GW1--06658_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ti rh,o Hi y J . En91 ish •.:FtwAlakwxss:- - r,' , ,. . :
FROM TO DESCRIPTION
Well Contractor Name , 5 ft 1 b ft *an!i odor'
(41ztB
i Lb ft 0a ft 'ti{4'('a,}iid-aFg men/odor
NC Well Contractor Certification Number : UIPTER CASING(fob.:mulif 'ii elfitiOA;i &:(R:- '
T"- -'"
1s
FROM TO DIAMETER THICKNESS MATERIAL
C,aro,oL 5erv►cL avid! C Mitt'bo 4 ".C. 4‘ ft , I S ft 1 tiq I in. scti rid PVC
Company Nacre �( 72.5
r -.16i 1NNE1t CASIi�G*11fili7SI iG'lReollia l: i
2.Well Construction Permit a: 3`� 1 Ly 2 by�J5 •-M I 1 t) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits tie.01C.County.State.Variance.err.) ft. ft is
3.Well Use(check well use): fL ft I to
17:.SCREEi+I:: iVi n-7 ':' 7*4. -i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unici aliPublic .3 ft ft t(in PV
Gothermal(Heating/Conlin Supply) Residential Water Supply(single) J IT
I C�l ' SGk`�� r`r C
g PP ) � fL H. to _
Industrial/Commercial EDResidential Water Supply(shared) ,Tisi.GROLrf :
.f - .0F is :1
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft' f 3 ft %'bentaitae poured
Monitoring 0 Recovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge ['GroundwaterRemediation ,. ,5. /GRA P 1 ; )•:> _5:, I _ ' %
Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
jAquiferTest DStormwater Drainage 13 fL [4 fL 9 4%.4 ice u.red
Experimental Technology 0Subsidence Control ft 1 ft
Geothermal(Closed Loop) Tracer "24:DI2II:LIDiGLOGIatt h: a7ce '-^ `r"
FROM I TO DESCRIPTION(color.hardness.soil/mekgrpe,erainsia;etc.)-_
3Geothermal(Heatin�Cooling Retum) Other(explain under=21 Remuks)
�j 6 ft ft brou.rt bavia �� �-' ,.e • :.k.f:.,•
4.Date Well(s)Completed:-1/271 20 Z3We11 ID# ft to ft r sty I l N '�"`�
5a well Location: ft l I ft 1_� (1('j C 023
layer
J tc.k Peoples f 2 ft 1 S ft- q:reY sand !!bide ck(L.s �'f.:: K.,
Facility/Owner Name Facility iDC(if applicable) 'r ft. 1(y ft. si(`firer C f' v) 'l"E y t t{^
aa1,So.1 T 1�Q r Corolla 1 Zi' -7 79 ft. ft. rtl �/
Physical Address.City.and Zip • ft- ft
' l '2.REri :.:..., ;:;;•.. :...c.,.:.•y-_c: .3�;: ?-"�� .its'ei
C;urrt11,ictc o�r7�-acb—ocdS=acn /�, �J '� /:::_.:; = >- ..�`::_
County Parcel Identification No.(PIN) 6-t"7513ky .Q_LR-L'-reY1Ce &-arddler €Vill
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Co`-' ry( 1 Parke•r
(if well field.one latloni is sufficient) tr
t 22.Certification: r
Signature of 5 . /Z7/eoZ3 -
6.IS(are)the well(s)acermanent or ['Temporary
d We ontractor Dare
Ey signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 1:2Ko with ISA a1t'AC 02C.0100 or/5A NCAC 02C.0200 tVell 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#2/remarks section or on the hark 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 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: 15 (ft-) ; . For All Wells: Submit this form within 30 days of completio
n of well
construction to the following::
10.Static water level below top of casing: Jr (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use'•"i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 34a
12.Well construction method: ihtge above,also submit one copy of this form within 30 days of completion of well
(i.e.auger.rotary.cable,direct push.etc.) construction to the following: •
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Pt ug&am,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gP ) at Method of test: (7Qf P1L1190 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. Amount: •S tea. completion of well construction 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

Permit: 381725 CurritLtck' f
• ,WELL•PERMIT �=
PIN: p87A0060005000�! _'
Ainewta[.2ReGioNt.LHEALTH SW/ICES
• . Farmers in FwSc Health •
Owner: Applicant:
Jack&Lori Peoples Jack&Lori Peoples
• 1505 Head of River Road 1605 Head of River Road
Chesapeake, NC 23322 Chesapeake,NC 23322
• • EXISTING CANAL
Location: • acasrrc
2215 Teal Road LADOFI�- -• - - .
•
4 ist1�G -L._r. .�' - _ _ s ro-44' a7' Es 10a04'
—WELL MUST MAINTAIN• le e.. i MINIMUM FROM ANY• •
• . 11 , .. ."' - -. .: .-.. ...,.: ,.. ,Fr
PART pp•SEPTIC SYSTEM/REPAIR AREA•• LOT 5
•WELL MUST BE LOCATED AT CEAST 25 FEET FROM Bt4 NC . • 15,54Z 14•Sq.Ft 1t°f
,,,✓
0.+36 AC.
-WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING • • 30" CAMA.
FOUNDATION � 1 I �
WELL MUST BE INSTALLED BY•A NC LICENSED V KILLER � � �,.
W- ELL PERMFG MUST BE ON LOCATION DU . G ALLTERIODS _ � • ih,1,P-NI?
OF WELL INSTALLATION • - 32QPi
-CALL AT LEAST I BUSINESS DAY PRIOR FOR REQUIRED • O I 4PRZRat .INSPCTIONS OF GBOLrr AND WELLHEAD - 1 - HOUSE o _ .380' I
• _ i .
• :� . - : : y
..kt ✓"�/> us•
mow•
. . ;sza iii:'-,---'--- • '' i
ric4 . lilt
•
`. •..- ' A '•'�rr> Tom'
ts
70a 00' 't- N 09' 03' 49" W •
• TEAL ROAD !(50' Rory)
Permit By: ' • Date: 09/26I2622 •
o ,Jo r r
•
Certification By. • • •Date:
•
Construction has been completed,a•Residential Well Construction Record Form GW-1a has been
submitted and'inspections have been completed in accordance with 15 P NCAC 02C.0300.

n
11A714;yo•. ROY COOPER•Governor
7,4'4F,, >� >, _ " NC DEPARTMENT OF s KODY H. KINSLEY•Secretary1,1:41 HEALTH AND
1:� 1 HELEN WOLSTENHOLME• Interim Deputy Secretaryfor Health
• , r HUMAN SERVICES P Y
�'� s , `< ,; MARK T. BENTON•Assistant Secretary for Public Health
. Yt
i Division of Public Health.
Onsite Water Protection Branch
September 27,2023
Jack&Lori Peoples
1505 Head of River Rd.
Chesapeake,NC 23322
RE: Approval.No.WWM1710 -
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2215 Teal Rd.,Corolla,NC 27927
On September 27,2023,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 2215 Teal 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,
�.._.Q_z::r rrn� ��..� .�.•_...
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 I
MAILING ADDRESS:1642 Mail Service Center,Raleigh,NC 27699-1642
www.ncdhhs.gov • TEL:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER