GW1--07412_Well Construction - GW1_20231117

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
• 1.Well Contractor Information:
+ t
• 1Th Ti01.0+t J J . Evt9 t 5h- Y�,WATFI�ZONES : :, . .
FROM TO DESCRIPTION
Well Contractor Name ft. 11 ft b(= w
arit 3Wily 64'04
tIStoi e IL fL Il fL clPkrllifeS►.ell
•NC Well Contractor Certification Number // ,1..r0(t"1`ER.CASIitIG(fair'htn}tia iAee'1 1)R' (i 7'- ' '"
• 4AHSTswvfrD A FROM 'TO DIAMETER THICKNESS MATERIAL
(,arrova SetvicJe oIr*� .I.( ft. 1)0 ft. t( in. se),yb _ PVC -
Company Name l ' 4Fi . �S sr A
Q� /� wp �7 76'tail+i£it;(itH'�IBIAtG^(eotGe�' e ; ''
2.Well Construction Permit#: 3t3Y-t 4q L>l wM 17 3 F FROM TO DIAMETER THICKNESS MATERIAL
ft. fL ' in.
List all applicable well construction permits(i.e.UIC.County,State.Variance.etr.)
fL fL
3.Well Use(check well use):
1.7 SCEEEt4 ;;..- , t —b€igW4gga:g:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0ivlunicipal/Public 1 CI ft. iGt FL I VI in' o o10 ith'c /C
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) fL fL in.
Industrial/Commercial DResidential:Water Supply(shared) / GRouvi R-. .w
' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ..
Non-Water Supply Well: 0 ft. 1(9 ft- T8 e,itoett k foweaQ
Monitoring 0Recovery ft- ft.
Injection Well: ft- fL '
Aquifer Recharge ®Groundwater Remediation
d9:SANDDGRAYELP-CK if applicable) :;,<;,a _ t?: . ' -°
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 1 It ft Z0 ft. it-ate 22+ul r o-,..
Experimental Technology OSubsidence Control ft- ft-
• Geothermal(Closed Loop) • DTracer -'.20.DRILIINt:-IOG(att/eeh irF Ifit t t•itAt 38 '-
FROM TO DESCRIPTION(colon hardues,so,Urock type,gram size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under'21 Remarks)
0 ft- (¢- ftfL re,wn route?
4.Date Wells)Completed: /I/II�23 Well ID# 6 ft-
1 . er ezia
Sa.Well Location: (t ft. (Z fL p v/-
i• Jot%evittr11 oecr4 FcF (Z f t- to ft- lief( 5ctcs4 ti 6 itell5
Facility/Owner Name Facility ID#(if applicable) ft ft
a,2e{$• 56ndP+Pe(I Co t•o(1ct:1 27127 ft. ft.
. Physical Address,City.and Zip ft. ft. : t `ts .'( ''y„'s', ie Z L,;:
Curt-;14.4 (38.14 001 c0 23oan ;- , It3ptw x u.
NOV1 ( I.County Parcel Identification No.(PIN) '
5b.Latitude•and longitude in degrees/minutes/seconds or decimal degrees: ??rt` 7;,,,":'-i'';1 "'•:::°.:V ''I I I r:71
I N Certification: 2'4+'Z .r O,.
(if well fieltL one lat/long is sufficient) 22
36. 31 Lib' N - '7 -� Si 57 W ��
III (1Zoz3
6.Is(are).the well(s)reermanent or"DTemporary Signature of Certified II Con tor. Date
By 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 dio with I5A NCAC 02C.0100 or 15A NCAC OW A200 Welt 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 1/2/remarks section 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 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9-Total Weil depth below land surface: 11.
1q (ft-) 24a. For All Wells: Submiti this form within 30 days of completion of well
For multiple,wells list all depths if different(example-3@200'and 2CI00`) construction to the following:
10.Static water level below'top of casing: 5— (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•" 1617 Mail Ser vi Center.Raleigh,NC 27699-1617
11.Borehole diameter: (in•) 24b.For Infection Wells: In'addition to sending the form to the address in 24a
etf above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6 construction to the following: j "
(i.e.auger.rotary.cable,direct push,etc.)
