25030398 DECEIVEN MAR 31 2025 EXCEPTION APPLICATION CBPEC 26- I SBeser An application for Exception is required for new, mon-water-dependent development, redevelopment, and construction within 50 of the Resource Protecrion Area (RPA). A Water Quality Impact Assessment is required for review of ALL: activity in the RPA. APPLICANT/AGENT INFORMATION: Name: Kevin D'Connell Phone: 757-403-6961 Mailing Address: 8342 Chesthut Roint Lawe City/State/Zip: Hayes,VA 23612 Email: gilliah.k bwra Ogmail.com LH PROPERTY OWNER INFORMATION: Pool Contractor: Dutdcors Name: SaMK as above Phone: Mailing Address: City/State/ Zip: Email: PROPERTY INFORMATION: 15 RPC 12597 TM4SI82) Tax Map or RPC: 638 E911 Street Address: 3342Chetnut Voiht Lane Date Lot Recorded: 1967 Nearest Water Body: Sarah Cyeck Distance to Feature: l1ft. Sq Ft. of Encroachment: 189 Sqft. DETAILS OF REQUEST: Remorihg cyishng Concrete pad ahd walleway ho Iushall 9x21f+ pool 3 3 ftof prymeakle paver boaider DIRECTIONS TO THE PROPERTY: locate d 6y backside of vesidehce PRIVACY ACT STATEMENT: Information provided in the Chesapeake Bay application willl be used in the permit review process and is a matter of public record once the application Is filed, Disclosure of the requested information is voluntary. but it may not be possible to eraluate the permit application or to issue a permit if the information requested is not provided. CERTIFICATION: I am hereby applying for all permits typically issued by Department of Environmental Quality, Virginia Manne Resoucce Commission, U.S.. Anny Corps ofE Engineers, Chesapeake Bay process, and/or Local Boards for the aclivities I have described herein. I agree to allow the duly authorized representatives of any regulatory or advisory agency to enter upon the premises of the project site at reasonable times to inspect and photograph stte conditions, both in reviewinga proposal to issue a pernit and after permit issuance to determine compliance with the perinit. In addition, certify under penalry ofl lawr that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my: inquiry oft the or persons who managet they syistem or those persons direcily responsible for gathering the anformation, the information submitted is, to the best of my knowledge and belief, true, accucate. and complete. am aw'are that there are significant penalties for submitting false information, including the possibility off fine and imprisonment for knowing violations. Kevin D'Cohnell naDluli 3)28/25 Printed Name Signature Datc Revised 2/2025 #25030378 CHESAPEAKE BAY PRESERVATION ORDINANCE Exception Process Guidance & Application For CBPEC Activities in the Resource Protection Area (RPA) Property owners interested in working in the Resource Protection Area (RPA) may be required to request a buffer reduction through the Exception process. The following are general guidelines and are not intended to represent every possible activity within the RPA. Please contact the Department of Environmental Programs for specific inquiries at 804-693-1217, or stop by the office, 6489 Main Street, Gloucester, or visit our website https: Lpboussteragov/cmsionmenmlprogam: Exception Process (Preservation & Erosion Commission), defined in Sec. 5.5-14; for variance to requirements for Sec. 5.5-7B and 5.5-9C, requiring Public Hearing: $275.00 application fee. Meetings held the 2nd Wednesday of each month, application deadline the last working day of the month. Applications available Online or in the Department of Environmental Programs. 1. New construction on an undeveloped, non-contorming lot (existing before October 15, 1991) with buildable area outside of the Resource Protection Area. 2. Construction of, additions to, accessory structures (garages, pools, sheds, pads, impervious area, grade alteration, etc.). 3. Construction of, additions to, principal structures within the seaward 50' of RPA (between 0' -50). 