Contractor Name J ft- it ft' da.-k.er(,tor
. L(fOf B II ft- 2e, f` rI
wiiit IIfF(e5nte(t
NC Well Contractor Certification Number k1+5,".O(rfrER.CA$PIG:{fo mel6 sed'tveliKtRIDIERFifa xQ`"a`'
FROM TO DIAMETER THICKNESS MATERIAL
(,otrova t$trv► c Censttrulvko n Lc.
+1 ft. Ho rft- t .f In. scyt" Yd PVC
Company Name QJ{ W W M ..]6:rIN1dEIC;CASING RTI1B1B1C�: m:I }` . 1 ieW:
2.Well Construction Permit it: t71 1 F 9 52 -- • •1 1 D 3 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
List all applicable well construction permits(i.e.UIC.County.State.Variance.rtrm.) I
ft ft. in.
3.Well Use(check well use):
,47 SCREEN .ice 'r:s -; Y,..r Kx : 4 rr
Water.Supply Well: OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ($(10 ft. ti ft (ti+f I in, ,OW Sch fp PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. ' in.
Industrial/Commercial' DResidential Water Supply(shared) ' ,- ; ,— , s 3
:f�-fiR011�':x� r rr..,'-';�,�w�.!'.a-rf�:� n._
La.r.
• ' irrigation FROM TO �M�ATERIAL -EMPLACEMENT METHOD&AMOUNT
' Non-Water Supply Well: D ft l C ft !g boLl'I'I'e pouce4
Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge 0Groundwater Remediation :•;19:SAiPD GRAVEI:P S1ift ble?:. A viz vt^_x . - .-
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL- -�'_,^ EMPLACEMENT METHOD
Aquifer Test DStortnwater Drainage ("S ft. 20 ft it/G nn 4 4 • pc srP -
Experimental Technology OSubsidence Control
f. i
Geothermal(Closed Loop) DTracer
0i DRI;IDIa-i OG.(attiettark iHoiiaFs 'Y} -•--r-h +'v;``�'�*=^Y
t-e• � A FROM TO DESCRIPTION(wbr hardness,sofVrads type.grata size,eft)
Geothermal(HeatingCooling Return) Dot ei( 1'to ur rVII Arnari s1A /� ft- F ft brawn
' M
. , t r e i:�r; r •-�cam V L2 b ra W` Sa
4.Date Well(s)Completed: O We11,II�#D y 2023 vIQ ft t( ft di. rlC bfowrllfrGv "-aria
,tr
5a.Well Location: I ft- I 2 ft P&+- taye/
"'iDff,,C�iPdD;'"uR+ ft ft Y/
�-k Kevin. Jr. collier t t2 ft. 1.lyh+ �re1/ w�sHells
Facility/Owner Name Facilit lb9 pp`fcab')
.i01. &urlr'13h CM Corolla, 279z7ft ft.
Physical Address,City.and Zip
C�jrt�l'fa�lc oe- 4�ol lt;ao�l ;RE�1 . -. �;: .....s • :..,: k ._ ZI
County Parcel Identification No.(PIN) Ft7$isi-Pe. by C.Osri Pa/le aM•c( 1.awretice
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lrafekner
(if well field.oneJat/long Iis sufficient) 22.Certification:
/ f �,p / /t
3(ob 31 2-4/ N 77 52 to w /__2(4Eg__Z.5
6.Is(are)the well(s) ermanent off-OTemporary Signature of Certified Contras D
. By signing tht3 form.l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or No with ISA NCAC 02C A/00 or ISA 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 ttnderK2/remarks section or on 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 OW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
jl
• 9.Total well depth below land surface: • Iq (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3V200'and 2@100') construction to the following:I
10.Static water level below top of casing: 5 I(ft.) Division of Water Information Processing Unit,
If water level is above casing.use"•" 1617 Mail Sertiice Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in•) 24b.For Infection 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: A-"7 " 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 Serlvice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .9.5C Method of test: tretS Ns'%f 24c.For Water Supply&Infection 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: TG Amount: 1•S of completion of well constru also'
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

