GW1--03717_Well Construction - GW1_20240621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: allirli
1.Well Contractor Information:
TI,v o4lity J . EnelCsK 14.WATER ZONES - _ -
FROM TO i DESCRIPTION
Well Contractor' 1
6 Name fy tr. to ft- bf.Q smyt t S ell!Iy
1 l 81 I lO ft f- /0 j2.5s Cilcrt C[,44-1e i,-eiI
NC Well Contractor Certification Number .1S.OUTERCASING(tarimidtiraeeitwells)t1R'I:BIIER 'T"' !
L0VIS{YUt,�'►O4 I C. FROM TO DIAMETER THICKNESS MATERIAL
(atrova Scrv�t c atnd t ( ft i 1 b ft I I IN in- silt fie pvc
Company Name16.
_. .,,
1�11 r� µ� + Q� 3ti.II�1A3ERCASING�QRTU$#NG(ueotiarsai �ao��., -' �, ,,� "'
2.Well Construction Permit#: c6O 10`DO W w 1v\ t 7 3 U FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
List all applicable well construction permits(i.e.UIC.County.State.Variance.etc.) 1
3.Well Use(check well use): ft ft. I to
.17..SCREEN . - -- . ,F ;+ s^ fi c
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ( ) unicipal/Public i ft. 1 I el ft. 1 li�in- 410s�f yd PVC_
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft L ft in,
I
Industrial/Commercial E3Residential Water Supply(shared) 18GROUT ,'._;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft (5- ' lib-totem-it rQtArc c[
Monitoring ©Recovery ft ft.
Injection Well: ft ft
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAM-PACK(if i ) rf ;
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage C 5 ft 20 ft 1 irashGQ,;�( tad tree(
5
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attack> 's)ketvfsaeilrC) f rk^
FROM TO DESCRIPTION(color.haleness,salienek type.train sue,etc.)
Geothermal(HeatingiCooling Return) 0Other(explain under=21 Remarks) U f t 7 2
fL k a w bt 5a v
4.Date Well(s)Completed: �`3I?.vZY Well ID# 3 ft. I1 ft ,her Sum
5a.Well Location: (i ft F!2. ft- rec.-
13+c t-totacis 4- Inv, r2 ft 20 ft fret SKd shells
I---- Facility/Owner Name Facility!DO(if applicable) ft. ft.
93Lfo 5waet35Ltrtc( SZI CO(011A 2.142.7 ft ft.
Physical Address.City.and Zip
2L REMARKS ri .: .:
Curr1 ha 087F4 t .1_100,05ocf) i t...
County Parcel Identification No.(PIN) •'....`), ..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J U N 9 1 2024
(if well field one lat/long is sufficient) I f t 22.Certification:
O ° iI
32' 30 N ice P. L 3 w .�- •In/ern..:. c,i T- -ar*e--
6.Is(are)the well(s) ermanent or Temporary Signature of cnified ell Co ctor Date
By signing Ina form.I hereby certify that the aelltst was(were)constructed in accordance
7.Is this a repair to an existing well: 1:1Yes or v'No with/5A NCAC 02C.010X)or/5A NCAC 02C.0200 IVeil 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.121 remarks section or on the back 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: �y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i-4 (ft-) . For All Wells: Submit this form within 30 days of completion of well
i-or multiple wells list all depths if different(example-311200'and 2 l00') construction to the following:
10.Static water level below top of casing: tt (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: (D (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-I k r- 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) Z� Method of test: tritf Puittar 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: HT(' Amount: 1.5 dZ 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