4. Reviews, waiver appeals, and violation. A Water Quality Impact Assessmenti is required for review OfALL activiryi in the RPA (Scc. 5.5-11). Revised 2/2025 Project #: WATER QUALITY IMPACT ASSESSMENT Required for all eelepmem/inelpment in the Resource Protection Area; CBPO 5.5-11 A site drawing, which shows the following, must be attached to this water quality impact assessment: Location ofthe components ofthe RPA, including the 100' buffer area; Location and nature ofany proposed encroachment into the buffer area, including type of paving material, areas of clearing or grading, location of any structures, drives, or other impervious cover, sewage disposal systems or reserve drain field sites, and wells; Type and location of proposed best management practices to mitigate the proposed encroachment; Location of existing vegetation onsite. including the number. type of trees. caliper. and other vegetation to be removed in the buffer to accommodate the encroachment Or modifications; and Type, size, and location of ceplacement vegetation. Setbacks in accordance with Zoning regulations. APPLICANT/AGENT INFORMATION: Name: Koin OConnell Phone: 757-903- l09lo91 Mailing Address: X342 Clreshant Point Lane City/State/Zip: Hayes VA 23072 Email: gillian. lanra Pgpmail-ton PROPERTY OWNER INFORMATION: Name: Same aS aloove Phone: Mailing Address: Ciry/State/Zip: Email: PROPERTY INFORMATION: Tax Map or RPC: 638 E911 Street Address: 8342 Chshut Point Ln Date Lot Recorded: Nearest Water Body: Suvah Cveek Revised 2/2025 FOR GRANTING EXCEPTION (Sec. 5.5-14) Kequired DV coae piease provige any inpur as to now your prolect compies. 1. Requirements shall be minimum necessary to afford relief. Dempviny N 500 S4ft 6 Cohcvete, Yeplacingw 189 S4f66 pbo) und uddibonal permeakk paves 2. Reasonable and appropriate conditions arc imposed, as warranted, that will prevent the allowed activity from causing a degradation ofwater quality. LesseY Square footngg 4h-ymEaL Sipace wil be veyplacing exisbng Coacrck 3. Granting waiver will not confer applicant any special privileges that are denied to other property owners subject to its provisions and arc similarly situated. Swilav pijacts hAve bech Comje leted by neigkboring kesidenty 4. Waiver is in harmony with purpose and intent of Ordinance and not of substantial detriment to water quality. 5. Waiver not based 0n1 self-imposed/created conditions or circumsrances. 6. Other findings, as appropriate and required by Gloucester County. Anporopriate hovs cul thaks to t ihcluded 1h plab as deemea necessany Pleasc use additional sheets if necessary for completing the questions above. Revised 2/2025 Wastewater (Septic) Element: Attach legible, clean copy ofHealth Department approval information to include calculations and dimensions. Description of potential impacts of the proposed wastewater systems including and proposed mitigated measures for these impacts: PRIVACY ACT STATEMENT Information provided in the Chesapeake Bay application will be used in the permit review process and is a matter of public record once the application is filed. Disclosure ofthe requested information is voluntary, but it may not be possible to evaluate the permit application or to issue a permit if the information requested is not provided. CERTIFICATION: I am hereby applying for all permits typically issued by the DEA, VMRC, U.S. Army Corps of Engineers, Chesapcake Bay process, and/or local Wetlands Boards for the activities I have described herein. I agree to allow the duly authorized representatives of any regulatory or advisory agency to enter upon the premised of the project site at reasonable times to inspect and photograph site conditions, both in reviewing proposal to issue a permit and after permit issuance to determine compliance with the permit. In addition, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering thei information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalt.ics for submitting false information, including the possibility of fine and imprisonment for knowing violations. Kevih O'Cownell wblall Printed Name 323/25 bignature Date Revised 2/2025 Site Conditions (of site and adjacent lands): Existing topography: flat Hlydrology: natual Soils: Sand,clayock Geology: Fill Materials (source and composition): Total Amount of Disturbed area (sq ft): 189 Total Amount of Cleared Area (sq ft): Existing Vegetation: Total Amount of Underbrush Removed (sq ft): Types: Number of Healthy Trees Removed: 0 Types: Number of Trees Limbed or