GW1--03748_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: SIIII71111
1.Well Contractor Information:
T I M,o411ty J . E n9 l i5 h 14.WATER ZONES --=•,
Contractor 1 FROM TO I DESCRIPTION
Well Co Name I ft ft '6"
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4 l O or r l 6 I t� Ywt1 O SMCtly Swap t,,ttiet
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tQ ft- l-' ft br...N d k1 t) less SMetl
NC Well Contractor Certification Number r
IS.OUTER CASING(for midti�cteeedtre�OR 1.31RiER(tl
FROM I TO 1 DIAMETER THICKNESS MATERIAL
CatrO✓A SerVv Gt ayla CO„S{Y1ACs�10 i l�C. ,{ ft. 1 l(.l ft i ( 1/4 in. ;.i4eio wC
Company Name •16 INNER CASING:ORTURING( eothetrsal. :.
2.Well Construction Permit#: /1 bl9 45- & wr& t O 37 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK:.C'ounty tr..State.Variance.e .) ft ft is
3.Well Use(check well use): ft ft. in.
•::17..SC&N ;: - - : .%'+x,.i +' 3:;k
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
A cultural unici al:Public ft ft 1 in
© p Fy (7 t (� ale 5'I,yo L
Geothermal(Heating'Cooling Supply) Residential Water Supply(single) ft. ft. in )
Industrial/Commercial DResidential Water Supply(shared) Y8.GRU03
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Well: I 0 ft (if ft g6b'lbmite rppi..;red
Monitoring ©Recovers ft ft
Injection Well: ft ft )
Aquifer Recharge QGroundwater Remediation •19 SAND/GRAVEL S PACK(if ble) a
Aquifer Storage and Recovers Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD'
Aquifer Test IDStormwaterDrainage �`f ftI �� ft hSwnd �o� .r�G�
Experimental Technology EDSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG(attachr sbeetslf>e f� [#=s. - , A=f
FROM I TO DESCRIPTION(color.hardness,eall/oek type.Mal stn.etc.)
Geothermal(Heating Cooling Return) }Other(explain under all Remarks) ft. ft.
C brew✓1 S'aitd
4.Date Well(s)Completed: (61 3 jZdt-t Well ID# 3 ft. 7 ft rey i aM.e{
Sa Well Location: f ,cr ft.
JP20.'f- -
' Ravi/ Mille( 't ft 1 ft I ie, a:
Facility/Owner Name Facility ID*(if applicable) ll ft 14 ft fray
ft. ft.
.jto-ILS
ft
<1.0 l nti-otvt Pearl U.f C:orol la i 21 I 2.1 ft. ft
Physical Address,City-and Zip
G rr("hAc.k Dto4 daoo....1 2L RF.b1ARKS .. 4 -.w t rt°
I!� ..-.:
i ( ,L r
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J U N A 1 2024
(if well fieeldepnnee layong is sufficient) v( t /r 22.Certification:
.3(e 31 3i ^/� J N l Z 44 w jtlkrtr.64'e;1 11•;^df►P..r+ V $
6.Is(are)the well(s) ermanent or Temporary Signature o Ce ed W' on Date
By.signing this form./hereby certift that the welts)was(were)constructed in accordance
7.Is this a repair to an existing well: ID Yes or No with/SA VCAC 02C.0100 or 15.4 A'CAC 02C.026ft 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#2I 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-I 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: C 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-3rd,100'and 1V100') construction t0 the following: y p
10.Static water level below top of casing: 2. (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: A,f�1- 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: (7A6 P ttr490 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: 4T6 Amount: 1•S et- completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

. ` Permit: 401945 Currituck www.arhs-nc.org
L. WELL PERMIT
PIN: 097A0000256000i AL8 MAALERu;►J1AlfeAL.TH Stavice> ,
Pannell In Pub c Health
PERMIT TO CONSTRUCT PRIVATE
DRINKING WATER WELL
Owner: Applicant:
Roxy Miller Carova Beach Builders
2635 Jade Run#2 2162 Salmon Rd
Beaver Creek, OH 45431 Corolla, NC 27927
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Location: `} ,y►
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2057 Ocean Pearl Rd
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WeltAi. i110.00(
*"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 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 DISINFECTED FOR AT LEAST 24HRS PRIOR TO USE*"
Permit By: 0--- Date: 10/30/2023
Melton, Tucker
Certification By: Date:
Construction has been completed, a Residential Weil Construction Record Form GW-1a has been
submitted and inspections have been completed in accordance with 15 A NCAC 02C.0300.

WO 1,0 " ROY COOPER • Governor
Fi''' 0:.: NC DEPARTMENT OF KODY H. KINSLEY • Secretary
d :' HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health
• `r f'
MARK T. BENTON •Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
May 31,2024
Roxy Miller
2635 Jade Run#2
Beaver Creek,OH 45431
RE: Approval No.WWM1837
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116
2057 Ocean Pearl 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 2057 Ocean Pearl 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,
t .. )�l u-7v, T'f v�•_
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