GW1--00611_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information:
: ,
? ContractorFROM1I TO DESCRIPIIO\
Well r � Nameft ft b row n slv 1
girl{ IJ 10 z,Ilr wake
or
to n" (7 ft r2 l/ lk. citie1/
NC Well Contractor Certification Number COI ;y.5;:p G(fp= y iiiied l t3lt"MP.IfIlt '=<i
CY1S�V1KrI'lO 4 �� FROM TO DIAMETER THICKNESS MATERIAL
C.irova See/Ctc I f- 1fft IS ft I t/4. 4011(6 PVC-
Company Name �t�{014 f,B -7 �•16 . I CA�TIMINGWaili `- _WT- , *'' '
2.Well Construction Permit#: 1 © 1 5- V"W't I c 51 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UCounty.IC. State.Variance.etc.) tt ft is
ft. fL in.
3.Well Use(check well use):
gi
icef
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural D unicipal/Public Va. ft (S fL I'/; in. r t11O Sssr1/6 PVC.
Geothermal(HeatingiCooling Supply) Residential Water Supply(single) fL f, in.
Industrial/Commercial ElResi ntt2WNLgie ppty sir "' ) . o4, , .. i nit - :. ,: ., >-a- ,_
!�.."-�* t 'r t�FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
-- hiigation - yv
Non-Water Supply Well: JAN 2 5 0 ft- I Z ft- /g beit'Fon.1Cp 4
Monitoring 0 Recovery 2U24 ft ft-
Injection Well: •
1-1 ligor aka n Prat-..53.rtng UF-a f ft.
Aquifer Recharge Groundwater ed..+jt/�a,+
-
��V Y 1..�19i�SAlYDIGI�AYEL':F�iR:B�t£iiii>pliiablei ......� ;..;v 2.hH�.rt�x..�.zFi.-.n,�'�^'.°+'���?w'
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL,,pp EMPLACEMENT METHOD
• Aquifer Test 0Stormwater Drainage ix ft (7 ft to fiiela coi..re4
Experimental Technology °Subsidence Control ft- ft. '
Geothermal(Closed Loop) °Tracer !;20:DRII;idPIG.RLlGfatt»k _. ` tie Y) • 44__ i
FROM TO DESCRIPTION(color hardness.soitrxk type.stern she.etc.)
Geothermal(Heating/Cooling Return) r3Other(explain under#2 l Remarks) ft
Ztfl' 20Z3 � ft. �rowit saH.c!
4.Date Well(s)Completed: I l Well ID# 5- ft' 0 ft r'e)f Sit
Sa.Well Location: (0 f I t ft ,0 t't layer
n. ""tit4411 15eve101pe LLC 6 I ft- (Z ft etrei/ sa tc{fedte skits
Facility/Owner Name Facility IDt(if applicable) ft.
FAO3 Oceesit P&-1 RA, Coroner V11Z7 ft. fL
Physical Address,City-and Zip ft ft I
Crtrri}Inc I 74063001160DV ilt1 ,.,;. — ,.:. :-- `: -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
..lo' 3! ' Li n N Zia S'1° S JI( W 1 fit`tizoz3
6.Is(are)the well(s) ermanent or EpTempoiary Signature at'Ce ed W Contactor Date
By signing tins form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 2rSo - -with ISA NCAC 02C DI00 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 ropy of this record has been provided to the well owner.
repair under#2/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 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: I (ft.) �. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differentent(example-3@200•and 1CI00') construction to the following:
10.Static water level below-top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter. 4, (in.) 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: AUiCr construction to the following:
(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) -t Method of test: ETA: Pk 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: 1-?T(• Amount: t L.S d4. 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

www,arhssitc.org
Permit: 401045 Currituck
•
PIN: 08 A0030011000g ALaEMAtu.ERa IQNALHEALTH SE11W:1:S • `.WELL PERMIT •:. " .
7 • Pannell in Public Halt •
• PERMIT TO CONSTRUCT PRIVATE.
• • DRINKING WATER WELL
•
Owner: . • " , • '. Applicant:•
Goodman Develope LLC • , Goodman Develope LLC •
• •
5004 Kemps Farm PI 5004 Kenips.Farm PI •
Virginia Beach;VA 23464 Virginia Beach,;VA 23464
r .
4,1
. EX. FENCE w
Location: ' IRON FLUSH :-' •
' 2203'Ocean Pearl Rd , x 6.0' X 6.6` �J ; - (2. X 6.7'
C I } fi/} r/ • 25' MBL r• PROPOSED 2 e
D �vl U/ (' .�,/Gr`� r-;[fe ` WELL Pa Trid
o
4 e o1 ec' 0 in I .R�" :sl y fell
v D c7 ji 74- "p 1/ii•e. 'dell ;rt. Ga/1; • HVA
X 5.^' . 2' CANT. ►A' 11, -
Area 414 - uld a f loc✓ "r„wevt er~' .1r.7 . . . ' X 50' 45A' o/ (''
.cc� led .aio .._.w.eL.o..4e'C.. - - : TYICAL °� 4. " ... .. ..
1. . ... ..... ... .. �. •
ROOF I 14 0 "'
. OVERHANG • ; PROPOB I
aWELUN
0 ON PILIN •
Za
•
g,l PART. CL. n.{`x OC7 •
. PROPOSED'
X 7.0' SEPTIC AREA X 5.4' I X 5. I
• . m. III 2s.o' 1.'1
'PaRCH
tf,' • • I M, ilta.o' � 11. •
I
_ - I.:_ iold__ - 4 .