Pruned: 0 Types: Number of Dead/Dying/Dseased Trees Removed: 0 Types: Proposed Vegetation Mitigation Measures: Number of New Canopy Trees Proposed: Types: Number of New Understory Trees Proposed: Types: Number of New Shrubs Proposed: Types: Proposed Erosion & Sedimentation Control Practices: Silt Fencing Temporary Construction Entrance Straw Bale Barrier(s) Inlet Protection Temporay/Pemanent Seeding Mulching Tree Protection Sediment Trap Other: Proposed Best Management Practices: a Dry Well(s) Infiltration Trench(es) Vegetated Filter Strip(s) Grass Swale(s) Other: Revised 2/ 2025 OFFICE USE ONLY 40275028 Project #: 25030398 Received by: BMuERe Paid: 275 Receipt #: Onine Date Reccived: 313125 Reviewing Authority: CPEC Lot recordation date verified with Clerk's Office YES Date: 3/3125 Project Meets Zoning Setbacks: Yes/ No_ Date Verified: 313125 STAFF DECISION: APPROVED: (Approval is valid for 36 months from the date of approval) CODE REFERENCE/COMMENTS: DENIED: *Please be advised, you may appeal the Staff decision, in writing, and apply for Exception to be heard in front of the Chesapeake Bay Preservation & Erosion Commission (new application and fees apply) CODE REFERENCE/COMMENTS: Environmental Staff Signature Date Mitigation plan required: YES J NO square foot minimum Mitigation plan approved: Entitled: Dated: Date mitigation completed: Inspected by: Amount of surety required: Date surety released: Date posted: Reccipt #: Payor Name: Phone #: Payor Address: Revised: 2/2025 STAFF ANALYSIS (OFFICE USE ONLY) Staff responses to applicant information provided 0n1 reverse page . 2. 3. 4. 5. 6. Reviewed by: Date: Revised 2/2025 VIRGINIA THREE RIVERS HEALTH DISTRICT DEPARTMENT Gloucester Health Department P.O. BOX 663 VDH OF HEALTH Gloucester, Virginia 23061 Protecting You and Your Environment Private Well Record ofInspection Health Department ID Number: 136-22-0255 Tax Map/GPIN: 51B(2)-15 Owner Name: Kevin 0 Connell Owner Address: 8342 Chestnut Fork Rd Hayes, Virginia 23072 Private Well Facility Information Property Address: Same as above Subdivision: Summerville County: Gloucester Section Block Lot Well Driller: Brown' s Well Drilling Well Class: Class II B Date construction started: 11-09-22 Water Well Completion Report Received: 12-6-22 Location Information Building Sewer: 75 + Soil Absorption System: 100' Pretreatment Unit: 85'+ Property Line: 30 Conveyance System: 85'+ Other Distance: Foundation 50' Comments: None Construction Information Total depth of well: 77 feet Pitless adapter used: yes Type of casing: Well Casing SCH 40 Pitless properly installed: yes Depth of casing: 57 feet Pitless properly vented: yes Diameter of casing: 4" inches Type of Well Scal: Well Cap Casing extends: 18 in. above ground Screens: constructed of: PVC Annular Space: sealed with bentonite to a depth of 50 feet, Comments: None Ouantity. & Quality Yield and drawdown Yield: 5 gpm Sample tap provided: Yes Drawdown: not reported Sample collected: Yes Static Water Level: Not reponed Result of samples: Satisfactory Type of storage: Pressure Date of Sample: 11-28-22 Comments: Nonc Satisfactory Construction: Yes on November 9, 2022 Well Approved for Use: Yes on January 26, 2023 KIA / 1 Signed January 26, 2023 Michael McMahan, EHS, Sr. Dec06 2022 2: 10pm Browns 8046429188 1 Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well # Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local # Page 1 of 4 VDH HDIN # 138-22-0265 VDH PWSID # Indicates required fieid or section DEC 6 2022 *Indicates required field or section, if applicable 1. Contact Information* Contact: Name Addreas Phone Owner Kevin O'Connell Driller Brown's Well Drlling Co. Inc. P. 0. Box 57, Achilles, VA 23001 804-642-4879 System Provider Joseph L. Brown H 2. Well Location' * Physical Address: 8342 Chestnut Pont Lane County/City: Gloucester Subdivision Name: Section: Block: Lot: Tax Map/GPIN #: 51B(2)-15 Latitude: N Longitude: W Datum Source Horizontal: D WGS84 D3 NAD83 D NAD27 Lat/Long Source (Check One): a Map D GPS D PPDGPS Survey - Imagery - WAAS Location Information Collected By: : Pbysical Location Description: 3. Facility & Use* Type of Facility (Check One): Type of Use (Check All That Apply): E