GW1--03745_Well Construction - GW1_20240621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor IInnforrmation: I
TI m,O-II y J . E h I t S� 14-WATER ZONES ..} : ir:1 9 FROII .TO L DESCRIPTION -
Well Contractor Name it� ft. /0 ft D/
N O-I ro.4 1ilce cara4I wa{•Qr
Ill f it• ft s4iii b#He• cq/..-,lo,,. S
NC Well Contra:tor Certification Number 15.OUTER CASING(for mvdticaeed"we'de4OR E £iE *s .:
1 FROM TO ( DIAMETER THICKNESS MATERIAL
Carovc Strv�I.0 at ConS{Yuivl�i �� .� ft I it{ ft i ( 11,,i in- sclALi0 PVC
Company Name
�^^ w r �/wtu �� FROM CASING R;TD$IAG'(f Tda .
2.Well Construction Permit#: oo l v 1^� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(i ./C. State.Variance.etc.) ft in'
ft. ft in.
3.Well Use(check well use):
•.17..SCREENi Nam- ��..;4�-f�M<'�
Water Supply Well: FROM ` TO DIAMETER SLOT SIZE THICKNESS MATERIAL
13 Agricultural © unicipalrPublic I� ft. f I� ft 1 y� in tote scbYO Svc
Geothermal(Heatine/Cooling Supply) Residential Water Supply(single) in,
Industrial/Commercial Residential Water Suppl (shared)
Irrieation FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: Q R t� ftilfDditt PAure�
Monitoring ©Recover ft. ft
Injection Well:
ffi ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GBAY€I:PtIiOK{d iiible} ;' kw r :tA'=?
Aquifer Storage and Recovery Salinity Barrie; FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage '� ft. �� fc it�9 5 Bu/Gd
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG(attach dd sllieblfsecane[# �,ri W5'�
Geothermal(Heating Cooling Return) Other(explain under=2l Remarks) FROM ! TO5 DESCRIPTION(color.ha,dnca,soiVrook type.pain sin,etc.)
ft fL t
// J� djfl�wNl SQA�
4.Date Well(s)Completed: lol3l20- 1 Well ID# , ft I D ft pre Y
5a. 'Well Location: 1' to ft- it ftIF,e l.,�
WiI(tawl *I- AlI Ct. e3eNtINS t I ft i ft !,i►e.v L.,/' 5.heft
-- FacilityiOwner Name Facility ID4(if applicable) ft ft j `
��77 2 p I ft ft -.
g 0cecol P&1�1 Corott z/eiZ7 e ,> ,.._ . 1
Physical Address.City.and Zip 1 ft ft. 1 '` `•'L. .'v �-'Ld
C„f.;k,..`k. o8'1‘41,660ctboo3 -2i.REUARRS - _ JLN f
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IrDoh-Qierir
(if well field one lat/long is sufficient) 22.Certification:
1
I[ O ( 1,
366 31 3b N '7S- 52 to " (oiSitee�
6.Is(are)the well(s) Permanent or Temporary Signature of Cent d W on roc Date
By signing this form.i hereby certifi'hat the wets,wac(were)constructed in accordance
7.Is this a repair to an existing well: Yes or (3-No with 15A NCAC 02C.0/00 or ISA NC.4C 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#2/remarks section or on the hark 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: Y l (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3rd200•and 2ri io0') Construction to the follow�n¢: y p
10.Static water level below top of casing: ti (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (C (in.) 24b.For Infection 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: All( 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) 2 k Method of test: (7af Pt&IN$ 24c.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: Hi(' Amount: I e 5 d'L• 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

- ? . www.arhs-nc.org
Permit: 400$79 Culrituck
,
WELL PERMIT' •
AtottAAat.KECtWVALHMITHStIPMI5
PIN: 487AQ06QQ1�QQ3 Patna M Pout Hetkh
PERMIT TO CONSTRUCT PRIVATE
DRINKING WATER WELL
Applicant
Owner:
Wiliam&Alice Jenkins Carova Beach Builders
214 62nd Street 2162 Salmon Rd
Virginia Beach,VA 23451 Corolla,NC 27927 r t
lRi.,':'"rl..aat:'rC' tA
Location:
2242 Ocean Pearl too'CANAL EASEMENT
Oa 2 PO 137)
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Y
0 Canso il. 1,/,t cleft Dr•:ik- - 4,, C-t[-ierf„.�,� w — ,.,
ar
i ct vir:rnc -- iS needed • _.: c1 .
,
--dere_ .
oYe e.p we i1 pa," 4. -�Fon-, 44'" ' L4L1
r 4
_..e p L;c- Syc,/-e,i a35 .
..coartkitkwrI P - t:An
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0,44
Ir OCEAN PEARL ROAD
AfTroveJ lie
**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
Only a Licensed Electrtcian or Uaerls.d Well Driller can wire VI*Pump**
SHALL MAINTAIN 2SFT+FROM BUILDING PERIMETER
SHALL MAINTAIN SOFI'+FROM ANY PART OF SEFTIC.JREPAIR AREA
MUST BE INSTALLED BY CER I SEED 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 e/eA91— ii ihril. Date: 10/03/2023
Melton,Tucker
Certification 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 NGAC 02C.0300.

j
' °' # ROY COOPER • Governor
I , a. :. NC DEPARTMENT OF KODY H. KINSLEY • Secretary
HEALTH AND
* "x'f HUMAN SERVICES i 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
William&Alice Jenkins
214 62nd St.
Virginia Beach,VA 23451
RE: Approval No.WWM1835
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
2242 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 2242 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,
I >...Q.cic.--. 11-1;,.
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