20'^`EM L M
L•
• X 6 7' -° "a` 7.4' '
a510' I d
X.6.2' �'
Ocec+M tn '� led • •
**The well pump must be Installed by.a Licensed Well Driller,a licensed pump installer Level C or •
D; " •
.or a Licensed Plumber with approved education within the last 2 years on-pump installation and well .
disinfection.Only a'•Licensed Electrlclanfor Licensed Well Driller can wire the Pump** I -
SHALL MAINTAIN'25FT+FROM BUILDING PERIMETER • '
SHALL MAINTAIN 50FT4 FROM ANY PART OF SEPTIC/REPAIR AREA- • I "
• MUST BE INSTALLEDBY CERTIFIED WELL CONTRACTOR • •
PERMIT MUST BE ON-SITE DURING ALL PARTS.OF THE INSTALLATION j
CALL AT LEAST 1 BUSINESS DAY PRIOR-TO GROUT AND WELLHEAD INSPECTION .
"WELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FOR AT LEAST.24HRS PRIOR TO use- • .
•
• ' Permit By: /�/ �'/�/� . . •Date•' 10/10/2023
G�/Ltii/ ' /'vim/ '{
• Melton,Tucker
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.
.

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THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION RALL BE VALID FOR A PERIOD OF 60
MONTHS AFTER THE DATE OF ISSUANCE.
. . .
. .
The issuance of the Certification of Completion in no way guarantees tile Issuance of other local,state or federal permits.
• . . .
The issuance of a Permit for Well Construction in no way guarantees the quality of the chinking water.
. .
Wastewater systems and.water supplies shall meet state and/or local regulations. • .
NO CHANGES IN THIS DOCUMENT ARE ALLOWED UNLESS PRIOR APPROVAL IS OBTAINED FROM THE HEALTH
DEPARTMENT. IF THE INFORMATION SUBMITTED IN THE APPLICATION FOR DRINKING WATER.WELL CONSTRUCTION
IS FOUND TO BE INCORRECT,CHANGED,OR.IF THE SITE IS ALTERED,.THE CONSTRUCTION AUTBRORIZATION SHALL
BECOME INVALID AND-MAY BE SUSPENDED OR.REVOKED. •. • .
• . .
When contacting the Environmental Health Office concerning this document,be sure to know the application number. The number must be ,
used in all inquiries and inspectiOn requests. • . .
. .
. . • .
The EnviromneatHealtla Staff can be located at the following telephone numbers.between.8:00 a.m.and 8:30 a.m.,Monday through
. . Friday,except hlidhys. The office telephone numbers are: . .
. • - • . .
. , . - • . --- ....,.. -
Camden. .N 338-4460 Pasquotank • - 338-4490 - ;
Cho . Piii... 482-1199. Perquimans. ........ .... 426-2100 . .
Curriirct\ V".-.232-6603 Bertie. 794-5303
Gates • 1,1 • • 357-1380 • •. . . •
'k • . . .
Well Contractors are responsible for netifYing the Environmental Health Offices for grouting inspection,well bead inspection,and required
---- • . water Sampling: Drinking water wells must heiiiip-icted and approved by a representative of the F4Viroimientalflealtlatiff before any
portion of the installation is•covered and/or used. .
. . . .
ISSUANCE OF A DRINKING WA rAt.WPI 4-X.PERMIT SHALL INDICATE THE DRINKING WATER WELL HAS BEEN
CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIONS,BUT SHALL IN NO WAY BE TAKEN AS A
GUARATEE THE QUALITY OF THE DRINKING WATER. . , . . .
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**Minim.urn Distances** • - '. . • 0 0 "
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Private Drinking Water Wells to: ' • • • .
(This listing is not all inclusive,please see 15A.NCAC.02C.6107 for complete listing) . .
1) Ground'Absorption Wastewater Systems 100 ft . •
(includes existing septic tank;drainfielci,repair area,.
.
or area permitted for an an-site wastewater system that has • - .
" .
• not been installed,and a,designated repair area for that system)
2) Other Subsurface Ground Absorption.Waste Disposal SYsioXis 100 ft . •
• 3)• Industrial or Minicipar sludge-spreading or wastewater-irrigation sites. ••. 100 ft • -
. 4) Water-tight soilage or liquid-waste collection or transfer facility • 50 ft . •
5) Chemical or Petroleum Undergrotmd Storage Tank - . _ 100 ft.
. , , - • •
(does not provide secondary containment) .
' . 6). Chemical or.Petroleurn Underground Storage Tank: . ' •• 50 ft • •
.
- (does provide secondary containment), . . • •
• 7) Spray or grip Irrigation Site . • 100 it
•. . .
(or any other trades 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 grotmdwater 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 . • •
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�� ;No� ROY COOPER•Governor
f — ,
1 tv, 1, 41 a�`5 NC DEPARTMENT OF . KODY H. KINSLEY•Secretary .
HIE LIFLAND
f' HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health
1 `' MARK T. BENTON•Assistant,Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 27,2023
Goodman Develope,LLC
5004 Kemps Farm Pl. ,
Virginia Beach,VA 23464
RE: Approval No.WWM1751
Well Cased to Less Than 20 Feet-Rule 15A NCAC 2C.0116
2203 Ocean Pearl Rd.,Corolla,NC-27927
On November 22,2023,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 2203 Ocean Pearl 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(9.19)-270-9665 -.-
Sincerely,
l - } 41T a� L,
•
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