GW1--07410_Well Construction - GW1_20231117

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: !
:Ya.,NYtt RAONK V i. r. . .t: RN
FROM TO DESCRIPTION
Well Contractor Name q ft. to ft. broJ'i. isn.e.11t/
NI S ft-B !0 f 915 ft.f liH-te caior/ 6. $$oeII
NC Well Contractor Certification Number -r SZ
L_-_� 'ISflL�£RCASL-'+IG(fia_ . ........ - #�'aiile3=�:;����=�<;:;::
C.ns{Yu'tiho Q I I FROM 1 TO DIAMETER THICKNESS MATERIAL
Cetrova Strvc tz avtdlt l ft. 16 ft- Ai ;in. s�,,qto PVC
11 � I
Companyvame Q �:a�- c.��sstrls--
2.Well Construction Permit 9: 3 O l 1 Z I W W l-3G FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits nix.UIC.County.State.Variance,etc.)
ft. ft. in
3.Well Use(check well use): ft. ft is
i'47-.:3 R501:`)...... .:i... Y;.,- .a--ter.._, _�_- -7._-.u-.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
A cultural unici al/Public ft ft I Iri
� P �� �.� Ilk( � .e)11) Stlz Ya PVC
Geothermal(Heating'Cooling Supply) Residential Water Supply(single) fL ft in.
Industrial/Commercial DResidential Water Supply(shared) :•--
ItliSation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
?Von-Water Supply Well: d ft. 16 IL 7fg (bcOe poafed
Monitoring QRecovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge 0Groundwater Remediation - -
•9.5 f ' :` } PL=EE _ 41W
Aquifer Storageand Recovery DSalinin Barrier FROM TO MATERIAL EMPLACEMENT
METHOD
Aquifer Test DStormwaterDrainage 16 ft- 20 ft- PGuruSit Saud PLlArCI
Experimental Technology °Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer '20iERILLENG O
Geothermal(Heating/Cooling Return) FROM i TO DESCRIPTION(colon hardness,soil/rock type.grain an.ere.)
g g DOther(explain under#21 Remarks)
C7 ft- t' ' (l-ki browIt 5u.tc{ .
4.Date Well(s)Completed: /0123 f 20 3 Well ID# S ft. to ft ?re y cew-d
Sa.Well Location: LC, ft. 1 f' per-- le-Ye(
, 1 054k LLC 0 ft- 26 ft- 9r y SattaCwf cite/Ls
Facility/Owner Name Facility LDS(if applicable) ft.
ebb Alba-4ro5S LGvte1 Corolla. 27erz7 ft. G _
Physical Address.City,and Zip I ft ft , 17- " I '�P_,. iR y 112— Y
Cwrr1-4-..L!C ldl/I-ado()ISDdiED2 `Z '1 tSiiKS .. _ .: . = ^= -,"=.
County Parcel Identification No.(PIN) N O 11"1-2023
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .•
n _ .CerttflfanOn: lrti.'�`••-•;";, r,r•.-- ++'+-.'�j Latta
(if well field one IaUlong is sufficient) ^t 22
6 Z'l f 1 4 N i J O 5-i t ' f/ w
r'';L-::'_,J'7
L
VIII2023 .
6.Is(are)the well(s) ermanent or QTempotary Signature of Ce ed Well ontractor Date
By signing this form.I hereby certlfi•that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 12- o with 15A:'CAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.Jill 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 sertian 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also;attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
I p
9.Total well depth below land surface: ( J (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-3e2o0'and 2@1001 construction to the following:
10.Static water level below top of casing: V (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'••" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (imt) 24b.For Injection 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: f'tia gr construction to the following:
(i.e.auger.rotary.cable.direct push.etc.) 1
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) v Method of test: �7s P 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: 1 L Amount: 1.5 � completion of well construction io the county health department of the county
where constructed. 4
1
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 ,

NC DEPARTMENTROY COOPER•Governor
OF
KODY H. KINSLEY•Secretary'
HEALTH AND I
''Y " HUMAN SERVICES g 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.WWM1736
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
506 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 506 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 dopy 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, i �K;y;:;;`'` 7 .�
Nov 1 i ZOZ3
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 276,99-1642
www.ncdhhs.gov • TEL:[phone] • FAX:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

,
,
Permit: 381121 - Currrituck
WELL PERMIT ,
PIN: 101 A0000150002- l
4
AtuewuieREGioNALtieAL'rrt SERvIcu
Owner: Panels in Public Health Applicant: -
ESTH LLC BECO Construction/Beau Richards
609independence.Pkwy .609 independence Pkwy
Suite 115 Suite 115 I
f
Chesapeake, 23320 Chesapeake NC 23320
i
Location: I
506 Albatross 1.4V -
_ tide .' i\
3gee Z. 1.."-r /19-- • — 9 \,: . . .. . 1 -09111... .
—WELL MUST MAINTAIN�1 FEET MINIMUM FROM ANY
SY •
PART OF-SEPTIC S- MPAIR E AREA / a .0,, _ --- �_�_ "•---:..
-WELL MUST BE LOCATED LEA
ST AST 25 FEET FROM B 4 ND '/ :.. f 'sr. - ^ ,•s.
WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING • ,i,,,,- xioa
FOUNDATION / L n ill
�f i
/ o ?'•l f
-WELL MUST BE INSTALLED BY'A NC LICENSED W • RILLER i ' .` Ai I- _ .I F .I
•WELL PERMIT MUST BE ON LOCATION o QALL'PERIODS 1 y *X. ( 1 -ti TT- . .,:.I
OF WELL INSTALLATION I I . I I �`- *=, '•I� - .1- •
-CALL AT LEAST I BUSINESS DAY PRIOR FOR REQUIRED - =• '_a s r % - • i :
INSPECTIONS OF GROUT AND VWELLHEAD • I tiz • _ .- • 1,r ,
i,
. • i . i :, Z1 :. '
. , I: �' �'1, -ill
�` 1 Y-�{ . yr ,r�' -,. I .
• 1I N
� I � Ir--I--.'
' �,\ • •
t
11
• � � . AL- ritos5 Lx
• . � mr✓ coul,,y,u,„0 11 J
•
Permit By: %/;,�.,. ° /, " I'a Date,: 09/1212022
f : Hc74.: (.:-.-.i, ,
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 15A NCAC 02C.0300. •