GW1--00616_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
fTt. oiii•ty J . Ent1 ish F.,44li..YATER:ZONEV;4 a.. . � : .,... '•n
Well Contactor Name FROM TO DESCRIPTION .
4 r 01 B • 1 " ft- 6-re,y$11 .i 51Attity
ft- fL ►� it
NC Well Contractor Certification Number O11T R�ING.(for � :OB, 'meal -V„ ,`-714
(,ctlrvVQ Ser1Ict,C atyta CofllSi'r1AGI'►D A 1 1 C 41 FROM TO DIAMETER THICKNESS'L MATERIAL
Company Name T�NVfI {i1ift L�1„ to ��'l�^ ���...;.. a�a .,<
93 I8' wwM b .,16tI R'CASi t1RIXIBING3 4— .,-= 4 .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(BC County.State.Variance,etr.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: =17 SCRWi _-s ,.. .> .-...:-.: Jai..:. :is 'Ar::-^srr1
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
D unicipal/Public 40 ft
12- fLObi !n 'OLD tch'fa PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) `-4$"GROIfI`A'.. :; :<'r +:r.,.: ,"4 .`
Y {
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O a- to ft- VSkIl+onre. pw-r i
Monitoring • ®Recovery ft. fL
Injection Well:
Aquifer Recharge El GroundwaterRemediation fL ft I
I
:19iSANU/GRAVFLPACKffa ble'): := , s:h""":'
Aquifer Storage and Recovery D Salinity Barrier , FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage t a- `'t f. #dew S pb Urfa
Experimental Technology Subsidence Control ft. ft. i 1
Geothermal(Closed Loop) OTracer • .r;'.2O D1WLIGIOG(att h iiribteSifis `_A:4 `:" -c t
FROM TO DESCRIPTION(color.batdnes,soi'/rock type.grain sin.etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
j 0 ft- 3 ft brown S'a+u�
421I 4.Date Wells)Completed: -, ZDvwen ID# 3 ' Is a- ei r y s'1 e' �la_ like wef-c &tcrek
Sa.Well Location: � ft.
ft. 1 grey 5alu 6Mefiy
n- r i C.k Cason ft. ft. J •+ , ,4 l ,>, � ,'
--�' Facility/Owner Name Facility IDh(if applicable) ft ft. '0.6..-•'tw-t'L„i V t""','U
50ci 6ran4 Ret Corolla 2.7 Z7 ft. ft. JAN 2 5 2024
Physical Address.City,and Zip a• ft. i
CA/dr►'I-ke,K- O8 7i4 coc o z boo 16 =- R€ ARIES , lnfao:, ter pew; . e ,
County Parcel Identification No.(PIN) d�� / �
5b.Latitude and longitude in deg
rees/minutes/seconds grEes/miautes/secoads or decimal degrees:
(if well field.one lat/long is sufficient) 2 e �0 2.CeCertification:'.(o 30 ' 9 it N +�S 521 , 3
it w ..........
�j �•
.ate 12-�Zl1?023
6.Is(are)the wells) Petvrdnent or DTempolary Signature of Ce fled W Con _or Date _ _
• By signing this form./hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or No with/SA NCAC 02C.0/00 or I5A 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 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 well depth below land surface: a Or I,g. (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30.200'and 2@100') construction to the following:
10.Static water IeveI below top of casing: 3 (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: 6 (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: G' construction to the following:
(ie.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
t
13a.Yield(gpm) Method of test: : Pawl24c.For Water Supply&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: %4TL •Amount: I•S d'L completion of well construction to the county health department of the county
• where constructed.
1
. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit: 393418 ' iiCurrituck w'ww.arhs-ic.org
•. I
PIN: 087A0000026001.( WELL PERMIT' ,
' ALBEMARI.EREGIQNAL.HEALTH SenvicL•s •
Palters In Milk Health
PERMIT TO CONSTRUCT PRIVATE
. DRINKING WATER WELL
Owner: Applicant: 1 •
' . Rick Cason_ Rick Cason •
50263 Monroe St 50263 Monroe;St '
Canton, MI 48188 Canton,MI 48188 •
' •
Location: '
(� 509 Brant Rd t�
vi - i ere f weft p�,O T f or- t't ore ''L ' ----L4--- ► N
�" ,, I - 1' WOOD 1'•WOOD 3
14' S ULKHEAD BULKHEAQ
� <®t'b'! my - x x2.6 x23 27
•
Dear well 6a�, or- y3t0✓8 Pd�'' •
\\ 30' GAMA
•�i^on1• • 6e i"t.. S yS n? x 1 e,\l t� ;\`SETBACK 39-.9'- I _
e(f a 54- - 1- p DECK s. ti Op
4N '/ sTd r-3 f . L.4x
` pia r w .- ,, ,. ._ o �.L _.