Private a Drinking/Domestic Use Agricultural Food Processing Waterworks Manufacturing Irrigation Injection Obseration/Montoring Well Geothermal (Cooling/Hcatmg) Fire Safety a Closed D Open: a Retumed to Surtace Retumed (D Agufer 4. Well Construction* Well designation, Name or Number: Date Started: 11-9-22 Date Completed: 11-9-22 Type Rig: Mud Rotary Class Well (Check One): I - IA D IIB D IIA IIB IIIC IIID a HIE IV Construction Type (Check One): D New - Existing-Modified: 0 Wel! D Pump: Date 0 Well Depth: 77 ft. Total Hole (borehole) Depth: f. Depth to Bedrock: ft. Hole Size (Include resmed zones): 8" inches from to ft. Inches from to ft. Height of Casing above Land Surface: ft. inches Casing Size (I.D.) and Materials: (below) Total Depth of Casing: R. 4 inches firom 0 to 57 ft. Oi infilled Material PVC sch 40 Weight per ft. or wall thickness in. inches from to R.O infilled Material Weight per ft. or wall thickness in. inches from to At. Dinfilled Material Weight per ft. or wall thickness in. Screen Size & Mesh: 2 inches from 57 to 77 ft. Oinfilled Mesh Size Type PVC sch 40 inches from to ft. D infilled Mesh Size Type inches from to ft. Oinfilled Mesh Size Type Water Zones: from 57 to77 ft. from to ft. from to ft. Gravel Pack: Size: Type: from 57 to 77 ft. Size: Type: from to ft. Grout Type: 0 50 Grouting Method: Type of Seal: B1 Bçnloste Slurry a Nçat Cement from to ft. Poured from surface B pitess adapler a Bentonite pellcisichips Concrete Poured through temmie pipe Ds sanitery seal Ncmt Ccment (6% bentonnc) from to ft. 4 Pumped from bottom ypward Camera Survey: D Yes D No Date Conducted: Additional Well Construction Form Information Attached: Yes No Deo 06 2022 2:10pm Browns 8046429188 2 Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well # Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local # Page 2 of 4 VDH HDIN # 136-22-0255 VDH PWSID # Weli designation, Name or Number*:51B2-15 5. Disinfection Well Disinfected: E Yes a No Date: 11-9-22 6. Abandonment (*When abandoning the well, Sections I thru 4 must be completed and/or attach original GW-2) Date Started: 11-0-22 Date Completed: 11-9-22 Static Water Level (unpumped level measured): ft. Casing Size (1.D.) and Materials: 2" Casing Pulled: D Yes a No Uncased Well Depth of Fill: Type and Source of Fill: Grout: From 0 to 88" Type: Bentonite From to Type: Method of permanently marking location: 7. Pump Test*a Static Water Level (unpumped level measured): ft. Date: Method (Check One): Water Tape a Airline J Transducer Other Stabilized measured pumping water level: ft. Date: Method (Check One): Topof Well Top of Casing Surface Level Test Pump Intake Depth: ft Stabilized Yield: gpm after hours Natural Flow: E Yes No Flow Rate 5 gpm Estimated Well Yield: gpm 8. Pump Data * Type: a submersible a Turbine a Shallow Jet a Deep Jet Other: Motor HP: Production Pump Intake Depth: ft Rated Capacity: gpm at ft TDH 9. Geologic Information Type Logs: Aquifer Test Performed: Water Quality Results Attached: Yes 7 No Comments: Fomation Lihology. Province Gcologic Map Uscd Elevation For Office Use Dec 06: 2022 2:10pm Browns 8046429188 Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well # Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local # Page 3 of 4 VDH HDIN # 136-22-0255 VDH PWSID # Indicates required field or section owIndicates required field or section, ifapplicable 10. Driller's Log (Use additional sheets if necessary)" Well designation, Name or Number: 518(2)-15 Depth (feet) Type of Rock or Soil Remarks Drilling Diagram of Well Construction (with Time dimensions) (Min.) From To (Color, material, fossils, hardness, Etc.) (Water, caving, cavilics. el) ) 11. Certification / certify under penalty oflag that this document and all utlachments were, prepared under my direction or supervision in accordance with a system designed 10 assure that qualified personnel, properly gather and evaluate the information submitted. Based on my inquiry ofthe person or persons who manage the sjstem or those persons directly responsible for guthering the information, the information submitled is to the best ofmy knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting. false information including the possibility offine and imprisonment, for knowing violations. Signature": Oeaphlbeaneiss Date: 18-l066 License Number: 2705 018849 Dec 06 2022 2:10pm Browns 8046429188 01/15/2014 00:42 FAI 002 5400 Enterprise Court Gloucester, VA 23061 PH: 804-594-8285 FAX: 804-695-1129 22241017 www. coastalbio.com (Laboratory Sample ID : Lab Use only) GARIE lorulyst, A. EPAI VA01118 VELAP! 