GW1--06657_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tiny, 4i y J . Enetish ....._._.
I4.'?VATEF.ZONESs:-c•:i:;:?.€.'::"rz.: h,,:.t....;1, i :;. ,:,: r:;= =t=^
' FROM TO I DESCRIPTION K.
'� Well Contractor Name �/
t $q B a it. 14 ft. I b'roiwn,s me Ili 1.�/ l rife tyre(
ft ft
NC Well Contractor Certification Number
•15©IlY`ER•CASL•�iG(for:l�ti<•absi��ce'�S3�A &f��p��bie�`�.:��-`�'`-�-.-.
car°va 5Jerviuc ex / „SL___1_O n t t C FROM TO DIAMETER THICKNESS MATERIAL
Company Name \+0 T�1AGsf1 VLi I ft I t' ft i l if
is 56h i1;1 PVC,
q >r6d NNER`cASING TEBet�ififit eaiie .lit/ :=�:..Tcia.1:.;
2.Well Construction Permit#: J 7 511 W W M 170(t FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ti.e.UIC.Camay.State.Variance.etc.) ft ft i in
3.Well Use(check well use): ft ft. in.
Water Supply Well: r.17i.SCREEidt i` ::. x ,t -` ,�v -T ;=
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13 unicipal/Public 42 ft D 14 fft. 1 lif in- Dla (10
ptic.
Geothermal(Heating//Cooling Supply) Residential Water Supply(single) ft 1 ft
Industrial/Commercial ---- --E3Residential Water Supply(shared) =1 { toII3= y r_i4 r
Irrigation —. ,.. „•-,,,. r:„a`.,� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: "t < ' - L ) ft- ft
Monitoring ©Recovery ft. ft.
Injection Well: O 6 2023
ft. ft.Aquifer Recharge OGroundwQt r emediation '
•.19 SANDIGRAYEL:PiMETif-" `S s:g . ti
Aquifer Storage and Recovery Salk 5: "P•=::•MEN _ -
1 t+ 8.,..-- ;Jr.^.!`.s/,3*i''�VS''•+FROM TO MATERIAL
EMPLACEMENT
Aquifer Test DStormwater Ilcziriiee 5 0 (Z 8- is— ft. Mead •SaH4 Pc ufefil
Experimental Technology OSubsidence Control ft. 1 ft.
Geothermal(Closed Loop) DTracer ZOi.DRILidNOSOGdattaehaddltleneF ..:.,.-• ...
Geothermal(Heating/Cooling Return) Other(explain under 7421 Remarks) FROM
TO DESCRIPTION(cob(.hardness,son/rook type polo sta•err)
a f- 3 ft S4 kid Cbr-awrl)
4.Date Well(s)Completed: 1 q J/'1Q�/7.023 Well ID# 3 F s ft grey S4Md
Se.Well Location: ft- q ft- yea-I" -
6dskici4e I' Bed.sW ilk I}ots es U.0 to ft Of ft- Trey..(A.I sheds
~-'- FacilityiOwner Name Facility IDt(if applicable) ft-
i97.3 dccch Pam+-�� C�tG�t , 27� (5 (co yreY st lt1claI
Z7 ft.
Physical Address.City.and Zip p ft. ft
Cctlrrt-I-(4(IC Oi)4ecoo I d 1Oil`. '23:<tEM�AifK3:'.'.. 4 cr a � .°
County Parcel Identification No.(PIN) ASS t (;cc G✓ �fv r c-ate fhlvotW'il' Lis
f �t
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �aV'7i Pti.V, r
(if well field.one lav1one is sufficient)
oo
q�D t �1 e� C r r. Certification:
J N 15 5t Y2 W
6.Is(are)the wells) ermanent or Temporary Signature of Ce fled w' Conoactor Date 1/2 7/2.423
By signing this form.1 hereby certify that the well(st was(were)constructed in accordance
7.Is this a repair to an existing well: QYes oro ' with ISA NCAC 02C.0100 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 copy of this record has been provided to the well owner.
repair under*21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same
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 i
9.Total well depth below land surface: I ft. o i
For multiple wells list all deptrs;fditferent(example-3 00'and 2C100') ( ) -� For All Wells: Submit this form within 30 days of completion of well
construction to the following:
I0.Static water level below top of casing: a. (ft-) Division of Water Resources,Information Processing Unit,
If water level is above caring.use"•-. 1617 Mail Service Cnter,Raleigh,NC 27699-1617
11.Borehole diameter.
