GW1--03718_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: air
1.Well Contractor Information:
TIrK,o4 J . Eintish [ 14.WATER ZONES • `;
IrFROM TO DESCRIPTION
Well ContractorName ft. t� ft
_ La4.41 via �{er 1Dtow 5s•Gt
48
1 " ft 1't ft. Clear 1,4-k sNtell
NC Well Contractor Certification Number 1.5,OUTER CASING({or ;ased welte}OR 1;g11gR(t' -;=:�.�' =7`:
FROM TO DIAMETER THICKNESS MATERIAL
(,arova Service at ins{wl�,lio n U.` + Itti, ft 1 i I/4 5d4 rya P vL
Company Name •14.10INER CASING-OR TU$iNG naintheeml : ^-0 TT"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County,State.Variance,err.) ft. ft in•
fL ft in.
3.Well Use(check well use):
Water Supply Well: '17-:Sf EEN - , :r v:t i- .., w -tiw
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ® �unicipaltPublic � ft. l ` ft. 11/,1 in. 0i p s 1 L'O (VC-
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ftL in,
Industrial/Commercial DResidential Water Supply(shared) 1g�RO[Ji =
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ft 4f fc *feria ,i-e jeoured
Monitoring ©Recovery ft ' ft I i
Injection Well: `I
ft ft
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK{if y lcabk) ' V4f.*y'
Aquifer Storage and Recovery QSalinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test EDStormwaterDrainage 15-ft• , 19 ft ;r `t ISctvc( your-Ed
Experimental Technology 0 Subsidence Control ft- I ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach add lti abeetaflseeirssy -4: 71"-s
FROM 1 TO DESCRIPTION(color.hardness,soil/reek type.Rain Asa,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under=21 Remarks) C
1
4.Date Well(s)Completed: (it 3(2oLt ft.Well ID# ei l.0 ft Pert
5a.Well Location: 10 ft- 13 ft- i✓ter Ss/7L
ft
JaieteS McCulIa� 13 i1 ft. fey w/ :AM s
�-"- Facility/Owner Name Facility 1D:(if applicable) ft• ft
51( p S Weth 1 / nefelta/ ZTi(27 ft. ft
Physical Address.City,and Zip ft. ft ` •. s V
�,u rri ktAc l� 0187� S5oo 1 ° :-2iarfataRxs: • , - +I.. ;. E
County Parcel Identification No.(PIN) JUN q 1 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one latflosuffi
cient)is p ( t t 22.Certification: hell nM,Pii w�^r,il4Q".c,
ah ►1i✓.;
��� 3Gt ��r` 75" 5Z Lie w -",.7- (01312/3Zif
6.Is(are)the well(s) ermanent or ra Tempory Signanue of C ed R'e onnactor Dare
By signing this form.l hereby certify that the welhrl was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with iSA.VCAC 02C.0100 or/SA VCAC 02C.020C 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:he 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: 1-Ip (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diff ferent(example-3(i2L.200'and 2 100') construction to the following:
10.Static water level below top of casing: Z. (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. ( (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 'q C' I 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
13a.Yield(gpm) 21( Method of test: (vas Pamir 24c.For Water Supply&Injection Wells: In addition to sending the form to
UT the address(es) above, also submit one copy of this form within 30 days of
L
13b.Disinfection type: 11 1 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

Permit: 399638 Currituck www,arhs lc.org
A.
PIN: 0$7A00000550011 4 WELL PERMIT
LHMAnuAE4K3NALHEALTI'I SERYIC@5
Pannell in Public Hretth
PERMIT TO CONSTRUCT PRIVATE
DRINKING WATER WELL
Owner Applicant:
James McCullom James McCullom
1305 Roanoke Arch 1305 Roanoke Arch
`x
Chesapeake,VA 23322 Chesapeake, VA 23322 ,1G
-__ _---- ----f. t!
e
Location: _ _
516 Swan Rd � .' I
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ce(oria / I- wjh ve fl ano,,,,,s30
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k.e-efortie!! . 5 k �cs t RV' l_ • . • ,L)- r 'kJ /'
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— 3H0 .--3I-ro -—1+45
An' ((gy�'pp v�r! il01./ �,,/G1�al -�v G oltec �. .
"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.Oniy a Licensed Electrician or Ucensed 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 ALL PARTS OF THE INSTALLATION
CALL AT LEAST 1 BUSINESS DAY PRIOR TO GROUT AND WELLHEAD INSPECTION
"WELL AND PUMP SUPPLY MUST BE PROPERLY MS ECTED FOR AT LEAST� 24HRS PRIOR TO USE''"`
' Permit By: G��// r��ik�t /a4T Date: 09/08/2023
Melton,Tucker
•
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.

J.
THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR A PERIOD OF 60
MONTHS AFTER TILE 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 IN THIS DOCUMENT ARE ALLOWED UNLESS PRIOR APPROVAL IS OBTAINED FROM THE HEALTH
DEPARTMENT. IF THE INFORIviATION SUBMITTED IN THE APPLICATION FOR DRINKING WATER WELL CONSTRUCTION
IS FOUND TO BE INCORRECT,CHANGED,OR IF THE SItE IS ALTERED,THE CONSTRUCTION AUTHOORIZATION 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 3:30 a.m.,Monday through
Friday, except holidays. The office telephone numbers are:
•
Camden 338-A460 Pasquotank 338-4490
Chowan 482-1199 Perquimees. 426-2100
Currituck 232-6603 Sortie. . 794-5303
Gates 357-1380
Well Sontractoirs are responsible for notifying the Environmental Health Offices for grouting inspection,well head inspection,and required
water sampling. Drinking water wells must be inspected and approved by a representative of the Envirottmentat Health beefore 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 IN NO WAY BE TAKEN AS A
GUARATEE THE QUALITY OF THE DRINKING WATER.
* 'Minimum Distances**
Private Drinking Water Wells to:
(This listing is not all inclusive,please see 15A.NCAC.02C.0107 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 sg'stem)
2) Other Subsurface Ground 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 manure piles 100 ft
12) Animal barns 100 ft

•
a""fron`, r ROY COOPER • Governor
I, 4 NC DEPARTMENT OF KODY H. KINSLEY• Secretary
I HEALTH AND
'9'011 1 7 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 31,2024
James McCullom
1305 Roanoke Arch
Chesapeake,VA 23322
RE: Approval No.WWM1836
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
516 Swan Rd.,Corolla,NC 27927
On May 30,2024,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 516 Swan 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�.,1....e_14-70, 31-.1").../;,—
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