GW1--00613_Well Construction - GW1_20240125

431b., -t..-n-.:. •`'Sal
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
."` Tirko}ky J • English
Well Contractor Name FROM TOyp DESCRIPTION _ -'n
'// QQ�� Q "I ft. t ( ft 6I-Goi 11'1,,,4,,Ier tI- le-le t5ikell
l Oi " L� ft x ft G4tur Irriee cclor la-hle,sIkef0
NC Well Contractor Certification Number ,,. %a--ire.,i4':�""''
;.15i`OCFTER:CASING'(f�tiialLtattd�e�'tHt�#NER#� -.. �,��_w-..
LGtrOVA SCrVitc atndl Cons{Ylnticon �� FROM TO DIAMETER'L THICKNESS MATERIAL
Company Name 41 � IF ft ( t/T in. SCA `� PVC
2.Well Construction Permit#: 11 TO FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(BC.County.State.Variance,etc.) ft. ft ID.
3.Well Use(check well use): et. t in.
G MN
Water Supply Well: FROM r Y�DIAMETER SLOT SIZE THICKNESS MATERIALA�Agricultural 0 unicipal/Public 16 ft. tt t in
Geothermal(Hearin Coolin Supply) R [ e h. atei'Sb leiL ® . G`� � ��
f� g PP Y) l[tr �• ek?tY S ft. ft. in.
Industrial/Commercial DReSldirntial V r SIITiP f(sham ;pk•G3ItOlir , x: ; g"4 :-.. ,_-;. =1
Irrigation J A N 2 2024 FROM TO C- MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- I't/ ft. y►6b[Ata a po
Monitoring QRecov_e n i.s ft ft.
Injection Well: , kv".C, fC 1' .._...- ,,,
D CAOG fL ft.
Aquifer Recharge ©Groundwater Remediation
,i 19 SANDFGRAYEEP 1CK appl cable} -z-: :4;.> r ,x.-F.__-r,?..c W-9
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage I ft. 20 f ,4144 pou,red
Experimental Technology D Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 10aIRI ;LINGLUGdatti 5addiffiidiPaTeeisi rYl 1 it
FROM TO DESCRIPTION(color.hardness.soiUroek type.grain size.etc.)
Geothermal(HeatinVCooling Return) 0Other(explain under a21 Remarks) it 5 0 ft ;ligkI- brown
4.Date Well(s)Completed: 14 lift
OZ3 Well ID# S ft II ft I)rey sue}
5a.Well Location: I,1, ft. 1,2 ft. pe }-layer
n. Case. De,I-or ( L2 f" 15 ft grey 5A44/1.(tr4k-1)
Facility/Owner:fame Facility ID:'.(if applicable) (5" ft' ZO ft iJ re.
v W' 6/Ie.4l,s
a3b0 Oeeansanets iQ 4, Coronet 1 L75'21 ft. ft
Physical Address,City.and Zip ft. ft.
Carr't IC tniii-01 f1y�j o eb'Oo i `21r4t€MilitXR ,:. -'. ._ -s" •,-= ;
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:
3 O 3Z1 -31" N 15 52 'el w e fZ/i�/�23
6.Is(are)the well(s)rgermanent or Temporary Signaturee6fee ed W Con or Date
/3y signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or No - with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 IVell 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 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 1 GW-I 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 I (ft-) , For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3g200•and 2 tt 100') construction to the following: "
10.Static water level below top of casing: 4 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"• 1•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 1i/ (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: A it j t✓it 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
ITh13a.Yield(gpm) Method of test: (Pets P*s if 24c.For Water Supply&Ii iection 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: 1•S 01, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
•
Permit:' 393318 Ctirrituck svww•azirs-nc.org
PIN: 087A0180008601 ' WELL PERMt�
• AL9E�rn t Ru nneao Pa h,I,,ic �a+nas
PPERMIT TO CONSTRUCT PRIVATE
• DRINKING WATER WELL i
•
Owner: Applicant:
Casey DeFord • . Casey DeFord
166 Whites Neck Lane 166 Whites Neck Lane -
Knotts Island,NC 27950 Kriotts Island,NC 27950 •
Location: ` I.- I• /00 _
2360 Ocean Sands Rd 1i
4 deep Ile it 50Pk or-,vnorc Apr"
Any f ovvi- & an v E'p i -6 y.Ocrn
• 4keer Wen 3,6Pi oral or i ; y,,t , , , _ - WC'
Any c&v,1e r _ _, ..... —
ip Lb/tsv(4- W•4A WeI ( Dr;ll_r "eD4-,aC'`'
v s
40 a1e-leri :r,e I P et. v ,-.;ctr -• . t i
• e
r5 yd. . '
. �_ • • ' •
•.Home I Q X -
1 •
/1.
as,;
1,le•IL frcpa L. Ucean 3ovt4 LA- Qrlytl
1 ""The well pump must be•instalied.by a Licensed Well Driller,a licensed pump installer C or D, /+' I ; -'`
or a Licensed Plumber with approved education within the last 2 years on pump Installation and well ve L ,
disinfection.Only a Licensed Electrician or.Licensed Well Driller can wire the Pump"" , A,r; ,
SHALL MAINTAIN 25FT+FROM BUILDING PERIMETER ep
SHALL MAINTAIN 50FT+FROM ANY PART OF SEPTIC,REPAIR AREA -
MUST BE INSTALLED BY CERTIFIED WELL CONTRACTOR • • •
PERMIT MUST BE ON-SITE DURING ALL PARTS OF THE INSTALLATION
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: 14 Date: 04/19/2023
Melton,Tucker
I Certification By: balls•
I
Construction has been completed, a Residential Well Construction Record Form GW-la has been
submitted and inspections.have been completed in accordance with 15A NGAC 02C.0300.
I -