-17
Permit: 401200 Currituck
WELL PERMIT www.arhs-nc.org
PIN: 087A02700Q5OOQ' Att.(MARI,ERFtilosalirAt_rii StswILLN
Pamirs tri Public Health
PERMIT TO CONSTRUCT PRIVATE
DRINKING WATER WELL
Owner: Applicant:
B&C Holdings &Investments B&C Holdings&Investments
4328 Ainslie Ct N 4328 Ainslie Ct N
Suffolk,VA 23434 Suffolk,VA 23434
Location: �,."`_""' .-
r ...:- r1---°t-- -- --,, '1
(- --
it ,. _ 7', - - e
2340 Swan Island Rd i . ' °
O. (0{16r1/ f WP.It cl! •jte,-- ` (T -fir .:' : — roodatrttrJ I
de-iec,en,,,e ;L_ !a .� ,e- -1 _ .J' 3&,.� 'I•``E a LvSr. 10-.1
VGIr. rh"Le ;$ reitty.recl. .,p -."''.rnva....s.- I
, q 1,di 1 — 1144tliiii__ i 0 j ) , -
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o c .
x2 G t✓e ( •'� l I — i I ---- I
O.n o-e . .4-�.4-. 4.v-o ici .adfini• _-.i. l\ 11 I .r... .. . ..
i,,t0'-- � c /f -we- k 1 , r r
. _: 1 to'\x RI. i I
.Li 1e '11;' p ...I 1.W"--Til i: fil .1
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1 t7 O 1 b g" '-'F
11 I .6j,'1 i I.
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"*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 PERIME t LR
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 WELLI-HEAD INSPECTION
'"WELL AND PUMP SUPPLY MUST BE PROPERLY DISINFECTED FOR AT LEAST 24HRS PRIOR TO USE"
Permit By,: { 1/� "� ` -gt Date: 10/09/2023
Melton, Tucker
GertifiGation By: Date;
Construction has been completed, a Residential Well Construction Record Form GW-la has been
submitted and inspections have been completed in accordance with 15A NCAC 02C 0300.

i. .
THE AUTHORIZATION FOR DRINKING WATER WELL CONSTRUCTION SHALL BE VALID FOR A PERIOD OF 60
MONTHS AFTER THE DATE OF ISSUA.NOL
The issuance of the Certification of Completion in MI 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 el+en meet state and/or local regu1atxms.
NO CHANGES IN.THISS 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,OF,IF THE Sim IS ALTERED,THE CONSTRUCTION AUTHRORIZATION SHALL
BECOME INVALID AND MAY BE SUSPENDED OR REVOKED.
When contacting tine Environmental Health office concerning this dcuetuuteut,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 am.and 8:30 a.m.;Monday through
Friday,except holidays. The office telephone numbers are:
Camden: 338-4460 Pasquotsnk .... 338-4490
Chow ,.. 482-1199 Perq . . 426-2100
Currituck 232-6603 I3ertie .......... .. 794 5303
Gates • . 357-I380
Well Contractors are responsible for notifying the lauiranmental Health Offices fgr grouting inspection,well bead inspection,and required
water Wiling. Drinking water wells must be znspsscted and approved by a repreaentatiTta Qf thd1.>;#A.Y t►entel,Me t before any .
portion of the installation is covered and/or used.
ISSUANCE OF A DRINKING WA IEK WELL PERMIT SHALL INDICATE THE DRINKING WATER WELL HAS BEEN
CONSTRUt; ti13 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 1.5A.NCAC.02C.010'1 for complete listing)
1) Ground Absorption Wastewater Systems... . 100 ft
('includes existing ' tank,drainfield,repair area,
or area permitted r an on-•c,- , ,water system that has
not been an4) , ',_ repair area for that system)
2) Other Subsurface cm Wasftf�'isp ysth a 100 ft
3) Industrial or tninicipal sludge-apreaduug or wastewater-irrigation sites 100 ft
4) Water-tight sewage or liquid-waste collection or transfer&clay 50 ft
5) Chemical or Petroleum Underground Storage Tank 100 ft
(does not provide secondary containment) 50 ft
6) Choral:al or Petroleum.Unde grou nd Storage Tank
(does provide secondary containment). 100 ft
7) Spray or Drip Irrigation Site
(or any other under 1 SA NCAC 02T)
S) Building Foundations,exalnding the faundatitm of the structure
housing the well head 25 ft
9) Surface water bodies which act as sources of groundwater recharge,
such as pods,lakes and reservoirs.. ...... .... . . ..... . 50 ft
10) All other surface water bodies,such as brooks,creeks,streams,rivers,
sotmds,bays and tidal estuaries '25 ft
11) Animal feedlots or manure piles . 100 ft
12) Animal barns . . . . .. .... . . ............ ....,..... .. . 100 i

•
43TEr, ROY COOPER • Governor
I NC DEPARTMENT OF
KODY H. KINSLEY • Secretary
HEAL T�' AND 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
May 31,2024
B&C Holdings&Inv.
4326 Ainslie Ct.N.
Suffolk,VA 23434
RE: Approval No.WWM1838
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2340 Swan Island 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 2340 Swan Island 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,
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