460030 CERTIFICATE OF ANALYSIS: Total Coliform Bacteria (Drinking Water) Please complete the upper portion of thie form. Incomplete information may delay processing of the sample. Payment must accompany sample unless charged to an established account. PWS D ( applicable) WATER SVSTEMI NAME AND ADDRESS Oboell la supply chiorinated? 934a Chestnut Rnt Ln. Vos No 518 (a) -15 Glauesket VA CL2 Rooldual:, PPM SAMPLELOCATION COLLECTIONT DATE & TIME SAMPLE DAY YA. TIME hhmm TVPE 1.0. OR LOCATION CODE MO. well ajs a o a ANALVSIS REQUESTED: Prosence/Abaence OR MPN (Count) 241 h Turn around C OR 18 h Turn around (Additlonal cost) COLLECTED BY: Phono #: Name (Print): Bownl Well Orly (source aitor E coll Afflation: poplive Taggered cample). RYrouline dotribution or Bample Vype ochoduled (PWS dnyzco-sonliymalont raw water, RP a Repoat (verification aitar posluve TC) STaspin (ac), TGetriggered ( sourea after TC entry point: positive ln distribution) BPmopealal fo4 9172 Malli a Pick Vp Resulla: a Emall: 62 * e - * su i CAEL - DONS & - & a 17 M 43 RECEIVED B: DATE mmddyy MME hhmm oèy 1 24 12 10 Payment Amount: a Check #. Gard a Cash "Sample Rojeotion Code: "SAMPLE CONDITION UNSATISFACY AV PLEASE RESAMPLE information, (ERebroken, VOsinsulicien! CLechlorine present. volume, EH-exceeds BPainvalid sampling 30nhola poinl, ume, HS-excersivel head space, FZ-trozen accident. sample. LTelesked INainsuficiont in transt. (No notalion - Sample Condillon Acceptable) Painvaild sampling protocol, LAvleb TEST METHOD: Collfors Absent Colforme Present COLILEAT E E. coli Absent A E. coll Present MPN (number o! organisma/100 mt): Tatal collforme:. E. coll: COMMENTS: The results pl analysis contained within this report relele only to the sample as received in the laboratory. This report sha!l not be reproduced except in full wthout written approvel from the laboralary. Unless noted below, these test resuls meet ah requirements ol NELAPNELAP. AMOMPLThomDs 11179122 Name Sighature Date Page 1 ot 1 VIRGINIA DEPARTMENT THREE RIVERS HEALTH DISTRICT GLOUCESTER COUNTY VDH OF HEALTH P.O. BOX 663 Protecting You and Your Environment GLOUCESTER, VIRGINIA 23061 804-693-6130 Private Well Construction Permit September 8. 2022 Kevin O' Connell 8342 Chestnut Fork Rd Hayes, VA 23072 Tax Mapl GPIN #: 51B(2)-15 Site Address: 8342 Chestnut Fork Rd HDID #: 136-22-0255 Directions: 17 S to R on Guinca Rd to R on Mark Pine Rd to R on Little England Rd to R on Oyster Cove to Chestnut Point Ln The atlached drawings and below specifications constitute your permit 10 install a private well on the property referenced abové. This permit IS null and void if conditions are changed from those shown on your application or if conditions are changed from those shown on the attached construction drawings and: spccifications. VDH may revoke or modify any permit if, at a later date, it finds that the site conditions, well location. and/or design do not substantially comply with the Private Well Regulations, 12 VAC 5-630-10 et. seq, or if the well would threaien public health or the environment. There may be other local, state, or federal laws or regulations that apply to the proposed construction of this private well. The landowner is responsible at all times for complying with all applicable local, state, and federal laws and regulations, and for ensuring that the water weil is properly located on the landowner's property and in the approved area indicated on the atlached schematic. Your private well nust be inspected by a representative of the local health department. Your private well may not be placed into operation until you have oblained a Record of chis Inspcction (ROI) from thc Gloucester County Health Department. This construction permit is transferabie until expired or deemed null and void. A permit transfer form may be found on the