•J is t't $. rr i s+ Y» •- 'l.. t 1!`✓.'..'�L
(t OS d r•J id j I
c ra
Sir, ''i r.
�y'7 1� kJ:
��jj►y�y N.
Co 11;51/ G ` ' �/� welt pn(Ie-- .. i ,'h ' 44::, ' _h • •� '� '
).(:: 25 W
, i �:(' :, 'F 24 .IIIItl11111IF �'9.6
o1 i-71"/n;ne• l A. well UpiN` 6 0; 1. ' ° ,� r= .� �' I' =.;•• ti s2a
. i:2,,,,I,,. "1 ----.-,-ct- i 1,,,,, , , ,-i-
;s re v„,fred, • ac,. : .. 1 . 1 -------.7":'-- i I -,,-'s 4„ , •
y? I -27 , �-II I ll N
��.fl-J 28a
r� Z
I , 1! ti
TANK 8 .,:.c• rz
HU
100.00 `x2 B ,. .�--- S8Q°06'39"W - •
"*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 •
'. ;Aisinfection.Only a Licensed Electrician or Licensed Well Driller can wire the Pump**
SHALL MAINTAIN 25FT+FROM BUILDING PERIMETER •
SHALL MAINTAIN SOFT+FROM ANY PART OF SEPTIC/REPAIR AREA
MUST BE INSTALLED BY CERTIFIED WELL CONTRACTOR
PERMIT MUST BE ON-SITE DURING AU.PARTS OF THE INSTALLATION •
CALL AT LEAST 1 BUSINESS DAY PRIOR TO GROUT AND WELLHEAD INSPECTION
**.WELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FO AT LAST 24HRS PRIOR TO USE"` .
Permit By: - j � ,/� p Date 1 04/19/2023' .
Met n,Tucker 1
Certification By: • Date
Construction has been completed,'a Residential Well Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15A NCAC 02C.0300. •

•
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 pemaits.
The issuance of a Permit for Well Construction in no way guarantees the gpality of the drinking 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"TIDE HEALTH
DEPARTMENT. IF THE INFORMATION SUBMITTED IN THE APPLICATION FOR DRINKING WATER WELL CONSTRUCTION
IS FOUND TO BE INCORRECT,CHANGED,OR IF THE s1Tt,IS•ALTERED,THE CONS`ERUCTION 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$:30 am.,Monday through " .
Friday,except holidays. The of$c`e telephone numbers are:
Camden • 338-4460 . . Pasquotank 338-4490 • •
- .
Chowan 482-1199 . Perquinaans.... ..... :., 426-2100 . • .
Cmriiuck • 232-6603 Bartle . • 794-5303 '
Gates 357-1380 : ••
Well Contractors are responsible for notifying the Environmental Health Offices for greeting inspection,well bead:inspection,and required . .
.. . waters ling:•Drip •g•water welIsiniis be riis'gected'luid'epprovedby a representative of the EnvironrrientatHbaitli:st before any. ' -. . '.
portion of the installation is covered and/or used.
•
ISSUANCE OF A DRINKING WATER WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL HAS BEEN
CONSTRUCTED TO THE STANDARDS SET FORTH IN THE REGULATIONS,BUT SHALL TN NO WAY BE TAKEN AS A •
GUARATEE iHI QUALITY OF THE DRINKING WATER. • .
*Minimum Distances** • . . . •
..Private Drinking Water Wells to: '
(This listing is not all inclusive,please see 15A.NCAC.02C.0.107 for complete listing) . '
1) Ground Absorption Wastewater Systems • . • •� 100 ft - •
• (includes existing septic tank;drainfield,repair area,
or.area permitted for an on-site wastewater system that has
not been installed,and a designated repair area for that system) •� .
2)- Other-Subsurface(around-Absorption=Waste-Disposal-Systems• - —_100 ft -
3) Industrial or minicipal;sludge-spreading or wastewater-irrigation sites" 100 ft •
4) Water-tight sewage or liquid-waste collection or transfer facility ' 50 ft
5) Chemical or Petroleum Underground Storage Tank • 100 ft '
• (does not provide secondary containment)
6)• Chemical or.Petroleum 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 It •
10) All other surface water bodies,such as brooks,creeks,streams,rivers, . _
sounds,bays and tidal estuaries 25 ft . •
11) Animal feedlots or manitte piles 100 ft ' •
12) Animal barns. 100 ft • ' .

ROY COOPER•Governor
-m NC DEPARTMENT OF KODY H. KINSLEY•Secretary
HEALTH.AND. ._.
f 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
December 20,2023
Rick Cason
50263 Monroe St.
Canton,MI 48188
RE: Approval No.WWM1762
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
509 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 not covered by 15A NCAC 02C
.0116(b). The approval request is for the construction of one(1)water supply well at 509 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 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,
Lti>:..1ZL�c ral 1r�1. i
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