GW1--00615_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1Tioo iw J . Ehgts a 5Rt
FROM TO DESCRIPTION
Well Contractor Name
Li $�{ FLfL (>rrty. 5I I4) j/(semen
1 ft t 3 ft 6tzwnish calm'w/ 5=Meij
NC Well Contractor Certification Number ,gS;Q(prEK ING'(formtilh i:IIYB&;t "•' '' z e==
_r°V& 5erV K a /_„SL__ 0 n �C FROM TO DIAMETER AIlC"KNESS MATERIAL
Company Name C. �1Wft �- I ft. ID ft 1,1r ,_...ia__Ali
�0 Qtf
�`�a�{/�f/� W y :.�14ar iERICASINGX:48AM� ilaeed`aaoa;< :. -�=
2.Well Construction Permit#:310120"V W A I-716 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK...County.State.Variance.err.) ft fL 1 to
3.Well Use(check well use): tt- ft I is
Water Su Well: =FROM
R:SCBTFti' _
Supply FR .- ...
OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unici allPublic ft. f- l ;iti
p tO 43 1 �¢ t`iv so lb pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL f(- t is
Industrial/Commercial D Residential Water Supply(shared) agitiotmii.,!,.,,,. .,,,:::._:; • _,�-.,M r7; c 4 7,77
Irrigation FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- L 8 ft 14 bents,ft-le pou-fed
Monitoring 0Recovery fL fL -
Injection Well:
fL fL ,
Aquifer Recharge 0Groundwater Remediation =19:SAND)GRAV PACK aitelicable) V z h1. r z0 a g
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage 10 fL U"t ft rw/s{&{5. poured
Experimental Technology DSubsidence Control ft. ft I
Geothermal(Closed Loop) EiTracer ;'•20::DRII;LING'Lt (attach alcet if ''. ` t 4,- 4, �"
Geothermal(Heatinooling Return) °Other(explain under f2I Remarks) FROM TO DESCRIPTION(eolor,hardness soil/rock type.grain size.etc)
0 fL a— fL brown dif' cikhd,, a)(
4.Date Well(s)Completed:iliel'�z3 Well ID# 7� fL 1 ft qti ty slt qe f s fT
Sa.Well Location: f ft-
5i 11 w1 Jl14IQshells
rTh. 6er i- l}arrel I ft. ft. .
Facility/Owner Name /� s� Facility(/D#(if applicable) ft. fL , ,(' � s� '
Physical k/ Airt �Ito I I t t a'`�R°L! ft.
JAM 2 r ��L�
.City.and Zipr
C/� 1��(6-6G 6117400600336610 `21'.•RLIv1ARKS. -....,rl. .w :=-f' .'''',t°�=e.:ii�
L/i4 1'� -_ ..- :J�i�lt trv�rerx it t .-' �Nu�.:v�Uf`t��i
County Parcel Identification No.(PIN) Db1/(`,. I1(=
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
(0° 30` 3R" N 7e? SZ z.31 w '^/7 Si I?/2/f ecs 23
6.Is(are)the weil(s) ermanent or Temporary Signature of Certified elve'I Contraefor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repairto an existing well: ®Yes or No with 15A NC:AC 02C.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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
:r S.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-i is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
, drilled: • SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@100'andd 2@100') construction to the following:
10.Static water level below top of casing: (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•. IL9 (in.) 24b.For Infection Wells: In addlition 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: Cr. 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
's
13a. �(Yield(gpm) T Method of test: �7A: Pawl24c.For Water Suppiv&Injection Wells: In addition to sending the form to
,1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: [4TC Amount: 1.5 o'L 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 Resourcei Revised 2-22-2016

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Atara1,t 111atenONActttAITII StWitd.cf _,
PERMIT TO CONSTRUCT TRIVATE
DRINKING WATER WELL
Owner:. Applicant
• ,Bert Harrell; Bert Harrah •
337 Back At Crescent 337 Back At Crescent
rginia Beach,VA 23456 Virginia Beach,VA 23456 .
. i 11 li
Location: ,; n
512 Brant Rd
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.PROPOSED stmaone tat
rt6•er
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*CThe�well pump must be installed by a�Licensed Welt Driller,a licensed`pump Installer C'or D,
or a Cleansed Plumber with approved education within the last 2 yeata an pump installation and,well .
disinfection.�Only;a't icensed.Electrician Cr Licensed Well Driller can:wire the,Pump"
SHALL MAINTAIN25FT+FROM BUILDING PERIMETER -
•,.;. SHALLMAINTAIN SOFT+FROMANY�PART•OF SEPTIC/REPAIR AREA '
MUST BE INSTALLED BY CERTIFIED WELL CONTRACTOR
PERMIT MUST 6E OW-SITE otigir'stn,Ati PARTS OF THE INSTALLATION 1 •
CALL AT LEAST 1 BUSINESS:DAY PRIOR TO GROUT N WELLHEAD INSPECTION
"dowELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FOtt AT LEAST 24HRS PRIOR TO USE"
`Date: 02/2/12023
Carver,Kevin •
Certification By: ._. ° __ Data:;
` Construction has`been eompteted,-a:Residential Well Construction Record Form GW-la,has been
submitted,and,inspections have beep-completed In accordance with 15A hNCAC 020.0300.

