GW1--03188_Well Construction - GW1_20240524

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For Internal live Onl...
WELL CONSTRUCTION RECORD
1.Well Contractor Information:
Ti IA o�ln J . Eh fish •14 Wk DESCRIPTION
FROM of
Well Contractor Name 44,
ft
® t
gl ` ft. Zp n- , ter,RfSk Color 1'WE 9/tell
cas 19HIBv€R'ff
NC Well Contractor Certification Number -Q C' DIAMETER THICKNESS MATERIAL
FROMuTER To PVC
�,La(oV . S e1N�t c avid Co ns�ry o n �~ ). i ft. i 5- ft. 1 t/i in.
1Ck''L L _ __.. _..�
lf:INNERCASINGDR ( 4OO�J � �'
Company Name MATERIAL
400 5 1 W IV v•S.�Y FROM TO DIAMETER THICKNESS
2.Well Construction Permit>I: ft fL in.
List all applicable well construction permits tie.UIC.County.State.Variance.err.)
ft- ft in.
3.Well Use(check well use): 3 y.r.. L t
Water Supply Well: FROM TO DIAMETER I SLOT SiZE THICKNESS MATERIAL
r3>`unicipaLPublic If ft. tQ R. `Vi. in. tat() 0I vo I VC
Geothermal(Hcating'Cooling Supply) Residential Water Supply(single) ft ! 4 it in.
Industrial Commercial Residential Water Supply(shared) z . ..� '= s��. -1
uPP ;1&GROLrf '-�
Imeation FROM 1 TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
r,
Non-Water Supply Well: I `0 ft ft a bf�1E09ttfC+ po .red
Monitc ns QRecovers Ir ft ft.
Injection Well: ft. ! ft
Aquifer Recharge 0Groundwater Remediation i 1 r
19.SAND/GRAVEL PACK:(if eta abio _ ,y,',- '
Aquifer Storage and Recover) 0 Salinity Barrier FROM TO 1 MATERIAL� EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage i S ft. 20 ft 1041I14a.t toe,tv-ed
Experimental Technology ElSubsidence Control ft. I ft
Geothermal(Closed Loop) OTracer 2o.DRILLING LOG(attack sleefiiffi lealoigil: ;'
FROM TO ' DESCRIPTION(color.hardness.sad/rock type.grain via.eta)
Geothermal(Heating Cooling Return) [,Other(explain under#21 Remarks) I ft-o ft. bIDWvt sdhd
4.Date Well(s)Completed: 5/101 Zo2Y Well ID# 7 ft. 10 ft 'rer Sr.4o(
5a.Well Location: lD ft 1£ R P ecd. l"Y e4
Sicario (3roser1-itS l( fL IS' f` grey saK.d /�
Facility/Owner Name Facility DO(if applicable) 1 s ft- 7-0 ft sy y w/ A/Le`! cl i 5
2140 S�►+dp i per Rdt Corolla 2ZQ 21 • rt. ft. / l l
Physical Address.City.and Zip t ft- ft
C4rrifiL k 0811005-000Y{6eo2 -i, 37,:,Iva.....,v,: : ` ter
County Parcel Identification Ne.(PIN) _ '1?4
•
Sb.Latitude and longitude in degrees/minutesiseconds or decimal degrees: (J
(if well field.one latlong is sufficient) t t 22.Certification: a '
it f% in..,.:rt., ifrit
O
3 4 12 N 7 c rt cZ W —,� uh.c.•!tx3 20 2°
6.Is(are)the wells) p° -
Permanent or Tem rare Signature of(Xfnfied\ ontrac Date' f/
By signing this form.i hereby certify that the wells),vitas(were)constructed in accordance
7.Is this a repair to an existing well: IYes or G;Ko with ISA VCAC 02C 4100 or ISA NCAC OW.0200 Well Construction Standards and that a
1f this is a repair.fill out,brown well construction information and explain the nature of the copy of Uus record has been provided to the well owner.
repair under*21 remarks section or on the bark 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-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nereccary.
drilled: QQ SUBMITTAL LNSTRUCTIONS
I 9.Total well depth below land surface: -1 (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(4200'and 1Cg100') construction to the following:
10.Static water level below top of casing: l0 (ft-) Division of Water Resources,Information Processing Unit,
If soarer level is above casing.use"•'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (In-) 24b.For Iniectiou 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: AGE 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
M 13a.Yield(gpm) 2-1, Method of test: (7A5 PlAP r 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: T 1 C Amount: 1•5 et- 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

www,arhs-nc.org
Permit: 400561 4 Currituck
ALUMARtr RSGIONAt HrMlnl SWIM WELL PERMIT
PIN: 087A005000400Q: 1161 h 1,110I'c ilalth
PERMIT TO CONStRUCl'PRIVATE
DRINKING WATER WELL
Owner Applicant:
Sicario Properties Sicarlo Properties
.PO Box 176 PO Box 176 .
Moyock, NC 27958 Moyock,NC 27958
•
Location:
2190 Sandfiddier Rd Lora I I LOT H Los s
&LOCCI i xaarr /LOCK5
CA
S�E+~'nbNT , l S5CTION+2 SECTION
CANOVASEACN , , CAROM 1 CAROVA&EAClf
PC X IN P.C.Y KO,la r.G Z atv.as
-—-- • Nf•I21X1 fY too cc'
t LOTI
.0--- ,*—--1---4 r 14,600 Si]
P,?ICO`11-11 ..N.. MOP
' t I AWNING t,fir.,.., , i 10011 SEM NSPNIe
I
' S
>3 r sTou. ,' l 8 Lora
LOTK I ! J4,l OS wLOC7rt
BLOCK a __ SECTI
' ' CAROVA e&lCff i i J SEPT C f CNIO AV SEAa+l •
PC.2,arA.f25 l 1( TANK P.c.Z fW.Elf
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I a 1 FT—I i 1111
' i-fox 1rPAP(%PG f ON a I ` I ( I
LACER DWELLING
MI A71EPTC LAW
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• PNKIV 9
, k.•; t I I 1 1LLI11I_!
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,� ® SI'45VOl f00.00
SANDFIDDLER ROAD(60'RIW)
'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 Electrician or Licensed Well Driller can wire the Pump°`
SHALL MAINTAIN 25FT+FROM BUILDING PERIMETER
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: C.---' _ Dale: 09/21/2023
Carver, Kevin -
Certification By: Data:
Construction has been completed, a Residential Well Construction Record Form GW-la has been
submitted end inspections have been completed In accordance with 15 A NCAC 02C.0300.

�'' STATE
ROY COOPER•Governor
tn‘teeS,. NC DEPARTMENT OF KODY H. KINSLEY•Secretary
I— ` HEALTH 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
May 17,2024
Sicario Properties
PO Box 176
Moyock,NC 27958
RE: Approval No.WWM1828
Well Cased to Less Than 20 Feet-Rule 15A NCAC 2C.0116
2190 Sandfiddler Rd.,Corolla,NC 27927
On May 17,2024,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 2190 Sandfiddler 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,
L- -"os) 1r�la,e
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