' s-y•Pet it: 201062 n Ctwrituck
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WELL PERMIT
PIN. 087A0010001'000.. .,.. .. ,, . . � :. .
• wnerY t .: :;w. ., , Ai.aer. Re,E, .t.io.•eta ticim, SIR/,cFs': Applicant: .
O
Para»�3 m P.O.W.'Health' ..
COLLIER KEVIN J.• COLLIER:KEVIN J -
:316 PINTAIL CRESCENT N_ 316 PINTAIL CRESCENT
• VIRGINIA BEACH,VA:23456 VIRGINIAFBEACH,VA 23456 • ,
Location I 1
..,Location.:,,, r s
s
401 SUNFISH wLN I% :� I '.
. I,
..5.Vic, 0�t< I Lever" .ft , r
v CANAL I
!JELL MUST MAI !'I'•�kE"I '`yMtNIMIM FROM ANY y ,' I ^-� -` .-.. --- :� ,I r _
?RT'OF'SEPTIC S 'STEMl0 !i r IR AREA :, _ I ,,, `--`-s-. I .� • .
/ELL MUST 8E LOCATED AT LEAST 25 FEET FROM B YI D Z� 1
—
mELL NIUST:STAY.AT LEAST 25 FEET FROM ANY'BUILDING : .3, r i
OUNDATION . . . ,7 u :,. .
/ELL MUST BE INSTALLED BY A NC LICENSEE]\HELL CPILLERt s
deLL PERMIT MUST BE`.ON E.QGATIQN DURING>ALL PERIODS j ` .
•!F WELL;INSTALLATION . . • ,
'''.'.`:"''-''','•' ' ''''''.:,.'''',''',';-J--iP-.."'''''•'''::-.C'' '''''''..:''''f?'',?Y'-'-',., 1;Z::!'-',1•'''IVI-liS2,Yefff 7 ,,... -N'`i-,F24.-rotivgarrfpft, . ,- -.0.o. --..-t--,-
.',„!,. „ • < '••7•'.!!.•"'•,!..y',"•••••••••':fIY.t.!4";•7:•'•"'!!: •'',7•••7:•!':'.:r'4•:!••.Ra".131-541:7*..*-`41,-•-•-•Wn! 't-"'"IiN) '''7i!e' •<.!'•• '
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Permit'By:: I ``, -f •-' Elate.,'12/0912019
H Joe .,-> MI
Certification By: . • : :;. .'. Date:
- •Construction has been completed, a Residential'Well Construction Record Form OW-la:;has been _.
• submitted and inspections have been'completed,in,accordance with.15A NCAC 02C.0300

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Environmental Health Services
ApEMARLERIGIONAL HEALTH SEctVICES
Thrtnem in Public Health
APPLICATION FOR DRINKING WATER WELL PERMTT
• Type: (13 New Well $374 ( ) Repair of Well $374
• County: (%10) Currituck ,( ) Camden ' ( ) Pasquotank ( ) Perquimans
( ) Chowan ( ) Gates ( ) .Hertford
Owner's Information: Name: - rtV„ irt-1
•
2-
Address: ?„,1 'Lv,it•-‘""*„tegtT
•
iH
Vt1)72:3119/
Phone: Cls46-,.t4. FAX ( )
- -
Type of Facility: (IC) Single-Family Dwelling _ ( ) Business ( ) Food Service
( ) ( ) Ch1I1 Care ( ) Other:
. ,
Property Information Property Identification Nimiber: I ill- - --
Lot# t Section Block LI „
Subdivision Ito vor -
eA Wevh-ti
[ot
Size (acres) 1'1 2 ktt-
- );- •
Physical Addreas of Property: gok_ 141 4.RI;- 1- • ne-
- •
,
Please check all that apply to the prepertY and speCifylocation on attached site plan:
Are there any existing septic systems(sitrfice or substeace)on the property?
Are there any existing wells,springs;or Water lines on the propertyl
Are there any surface water bodies or disentitedivetlands on this properly?
,Are there any easements or rieit of on 044 property?
Are.,there any belOW ground cheniical-nr:petroleuni storage tanks on this property?
,Are there any known landfilis waste storage on this property?
• Arwtherennyknown initiereinnao on-thlijproperty2
I HAVE READ THIS,APPLICATION AND CERTIFY THAT THE INFORMATION PROVIDED HEREIN IS
TRUE,COMPLETE AND CORRECT AUTHORIZED'COUNTY AND STATE OFFICIALS ARE GRANTED
RIGHT OF,ENTRY TO'CONDUCT NECESSARY INSPECTIONS TO DETERMINE COMPLIANCE WITH.
APPLICABLE,LAWS,AND RULES. ,IUNDER$TAND:THAT TAM SOLELY RESPONSIBLE FOR THE
PRpPEEittNTIFICATION AND LABELING OF ALL PROPERTY LINES AND CORNERS AND MAKING
THE,SIti ACCESSIBLE SO THAT THE compLug FrPND INVESTIGATION CAN BE PERFORMED.
IIINIWRSTAND IAT ThE PKRMIT,WISSIMD,WLLL ONLY PERTAIN TO THE WELL
'CONSTRUCTION AND IN NO WAY,-GUARANTElESTHE,QUALITY OF.IH DRINKING WATER.
Dill)lei
SIGNATURE OF OWNER DATE
Gates Co. Pastpiotank Co.
'Mail To.ARHS Environmental Health,P.O.Box 189;Elizabeth City,NC 27907 P:[phone] P:[phone]
F:.[phone] F:[phone]
BeHrtie Co. ',Camden Co. Chowan Co: Currituck Co. Hertford Co. Perquimans Co.
P:'•[phone] P:[phone] P:(252)4824199 P:[phone] ' [phone] P:[phone]
F:,(252)794.-5361 F:[phone] Ft(252)'482-6020 F:[phone] F:[phone] F:[phone] '

:C I
ROY COOPER•Governor
;; ;' ( G DEFAF2iMEN 1 OF KODY H. KINSLEY•Secretary
�1 . t i iiuEk ?sEARNvPcEs HELEN WOLSTENHOLME• Interm Deputy Secretary for Health
�-;othit MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
September 20,2023
Kevin Collier
316 Pintail Crescent
Virginia Beach,VA 23458
RE: Approval No.WWM1703
Well Cased to Less Than 20 Feet--Rule 15A NCAC 2C .0116
401 Sunfish Ln.,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 401 Sunfish Ln,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.i 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