GW1--07409_Well Construction - GW1_20231117

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: •y1w • E ';Sh •:Y4;�Y(t�R:ZONES �-;.:. , � _s ue �,�.:-: ..
i Ti(M,o {I`i V n9 FROM TO DESCRIPTION
Well Contractor Name rl ft' (O ft b iLo w' Ai July eL'L/
• l
({I s-4 s to ft Zv ft itlftie (40V' tow Slt,ed
NC Well Contractor Certification Dumber (45:!OI)1`ERCASING(fermnlh•caseiiiiii s'EtHt' iiiikilieiNW
FROM TO DIAMETER THICKNESS MATERIAL
Car() 5a icc avid. Cos*4l& o A I L -(- t ft. (4, ft OM in. sit cib PVG--
Va tfv -�"�-'
Company Name :•16:3LVl+l£Rci1S1i��'�1BIl�'lR�o -
- W.
**��Q 23 ,A,L>AA 11?'7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: iJ 0 J Y- 1 J R, ft 1 tn.
List ail applicable well construction permits(i.e.UIC.County.State.Variance.etc.)
ft. ft. 1 in.
3.Well Use(check well use): Tq� x ?:. ,} r ""w-
:-t7:SCREEN';;._. ,._., __
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Ivlunicipal/Public 16 ft CCt ft- (t(q i in. .010 SQl4O Ike
Geothermal(Heating/Cooling Supply) IffResidential Water Supply(single) ft. IL in.
Industrial/Commercial Residential Water Supply(shared) VGROUT,b ,,• g.•,,o ,. '; .; , - is
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation
Non-Water Supply Well: D FL
lc ft f���oeotFat'+. pOULteC(
•
Monitoring ©Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation :r rh tiM E ?
19'3ANDTGR;SYEI:PA {ifable}::. ,
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage `(t ft 2a ft 1$ 1-,a51teetSan en d
Experimental Technology °Subsidence Control ft. ft I
Geothermal(Closed Loop) °Tracer -,•21XDRILLINGLOG(attiiiilts tEsiitiFa ifi a ls3==(ga-`'-%`ii( •eiti n
g C they(explain under f2l Remarks) FROM TO DESCRIPTION(color.hardness,soil/rock type.Rain size,ete.)
Geothermal(Heating/Cooling Return) ( p 6 ft- 5" ft- film- 6,-0,4
4.Date Wells)Completed: t O f /Zoa3 Well ID# 3' ft- to ft yreY Satid
5a.Well Location:
16 ft' (1 ft ip-ea4- /a e(
r E4- .I,I,C it ft ADft. qrey Sul 4 'Li S
-.-� Facility/Owner Name Facility 1Db(if applicable) ft f V -__
5 0 Al ba�-tro55 l.a.�tel corona ejna 2Zfl7 ft ft i:.:-- " < �`.-7 1 `'pd lh"''l-_s
Physical Address.City.and Zip
Ctcrrt'{u(,!c to(ABOooll(,,0062 `21,4tE5FAItK3 rs- Ff #
County Parcel Identification No.(PIN) ,u iyt;,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tn.,—, i ' -
(if well field.one lat/long is sufficient) t t t 22.Certification:
3I(i8 271 III N ?s0 �� w
6.Is(are)the wells Permanent or Tem Signature oFCerti ed d We ontractor D l 20 Z
I( ) () Pot ary
!3y signing this form.1 hereby certify that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or Ili No with 15A:NCAC 02C.0100 or 15A 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 under#2I remarks section or on the back 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 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: L (ff•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@l00'and 2@1001 construction to the following:
10.Static water level below top of casing: cL (ft.) Division of Water Resources,Information Processing Unit, .
If water level is above casing.use"•" Co1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. I� (in.) ?lib.For Injection Wells: In addition to sending the form to the address in 34a
ail( above,also submit one copy,of this form within 30 days of completion of well
12 Well construction method: construction to the following::
(i.e.auger,rotary.cable,direct push.etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) l/( Method of test: (seas Py�� 24c.For Water Suaaly&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: I L Amount: 1.S 01. completion of well construction to the county health department of the county
. where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1 I�
Permit: 381123 Currituck • %16T LLC.-
.PIN: 101A00001160002 WELL PERMIT
,4
AL 6EbtAR ittGioNAL HEALTH
$ER'c s
eablic Health 8
• Owner: • - Applicant: ,
• ESTH LLC • BECO Construction/Beau Richards lisklist.`1
609 lndependence Pkwy 609lndependence Pkwy
Suite 115 •
Suite 115 �/
1#41:\
Chesapeake, 23320. • Chesapeake, NC,23320 ,,,w''" .
•
Location: • `2 -,in.m'� - I ` Arcot .,
• 508 Albatross Lane t i li
$04 2• Lo-r g i . .
5orld ....,
�INEL'i.'Mus1"MAil�i'Fi�ilal '�a.��BfrJ�,t7Fi1+19 FouND,aTioc� l�si�$-- �.'------ ----�------=------_�M--- --,
WELL'
MAINTA ICI OVV1A 'f p) P.T OF SEPTIC SYSTEM• . o > S'e
AND REPAIR AREA •
WELL MusTse INSTALLED EY A NC CERTIFIED WELL•DRILLER' ,. — --' : -' '..' m I'l 9,a° s I :
-',':;
Miegt:0ERM114 MUST SE ON LOCATION QURIIVC ALL PERIOD a' L L•s . -- . s'.:
OF•WELL.INSTALLATIOt�I • '>-'I.:-`',, ~1.;
-CALL'AT LEAST 1 EIUSINESB•DAY PRIOR FOR RE UIRED • • ` r • , '91-
INSPECTIONS OF GROUT AND WEI LHSAD- f '' ' __ '
itil rS L i r„.w.y '�A'86 I.
I =`y '{ x Iy�
el 5 1 xoaa . I and i`
iirp- •---r- --
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Permit By: �'" , , ;1/,•: P' Date: 09/12/2022
•
Ho-. Or '' Joe
• 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.
.

THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR
A PERIOD OF 60 MONTHS AFTER THE DATE OF ISSUANCE. • '
The issuance of the Certification of Completion in no way guarantees the issuance of other local,state or federal
permits. .
The issuance of a Permit for Well Construction in no way guarantees the quality of the drinking water. •
Wastewater systems and water supplies shall meet state and/or local regulations. .
• • ' . .'•NO CHANGES IN THIS DOCUMENT ARE,ALLOWED UNLESS PRIOR:APPRO',V,AL IS OBTAINED FROM ", •. ' ...
. •' THE HEALTH DEPARTMENT: IF THEINFORMATION SUBMITTED IN T APPLICATION FOR. . • • - .: . ;N ,.....*,
•• K.: DRINKING WATER WELL CONSTRUCTION IS FOUND TO BE INCORREC"I`,:CHANGED,OR IF THE Sl'1'x . ':i, '.:
• • 'IS ALTERED,THE CONSTRUCTION AUTB'R.ORIZATION SHALL BECOME INVALID AND MAY BE . ..-.', .:,..-.•';: . - . •
• SUSPENDED OR REVOKED. . : "!
• . -When contacting the Environinental•Health office concerning this document,be:sure to Imow the application _ .
number. The number must be'used in all inquiries and inspection requests,.:. . . -
•" The Environmental Health Staff can be located at the following telephone numbers between 8:00 a.m.and 8:30 a.m., • . •
• . ' Monday through Friday,except holidays. The office telephone numbers are: •
. Camden 338-4460 . Pasquotank.. ... ..... . .. 338-4490 '
. • Chowan • • 482-6023 Perquimans • 426 2100 . .
Currituck 232-6603 • . Berrie - , 7944-5303 •
Gates " 357-1380 '
• . Well-Contractors are responsible for notifying the Environmental Health Ofl.-tces for grouting.inspection,well head •
' inspection,and required water sampling. Drinking water wells must be insp'e'eled and approved by a representative ' •
of the Environmental Healt} staff before any portion of the installation is covered and/or used.
e
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATETHE DRINKING WAIIR WELL
. HAS BEEN CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGII LATIOTS,BUT SHALL IN
NO WAY BE TAKEN AS A.GUARATEE THE QUALITY OF THE DRII IING'WATER.- .
**Minimum Distances** •
•
Private.Drinking Water Wells to: . ' -
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 for complete listing)
•• 1) Ground Absorption Wastewater Systems:.. ...... .....-.: .::.:: ..: ;_.-. 100 ft -•- -- -- - - - - .- .
(includes existing septic tank,drainfield,repair area, . .
- - or area permitted for an on-site wastewater system that has ,
. not been installed,and a designated repair area for that system) .
. 2) Other Subsurface Ground Absorption Waste Disposal Systems 100 ft. • '
3) Industrial or minicipal sludge-spreading or wastewater-irrigation sites 100 ft• '
4) Water-tight sewage or liquid-waste collection or transfer-facility 50 ft .
5) Chemical or PetroleumUnderground Storage Tank 100 ft • '
(does not provide secondary containment) . •
6) Chemical or Petroleum Underground Storage Tank 50 ft
. (does provide secondary containment) . •
7) Spray or Drip Irrigation Site • . 100 ft
(or any other under 15A NCAC 02T) •
• 8) Building Foundations,excluding the foundation of the structure.
'housing the well head. 25 ft
9) Surface water bodies which act as sources of groundwater recharge, --
such as ponds,lakes and reservoirs . - 50 ft • .
• 10) All other surface water bodies,such as brooks,creeks,streams,rivers, . "
sounds,bays and tidal estuaries • 25 ft
11) Animal feedlots or manure piles .\ 100 ft +
12) Animal barns 100 ft
.

ROY COOPER•Governor
i � NG DEPARTMENT'QF l KODY H. KINSLEY•Secretary
1.1:J --„e•:1,„ .,,HEALTH AND
c-HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health •
Onsite Water Protection Branch
November 2,2023
ESTH,LLC
609 Independence Pkwy.
Suite 115 •
Chesapeake,VA 23320
- RE: Approval No.WWM1737 . --. - _
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
508 Albatross Ln.,Corolla,NC 27927
On November 2,2023,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 508 Albatross 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! 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.I
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,
inn
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