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) • C.� Method of test: t7'axi Pyt.1.
24c.For Water Supply&Iniectlon 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: 4TL Amount: I. d'L completion of well construction',to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit 389494 Currituck • www;arl s=nc,org
• .. WELL PERMIT •
PIN: 087A0070023000( • •
AL6iMAHf,E'kVAc 1.Hkntm f!&VICCS
• . .Mantra In Pout Mott
' •PERIYIIT TO CQNOTRITCt.PRIvATE .
. - DRINKING WATER WELL '
. OWner Applicant:: ?
•
Jonathan Becraf Slcarb Properties I. ,
• 14361.Chatter Landing'Dr • PO Box:176
. Midlotian,VA23114 - Mo• yack,NC 27958` .
Location: I
•
2245 Bantlpip'r Rd. a.. I . . .
• st^ " ioaelY `, •
.�- 1450SF
45. i
} 1 .dnCS.- I
i 1+ :
i mow ��;
I.,, v : , 7 . .. •
t vi -4$J 4 ,..."' t wit e
°�, as ,rb "" I�
,�� 1, ��,1)1041`'2.roxts�• 01. i
Ala •
Jr •
Oi�<t6 4t4 , .ip446tb..- �'`
n ,� Nt'dgi?flW 1CaOO j •. a� • . .
t _SANDPIPER ROAD(6Q ,
Well pump'm be installed by•a tensed Well Driller,a licensed pimp installer Level E or P ,.
. `'. The - _
Or a Licensed Plumber with approved education within the last 2<years.on pump instailattori and Well `
- ••disinfection Only a Li'censed,Electrician de-Linen'sedl Well!br'iller can wire`the.Pumpfk'. "
• . ' SHALL MAINTAIN•25F 4 PROM BUILDING PERIMETER '
SHALL MAINTAIN.5OFT+FROM ANY PART OF SEPTICIREPALR AREA, • . '`
MUST BEINSTAI.LED BY'CERTIFIEDWELL CONTRACTOR
PERMIT BE ON-SITE:DURING ALL PAR1`S OF THE INSTALLATION
CALL,AT LEAST 1 BUSINESS DAY PRIORTO GROUT.AND WELLHEAUIt4SPEGTION
• "'1NEi.LAND`PUMP SUPPLY MUST BE:PROPERLY SINF. E;CTEDFORATLEAST.24FIRSPRIORTOUSE* •
PermitBy: •
- •= `., , •• Date: 02101f2023: ,
• Melton,- cker
Certl lcat ioii By: Data:
,.Construction has been completed,a Raeidehtial WelLConstruotion Record Form 3VWI-1 a has been
• , submitted and.inspections'have-oeeri campietad in accordance:wltfi 1`5A NCAC O2C:03OO:' •

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THE AUTHORIZATION FOR DRINKING WATER.WET.i.1,CONSTRUCTION SHALL Br.v.A1.0ROR.A PERIODOF 60
' MONTHS AFTER THE DATE OF iiRS.UANCE, - . • „ ,. ' • ' •
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The issuance of the Certification of Completion.MO way guaranteastelssorinoe..of Otharieeat state. orfederal pens*,
The issuance of a Permit.for Well consult-41ot In-nor'way guarantees the.'quality of the MS10401140. :. '
,
Wastewater systems and water supplies shall meet state tardier Idea:4000mb. ,
.
NO CHANGES•INTERS DOCIIMiENT ARE ALLOWED U/NIESs PRIOR Amovn 1$OBTAIIWINPMTREEE4' TIT
DEPARTMENT: IF THEINFOIMATION SUBMITTED Tht THE APPLICATION WATE0.*ELLCONSTRUCTION
• IS FOUND TO REINCORRECF CHANGED.OR,:IF THESITEIS ALTERED THE MINSTRUCTION AUFFIRORIZATIONSEALL „.
BECOME INVALID AND MAY.BE SUSPENDED Ott REVOKED. -
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When.cOntadtingthe.EnvironmeutatHealth office cenc,erning this docoment,,be sure to know the apnlioation,member. Ilieritiniber.innat he
used in allhupdties and inspection Mama. . . •
The.Envhonmentrd Health Staff canto located atthe following telephone nun:Mars hawks:00 am.-and 100 air1Vionday thteugh. ....