•
•
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 INTHIS 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 AUTHRORIZATION 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 Environmental Health Staff can be located at the following telephone numbers between 8:00 a.m.and 8:30 am,,Monday through
Friday,except holidays. The office telephone numbers are: .- •
•
Camden 338-4460 Pasquotank 338-4490 •
• Chowan 482-1199 , Perquimans 426-2100 , - , _
Currituck .. 232-6603 Bertie 794-5303 '
Gates ' 357-1380 '
Well Contractors are responsible for noiifying the Environmental Health Offices for grouting inspection,wellhead inspection,and required_
• • ' water Sampling. Drinking water wells hilt ifeihspeotdd and approved by a repre§entative at the Em irotrneniai}karma any •
portion of the installation is covered and/or used. •
•
ISSUANCE OP A DRINKING WATER WELL 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‘ •
GUARATEB THE QUALITY OF THE DR]NKING'WATER.
**MinimumDistancesc* • / •
Private Drinking Water Wells.to: CC
(This listing is not all inclusive,please see 1SA.NCAC.02C.0107 for complete listing)
• - r
1) Ground Absorption Wastewater Systems 100 ft •
3 pa-i
vvi
• (includes existing septic tank;drainfield,repair area, •
or area permitted for an en-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 - ti'L°
3) Industrial or minicipaTsludge..sprealtng pr wastcwate.-irrigation sites . 100 ft •
. 4) Water-tight sewage or liquid-waste cbllee,t* of transfer-facility: .": 50#t _ ---- - -
5) Chemical or PetroleumUnderground Storage Tank • 100 ft
•
(does not provide secondary containment)
• . 6). Chemical.or.Petrolerrm 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 fl
12) Animal barns 100 ft

} ROY COOPER•Governor
gs v}
'1-HEALTH
DEPARTMENT OF � KODY H. KINSLEY•secretary
H FAUN ERV1
HUMAN SERVICES._ ._. HELEN WOLSTENHOLME•Interim Deputy Secretary,for Health
h MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 27,2023
Casey DeFord
166 Whites Neck Ln.
Knotts Island,NC 27950
RE: Approval No.WWM1750
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
- - 2306 Ocean Sands 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 2306 Ocean Sands 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 welllannually 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