GW1--06143_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
` ..fi4:.wAI'ER7.ONFS:,,-::.1,..,':.;Ii..). a.. ...:....
FROM TO DESCRIFTION
Well Contractor Name 3 ft- 10 ft- dark,- Cf7to(
K(81 e rf 1(f I Lb ft I IA ft t�ZC r I.f flit Sort((
NC Well Contractor Certification Number 15;o[YI`ER CASING(foi'.in OE {i'-- :•'z,e.;:
"� �-flM I TO DIAMETER THICKNESS MATERIAL
(Otrovo strvca avt0� (,p�gSf 1f1FL�'Io 9 (.t.c. ticftMETHCompany Name3� il33 vv WM t e1� � I>r-�R:���I;�-{ :�-��r-:��:�-;��_�-�=,��_:-.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL fL in-
1 In-
list all applicable well construction permits ti.e.WC.County.State.Variance.err.) ,
ft. ft. I in:
3.Well Use(check well use):
;11.SGREIEI:.: :?_.... •.,-;'':,:_, _;-;-; >=~:-=_?:''"; 1:;.-°:T--
_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • Ep unicipalJPublic II(t ft.
t I( ft- E t(c f i"' .d l0 S Ci'L If O PVC. —
Geothermal(Heating/Cooling Supply) �R'esidetitiarWi>:ter Supply(single)— [ (C to -
Industrial/Commercial DResidential Water Supply(shared) ,:rz•;-Y - __ ;z=:_�:; v. `Y-=4< - =
Irrigation FROM TO y MATERIAL, ,� EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft (,C, ft •ilpp,f.14-te fro oat(
Monitoring ©Recovery ft. ft. j
Injection Well: ft ft
Aquifer Recharge 0 Groundwater Remediation ter.
�'I9 SANDIGitAcFEf;:P-AL$ftfa'PPe).':-.:.:.;,:�:_t�'�: ;`;.4 -.:`,=-�=�-_a._
Aquifer Storage and Recovery °Salinity Barrier _FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage t( ft- tQ ft 1*4 SakJ eowred
menta Experil Technology DSubsidence Control ft I ft 1 •
Geothermal(Closed Loop) E3Tracer 2()•T3ItIII IIiGlt' (attrseh'atfeTa7xr " -`°_ v^
FROM I TO DESCRIPTION(color.hardness.soil/rock tree.gram sit.etc.)
Geothermal(HeatingiCooling Return) °Other(explain under#21 Remarks) ft I 3
es brp.Jlt Sarah(
Well
(s)Date Completed: Q/2/zva3 Well ID# 3 ft- 1® ft- dark hit,UM SGs.04
5a.Well Location: f O ft.
l( ft 1Ie-a- - layer
�vetrl. 54-erne r t L ft sr i 3 ft- rer - I<
-• Facility/Owner Name Facility ID6(if applicable) t 3 j i fL q re' $-anj pi.Ste((�•
-D 1O Saeidrtddler Pot Coro[[a V/2.7 ft. ft.
Physical Address.City-and Zip t ft ft
C.tr►t 4 k O$7AO000C9 ZdoD`r '?d;tRE;fdiTRIS.4,:..,. ti. 74i.":711A1-.'$M'e `�:W_x.-I:r:-,=< --t
1 County Parcel Identification No.(PIN) d ``I''7 1.....ii V L.Li�� A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I SEP P 2 9 2I 23
(if well field.one lat/long is sufficient) 22-Certification:
t II r 4
3c
30 �1 N "Z S- 5 I ,4saEFr?.ct Prr.-;;so:eqi(;its
6.Is(are)the well(s) ermanent or DTemporary Signature o ertifi 'ell C ctor • Da
By signing tits form.I hereby cert(•that the wellf t arts(were)constructed in accordance
7.Is this a repair to an existing well: 1:1Yes or No :with/5A NCAC 02C.0I00 or 15A NCAC 02C.0201 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the ropy of thus record has been provided so the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
•
S.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 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 below land surface: 1 (ft-) 24a. For All Wells: Submit Ithis form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 32(m`100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water R(m-ces,Information Processing Unit,
If water level is above casing.use'••'• 1617 Mail Seri j e Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wells: In'addition to sending the form to the address in 24a
�1 1 e r above,also submit one copy of this form within 30 days of completion of well
12.Well constructiontary, method: rT w 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 Serice!Center,Raleigh,NC 27699-1636
.'---) 3� '
13a.Yield(gpm) Method of test: S PiMIII f 24c.For Water Suonly&Injection Wells: lb addition to sending the form to
,..- T t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �1 L Amount: t•S 01, completion of well construction to the county health department of the county
where constructed. If
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ROY COOPER•Governor
-444 r µ,t NC DEPARTMENT OF KODY H. KINSLEY•Secretary
{ HEALTH AN HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
Ilk,''I cr c HUMAN SERVICES
�. • ,.: MARK T. BENTON•Assistant S Icretary for Public Health
Division of Public Health
Onsite Water Protection Branch I
July 29,2023
Evan Sterner
• 1320 Holly Point Rd.
• Virginia Beach,VA 23454
RE: Approval WWM1672
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2090 Sandfiddler Rd.,Carova Beach,NC 27927
t p
On July 28,2023,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 2090 Sandfiddler 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.-
t If you have any questions regarding this variance,please contact Wilson Mize at(919)270-9665.
Sincerely,
1_....1.4_.12.... ^71)'1 17 .51s,�7..-._ .
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 27699-16142
www.nedhhs.gov • TEL:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

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