GW1--00612_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Ti fro}ky J . English
Well Contractor Name FROM TO DESCRIPTION
1 ft- g' n <uric Y tr r wi ..e1(
�(t $� ` it , tc. ft 444 iwt t:4-4.1e.. smell 0,..,)
NC Well Contractor Certification Number :.-a;_
73 01.FrER.CASING(€iii ti �aw`r 3R$ #ig-'-. a : :,
Car°✓A 5ervccc autd Co a*r c k0 A 1e{.C- FROM 1 To DIAMETER THICKNESS MATERIAL
Company Name
t ft Ita ft l I..` , in. s444ID PUc
_ _ __ _. _.,_..�_.�_
q G 2 •:1ti NNER:' (seatirer ); ieo : i:f . =
2.Well Construction Permit#: 3 q ° 0 71 Ni,) 163 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County.State.Variance.etc.) ft. ft. In.
3.Well Use(check well use): ft ft in.
Water.Supply well: FROM TO _DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 1:3 unicipaliPublic f(0ft- 1 g- ['fly m- e of o c�Ili PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft 1 in,
Industrial/Commercial Residential Water Supply(shared) 4w � .�
p �8-GAflEf�'::
Irrigation t--7f"t... ,4 r* FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: " 're' r Nsti a ., V ft.
1 s_ft 7kIa +vte call e4.
Monitoring 0Recovety(N 2 r q(I24 R ft
Injection Well: J71 sA LU
' Aquifer Recharge G��Ooundwter Re�nediation. I
�I5gTT1*,?-.,.,VII: rigNsf n um ''19:SANDiGittvEIa:P-i acci iiwtrvats...-'+. a>. i.rw ; :
Aquifer Storage and Recovery L}}Salinity Bit�'`+�,J w FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 1(ft. 2,6 ft (q 404.4 p Wed
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer :.D1tILLINt€-dt3Cs(attlett ..- __f } ,.,i_'_ .lY
FROM TO DESCRIPTION(color.hardness.soiVreek Me.gum du,etc.)
Geothermal(HeatinPiCooling Return) Other(explain under#21 Remarks) 8ft- ft. �� J 1
I ,,�( Oda lilt) 10K
4.Date Wel(s)Completed: 9 I 3 12 0JT Well ID# c ft. ft.
l'! r hid� GlOy G®!®r
Sa.well Location: ` Q' f- °[ f e d- I e d
Me &aye Skdvehy t fit LP ' ir6r co eke. 6- lIs
Facility/Owner Name Facility ID#(if applicable) ft- ft
Z35 fe4ce. Cc ftrC0r.(l�L t Z1RZ7 ft. ft.
Physical Address.City.and Zip ,g ft. ft.
CIA.rtl'1. la,c(C. ®�'1flb IQ o o � , `21--. Ih1iK&,::,, • .=',z :" .r^n?
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) e 22.Certification:
3(PO 3 Z' 2, N 7 J a y Z zil1 'f w < ", / ir oz-
6.Is(are)the wells) ermanent or °Temporary Signature o ertified A ContcadFor Date
Hy signing this form.I hereby rangy that the well(s),vas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or rNo with-ISA.NCAC OW.0100 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#2I 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: /Qj SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Par multiple wells list all depths if different(example-Prz.200'and 2@100') construction to the following:
10.Static water level below top of casing: 1-. (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"•"rr 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter. b ciao •
24b.For Infection Wells: In addition to sending the form to the address in 24a
11 Well construction method: Qufe( above,also submit one copy of this form within 30 days of completion of well
(i.e.auger.rotary.cable,direct push.etc.) I construction to the following: i
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicejCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) (2_1 Method of test: 612S Nair 24c.For Water Supply&Infection Wells: In addition to sending the form to
4.. T` A C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 mount: I.7 dl. 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

i
Currituck
PIN: t . Wfl
ELL PERMIT
.
Owner: 4 .
, ,
Applicant:
Meladye Shively ALUwate RaGNwLHe In be
Ica Carona Beach BuHderta
6405 Wyandotte St ��'�►N«�n
. 2182 Selman Road •
Kansas City, 64113 Corolla,NC 27927 -
• ,
ocation: W
. 2353 False Cape Rdf 0145 001 E � fQ0
•1NQLC' 44A014 ,47A,4 Orr+ trOUNoiktotilitg IGp'1�64 • 11 �� •
A�oK WILIST w 1 fit% 'Amy OAT co SEPTIC V i e,EM r� ..r•�r-7�1.� w
AND r..
..fir
aNE.L dIUST BE INSTALLED B.Y A NC CERTIRED WELL•DRILLER• f
' t
o 14 1 8
-MIMI.I ERMf1'MUST BE ON LOCATION ISJR1Nt3•A .PEWQDS'a• u�.j ''
F.i OF WL JNBTAL•tATtON ;• . : . y. ,,r:-,.._?•f,'-CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED • -`s'- T `�' •irl A •—
INSPECTIONS OF OROUTAND WEi.k�FlEPD• i }7 i-', t:
`1 207 • air, S. ..
L• . "Vri 11 I 1 11 ,_r • t
liar l'
. = ' /i E[ii f.r`• %
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to •rr ' :'� �• ,,: • 0r KjXBr�i ^ t-!_��1.�r ill = I
. a w,. .:......W 0 e�
in
F 0• l me.-• L . . r , r
tz:,r lg.
N01'45'OO"W 100,00' i
O fatsel C Road
.4
UnyorevedSand Rotdlwry •
tin'•"
f / ,
Permit By: Airz ,//gip .' I Date: 09/0212022
, ob•- oe .5 •
• Certification By: • Date: • .
•
• 'Construction has bean completed,a Residential Well Construction Record Form GW-la has been
• • , submitted and Inspections have been completed In accordance with 15A NCAC 02C,0300. .
1

•
ROY COOPER•Governor
"� NC DEPARTMENT OF
KODY H. KINSLEY•Secretary
HEA.LTH AND
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
June 2,2023
Meladye Shively •
6405 Wyandotte St.
Kansas City,KS 64113
RE: Approval No.WWM1636
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2353 False Cape Rd.,Carova Beach,NC 27927
•
On June 2,2023,the On-site Water Protection Section received your request to approve construction of an irrigation
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 2353 False Cape Rd.,Carova Beach,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 flaw,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- .c ,am T
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