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NORTH C.AROLKA.DP.PARTIVONTOB iPitimo, NMEOTAINDI4AnntAL RESPURCES,
. -
VARIANCE APPINATIOK FOR 2C.0100 WELL 'CONMITICTION STANDARDS:
PRIVA,TE DHVICIld WATER'WELLS UNDER MtiCAC 02•C.0i00
•
• • - • WATS&SUPPLY WELa UND8R.15A.SW DiC;0107
Ail wan r supply wells izoi evattdayea"PitatieDrigthsgl&c:RFs'and inchtdIngfitvgivit,Lao*coutaxanarcial web.
. . it/ELLS OTHERTHAN WATER SUP3iLY IINDER VA.?MAC(.12C MOS .
• ,Atcludit g ignitorinc e i n a f recoveytedic • •
. .Print airy or owe litfortnatip. Ilitigitgo sibmitiolo logi ktedurned els frionvielL .
. .
_.
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, DATE: 3— r,== .) • , 20„ PERIWIT NO.: .Z430 (ie b5 ,eceepleted by DW(111;PI) •
• -- : ___•_, _ .__ -
.. . ,, •
. A. WELL.OWICIER-Por single fanny.pesicleneeslitit the'minty cowno(s). Fornll others,list name of the htsinels,
. .:orgolfiztoion,or Sovanment agenCY11.4POrsPndelePtedsiViataro-ealcar.
. .
914;2- .- 0-a ad_)s\ . .
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. . . IsotaiEng Address:. 3 -4>, CZ • ' ' *
• City. '9 .17-7 ,e10 '..#9vN State: *CodeA*CaUnty: .
• Day Tele No.,: .._ • ,. „‘.. Collitto.r). ), - '5 k'..t- ‘PA.g' -
• • MAIL Add=6e,,AL-k.‘') .%c,t).,.., (N.& .. Fax • , "
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B. PHYSICAL LOCATION OPVELL an. . .
a.,.,..,,, EN'
(I) panel TrientiftOadon Number(PIN)of well site: 0 F714 fP1')P• '8.-'41P3-3- --- 1 ---- • '
County . CU.('ek-kV,C.AC...- : , •
• •
' • (2) Physical 4dcinss(if Mama thairtmling address) 5 I Ze';($i:ox)*-rezi: -
. . „..... 1;k4015:1/41(-x, ,teiR041,4
car CpeR‘k& fe &dr:Ng: tip Ccidt. ' ti1-C1 ti
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C. WELL iiIILIXEENTORIVIA.TION Of known) " ' •
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Well Dollieg Contactor's NaMa;• ' : Ti mat/1y J Fiiii 1. 1i ' .. , .
Ne Well Drillg Contractor CertiEcatiotado. • LI.1 8,6 ' ,, - : • •
.. companyttakeet Growl Sec cuict 6,456,1411.1 U- ContaelPeocer, 7.1 FA•if/4Y11 •
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• City. (11)ro 1,la State: 0 C zii Code:/lii7 Crenty. (_...k rri+ti,ttc
pay Tele No.: • , ceil...: a_5-0 -toll 6 7-S-5.6- ,7 •
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EMAIL lkddrus; 1 ..s exp.,vc,5,r....co ix.. .
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Page 1 • ,
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4f " °c ± ROY COOPER• Governor 1
"e�•i ' �*$ N:C DEPARTMENT OF KODY H. KINSLEY•Secretary,
, 47 �iti � H E A:LT H is A N D HELEN WOLSTENHOLME•• Interim Deputy Secretary for Health
' Vvp' tr., HUMAN SERVICES
• 4 MARK T. BENTON•Assistant Secretary for Public Health
a
Division of Public Health '
Onsite Water Protection Branch '
December 20,2023
Ber[Harrell
337 Back at Crescent
Virginia Beach,VA 23456
RE: Approval No.WWM1763
__ __ _ Well Cased toLess Than 20 Feet—Rule 15A NCAC 2C.0116
512 Brant Rd.,Corolla,NC 27927
On December 20,2023,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 notllcovered by 15A NCAC 02C
.0116(b). The approval request is for the construction of one(1)water supply well at 512 Brant 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 limitation 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,
L. >,..0...v.c_ 11-1-Ni
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