WQ0004823_Compliance Schedule I.4_20240723

Initial Review
Reviewer
nathaniel.thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other Compliance Schedule 1.4
Permit Number (IR) * W00004823
Applicant/Permittee Pine Island-Currituck LLC
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
......................................................................................................................................................................................................................................................................................... ... ... ... ... ... .. ... ... ... ... ..
Name* Cathleen Saunders
Email Address*
[e-mail]
Project Information
.........................
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Compliance Schedule 1.4
Phone Number*
252-202-7112
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https:Hedocs.deq.nc.gov/Forms/NonDischarge Monitori ng_Report
Permit Type:* Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number:* WQ0004823
Has Current Existing permit number
Applicant/Permittee Address* 106 York Way, Suite 201 Bermuda Run, NC 27006
Facility Name* Pine Island-Currituck Club WWTP
Please provide comments/notes on your current submittal below.
Current documentation is for installation of MW-18 (between the RWSP boundary and the property).
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
Pine Island MW18 GW1 7.18.2024.pdf 399.19KB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be accepted for pre -review until the fee (if required) has
been received by the Non -Discharge Branch. Application fees must be submitted by check or money order and made payable to the
North Carolina Department of Environmental Quality (NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
Submission Date 7/23/2024

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
David E. Meyer
Well Contractor Name
2527-A
NC Well Coutractor Certification Ntunber
protocol Sampling Service, Inc.
Company Name
2. Well Construction Permit #: na
Us; all applicable ivell consimctlon perouls (i.e. WC, County, State, Varlance, etc.)
3. Well Use (check well use):
Water Supply Well;
[]Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ IndustriallCommercial
❑ Irrigation
Non -Water Supply Well:
nMonitoring
Injection Well:
OAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technoicgy
❑Geothermal (Closed loop)
❑ MunicipallPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells a 100,000 GPD
❑Reeovety
00roundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
[]Tracer
❑Geothermal (Heating/Cooling Return) 00ther (explain under #21 Remarks)
4. Date Well(s) Completed: JUIy 17, 24ell 1D# 18
14. WATERZONES '
I
FROM To
DESCRIPTION �
I5.5 ft 113.0 ft.
surficial aquifer
'L I ft.
1 15. OUTER CASING {tor multi -cases! wells) OR LINER (if ap lica de)
I FROM TO
DIAMETER THICKNESS MATERIAL
14-10 ft- 1-3.0 ft
2 in. Sch. 40 PVC
I
1 16. INNER CASING OR T;tjN1-G (aeotherutal closed -loop) _
I FROM TO
METER __I THICKNESS MATERIAL
ft
Iff ft,
in. I
1 17. SCREEN
I FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
-3.0 ft' -13.0 ft• I2
in. 0,010 Sch. 40 PVC
rt. -3.0 It.
in 1
118. GROUT
F'RO@I TO
hATERIAL EMPLACEMENT METHOD & AMOUNT
+0.33 ft• -2.0 f
Concrete Pour
I -2.0 IL -2.6 ft
Dentonite Pour
+ ft. I It.
1
119. SANDIGRAVEL PACK (ifaPPlicable)
I FROM TO
MATERIAL EMPLACEhIENTMETHOD
-2.5 ft- -13.0 ft
#2 quartz sand pour I
ft. ft.
1 20. DRILLING LOG (attach additional sheets it necessary)
I FROM 7.0
llES<RIPT[Oti[eotor,hArAneas•sodllroCk7YPe eraSnSaREh•)
I0.0 ft 1.0 ft.
Yellowish brown fine sand (SM)
11.0 ft. 5.0 fR
Brown fine sand (SM)
15 0 It. 13 0 fR
Grayish brawn silty fine sand (SM)
Sa. Well Location: I
Pine Island-Curritvck Club *if WQ0004823 fts
Facility/Owner Name Facility 109 (if applicable) I ft ft
ine Island-Currituck LLC 106 York Way Bermuda tR�WJ ft. fr
X, tu-6 ft tT I
Physical Address, City, and Zip
Currituck 0117000001 HO 0
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(ifwell field, one latllong is sufficient)
36.289 h-75.805 W
6. Is(are) the well(s): In Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or 11No
If ibis is a repair, fill our knowwell cwnrrwilon inforrnaiiou and explain the nature of the
repair under :r21 remarks section or ins the back of this fnnn,
S. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 13
For multiple wells list all depths if d ferew (example- 3 200' and 2@100')
10. Static water le►+el below top of casing: 5.50
1firater level is aboly casing, use "
11. Borehole diameter: 6.5 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
21. REMARKS -- -
Static water table at -2.50' bIs; set well screen shallow but with enough
concrete to prevent any surface contaminants from entering well
22. ' f
7 7/18/2024
Signature of Certified Well Ca or Date
lly.signing this form, I hereby certify that the trell(•s) was (mere) comerticted it? accordame with
15A A'C A(' 02C ,01(N) or 15A NC ACOX .0200 Well C'onsrruclion Sfa lards and drai a copy
of ihis revord has been proi4ded to the moil o"Wer-
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add'See Over' in Remarks Box). You may also attach additional pages if necessary.
Z4. SUBMITTAL INSTRUCTIONS
fff.) Submit this GW-I within 36 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, I MSC, Raleigh, NC 27699-1636
24c. For Water SupplV and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells pp oducine over 100 000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 CO, Raleigh, NC 27999-1611
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount -
Form GW-1 North Carolina Department of Environmental Qwlity - Division of Water Resources Revised 6-6-2018