Friday,except holidays.The office telephone anthers
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Widen 3384460 . . .gamin:titanic••,,,...„.....3384490; . • , .
. Chowaa........,..... 482-1199 ' Percmimans.i:........426-2100:•„
Canto:It..•......,. 2324603 Boras,.............,,,,•.,, 7944303 .
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Oates"......,...'.... 357-1380.
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Well Palltraetem ere feePensiblafornOtifyin, g the Envitonraeut, al-HealthOffices fOr grouting ins.pectionlllieailinspectiOn,:indieiptireil
.... .. .-**er sansplint.,Drinking water Wells disk iierhaliehted and approved by a i4vaieiltielyd Of ManikanMentatiltialtnalfbefore any
• - • portionof the installation is covcredvidfor used. . - ., .
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' ISSUANCE OF A DRINKlisiGWATEE WELL.PEPRT SHALL IMPATS ITIRJ0 Mime wikra.lav vi5f,,,i1 frm wit 11
' CONSTRUCTED TO TEE STANDARDS str FOltsEt Dr:Va.itEdtuderiON6,BursaALLIN.NO WAY BEI'41ZIA$A
- -Gu4krai THE,QUAlifY OF THE DitINKII,*WATER. ' .
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**Minimum DiStance.S44 • . ... . • .
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.. Private Drinking Water Wells tat .
(This listingis•aot a4 inclusive,please see ISA.NPAO.02C.0107 ibr ooreplete listing) • .,
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. • 1) Ground Absorption Watbhvater SYstems-.......-.•.„..,,,.,.,-,.,. 100 ft . . " - -
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(bneledegMdsting septic tank;drakfiala.•repair area, . .
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or era permitted:for an on-sitewastewater system-that has. *. ..: . .
not teen instaRed;and a designate&repair'area for.that teea)
• 2) Other Subsurface Ground Absorption Waste Disposal Systems...•,..., 100 ft . . .„
3) Industrial cc Miniciparsludge,spreading or WesMwaMr,irrigatian Otog . 100 it -
• 4) Waterttight sewagOor ligtdd-wastocelleation ot transfer fealty..'„..„.
. 5) Chemical or.Pettolemallnderagenad Sterage.Tatik...,.:,.,..,,,,,,,,„4, 100 ft. .• -
(d.06.5.aoi provide sOmictaiytbitaipident) , .. .
• ' . 6)' aasnietif Oilietrolenta-thidttStnikkalW........::::::-.:.7.-'---50 - .--- --------1- - - - —- — -
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(does provide secondary enmaiument>" '
, 7) Spray.or Drip Irrigation Site.: .• ., .a.,„,,.,...........a....a,..,,.,... 1001 ..
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. (or any other under 1:5ANC . 'AC 021): . .
•8) FhrildingPoundahons,excluding the foundation oithesueture
housing the well head.,'a......,.....,,„......-..„.......i.,.,., 25 ft
• 9) Surface waterledies*hick ad as sources of.groundWateirebharge, .... . .
. ' such as poncts,lak®s atalreserVoirs.....,.,- -:. .-• _.,.: ....- SO ft , . ' • -
10) All other surface Water'bodies,such aSinoolcs,creeks,streams,rii.iers,
sounds,beoandlidal estuaries-.'.....,._,,.,,..,.a...,:•,a...-,, 25 ft .
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11)Animal.feedlots or manure piles,.........,..;,.,.......,,,„.„..:, igi ft .
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• ROY COOPER•Governor
. P � NC DEPARTMENT OF _
d �� KODY H. KINSLEY•Secretary
H E, LT'H AN DHELEN WOLSTENHOLME• Interim Deputy Secretary for Health
9 , .. HUMAN tERvicE;
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 6,2023
Jonathan Becraft
14361 Charter Landing Dr.
Midlothian,VA 23114
RE: Approval No.WWM1738 _
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2245 Sandpiper Rd.,Corolla,NC 27927
On November 6,2023,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 2245 Sandpiper 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,
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