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(in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: Ai er above,also submit one copy of this,form within 30 days of completion of well
1 construction to the following:(i.e.auger,rotary_cable,direct push•etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
e�
13a.Yield(gpm) 'mil Method of test: (PAS Pul11t 24c.For Water Supply&Injection Wells: in addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H 1 L Amount: 1.7 dL 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

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Permit: 375998 iCurrituck
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PIN: 099A000010900�ti-3 .. WELL PERMIT
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ALDEMARLE REGIONAL Hi &,TH SER"ici
PaRners in PGul3C Heelm -
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Owner: Applicant: 1
• Barksdale&Beckswith Homes LLC Barksdale& Beckswith Homes LLC
444 River Way Drive 444 River Way Drive
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Greer,5C 29651 Greer,gC 29651 -
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20r:Drignage
Location: (PerM.fl.3 Pg.54) '
1923 Ocean Pearl Road • • .' ,4 a a✓.,.r,r,a' ✓..A.:.
3'42.00"°E:Zdfr.t004 '17/4
PeftvrH- .Swordl,fJ r- -1-- :.: Lt�WW I I)El7 ARE;4• ,r_,. C
-WELJ.'MUST DAM-AIN•WY+l M.VIO FOUNDATION , - •'
WELL'hdtt ST MAINTTAIN.•50$'FROM .Of:SEPTIC s - . x 'r''r7 - + .
AND REPAIR AREA • •.•w rr• ..,' r : ,::r .' ,._ -.. "�' i. ��r :� - • r
WELL MUST BE! TAl_ FED WEL 'D�t `•`•'•�`•• f
t�ES E_l137'`i3Y A NC CERTi t 4 ! `•.. ., '
WEt L PERIV IT MUST E3E LOCATION OLt7iNG ALL�P CI4J {, fill, ,} `ti
OF WELL'!N'.a�'YAI:VA'I`IOi`f • . • r r • ,• • �' "1f• Gi.� iU.k Y
_-.-•C LL:AT.LEAST1 S PAY PRt,9R�POR REQUIRE,_ 8' 6;,�.,.... ; •
IN PEOTIONS QF WELLI,OAf] 7! -▪ ``▪ � L . . ,�.._
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�` pa R�•��'re Wit- . witt�j-ricl ; 9 ..:�.t:.::...----• �.y:�.. ..�_..._.:.�•:_ ._�...,.r.
v e'`� �vOI� t,.( oe ��moio-r- f i Pi,.J /:H�j �E R' ,
�-®G*'r ,L W"L i— 0 is m�`J'� ,::id o ; i;
Fly �, .. ....b- .' --->
wMA
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V `7 .i 1. i ' - PARKING. may•• , f
, #4 _ I - 1 AREA.., , '.t6
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LOW.AttE• f.. �/.IP'�' � .rp(V4'
• r«.WW *0*i fic44 I~' •-.:•,n rr
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1ueeati.Peadlif I. , P .
' t/i±rrrip10.1101 In Raatlltriy V. -V •
Permit By: erej,zji •• ' •Ai i r . Dat l: 10/28/2022 NO
p�
eCertification‘By: Date: el e'
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Construction has been completed, a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15A NCAC 02C.0300.

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ROY COOPER• Governor .
NC. DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTH WiEs
HELEN WOLSTENHOLME• Interim De ut for Health
AN SE � Deputy
Secretary
,• ti y * MARK T. BENTON•Assistant:Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
September 25,2023
Barksdale&Beckswith Homes,LLC
444 River Way Dr.
Greer,SC,29561
RE: Approval No.WWM1706 - - - -
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
1923 Ocean Pearl Rd.,North Swan Beach,NC,27927
On September 21,2023,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 1923 Ocean Pearl Rd.,North
Swan 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, // f
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