VDH website at hup:'www. vdh. virginia govienvironmental- ksaltlMgmp,0150l-om. Before you can obtain your ROI, or O.P. you must provide the Health Department with a complete Water Well Completion Statement /GW-2 from your well driller. Well Purpose: Residential Drinking Water Minimum Casing Depth: 50' Well Class: Class IIIB Minimum Grout Depth: 50' Distance from Building Sewer: 50' Distance from Septie/Pretreatment Tank: 50 Distance from Conveyance System: 50' Distance from Absorption Area: 50' Distance from Property Line: 50' Distance from Home Foundation 50' THIS PERMIT KPIES: Mach 82027 Issued by: Date: 9/8/202 Mickael McMahan, EHS, Sr. WELL CONSTRUCTION PERMIT 8342 CHESTNUT POINT LANE PAGE 2 OF4 TAX MAP 51B(2)-15 HDID 136-22-0255 INSTALL HI B WELL CASE AND GROUT 50' MINIMUM DEPTH KEEP WELL 50'+ MINIMUM FROM ALL PARTS OF EXISTING SEPTIC SYSTEM KEEP WELL 50' MINIMUM FROM ANY HOME FOUNDATION THAT WAS TREATED WITH SOIL POISONS FOR TERMITES KEEP 50' MINIMUM FROM ALL SOURCES OF CONTAMINATION OWNER IS RESPONSIBLE TO TO OYSTER COVE ROAD ENSURE PROPOSED NEW WELL AREA IS LOCATED ON CHESTNUT POINT LANE THEIR PROPERTY RECOMMEND THAT EXISTING WELL BE PROPERLY ABANDONED BY A LICENSED WELL DRILLER R N A SEPTIC SYSTEM EXISTING SEPTIC TANK EXISTING HOME SHED 50 EXISTING WELL 50' 10" PROPOSED 10' X15' IIB WELL SITE CALL MISS UTILITY AT (811) BEFORE ANY CONSTRUCTION PIER DREDGED CHANNEL TO SARAH'S CREEK SCALE 1" = 60' +l- Page 3_of.4 Tax Map 51B(2)-15 HDID # 136-22-0255 Private Well Construction Permit with Abandonment of Existing Before you can obtain your ROI, you must provide the Health Department with a complete Water Well Completion Statement IGW-2 from your well driller and a record of a satisfactory bacteriological sample result. If) you desire a refund for the well construction permit fee, also provide the well driller's abandonment documentation along with the enclosed Refund Request form. The $300 well construction Permit Fee is Refundable upon submission of the well driller's well abandonment documentation. Notes: This permit authorizes construction of a new well and abandonment of the existing. The applicant is to contract with a licensed well driller. The well driller, or home owner, is to contact the health dept. with an expected construction, installation date. The well is lo be constructed according to the 1992 Private Well Regulations Class 1IB well: case & grout minimum 50' Class HIA well: case 100' minimum and grout 20' minimum Per 12 VAC 5-630-440 a copy of the well construction documentation report shall be provided to the health department for approval of the well as a drinking water source. Per 12 VAC 5-630-370 a water sample absentnegative for the coliform bacteria shall be provided to the health department for approval of the well as a drinking water source. Note that the well driller will not conduct the water sample unless applicant specifically contracts with the well driller. The well must be abandoned by a licensed well driller (effective July 2010). A Record of inspection is issued as documentation that the new well is approved as a drinking water source. Class HIA or 1I8 Setbacks: 50' from on site wastewater disposal system, 50' from chemically soil poisoned foundations, 50 from underground fuel storage tanks, 10' from building foundations not chemically soil poisoned, 50' from cemetery, 50' from a dump station, & OSHA required safe distance from overhead power lines or utility policy (25' for Dom Va Power), and 50' from agriçulture field. It shall be the landowner's responsibility to ensure that the water well is properly located within their boundary. issuance of the Record of Inspection can be delayed if the health department Is unaware of the well insalaionlconsinction. After receipt of the required documentation, it can take up to 5 working days to process a Record of Inspection. Page 4of4 Tax Map 518(2)-15 HDID # 136-22-0255 1992 Private Well Regulation - Abandonment requirements 12 VAC 5-630-450. Well abandonment. A. Well abandonment is governed jointly by the Department of Environmental Quality and the Department of Health pursuant to section 62. 1 44. 92(6) of the Ground Water Act of 1973 (Repealed). In addition, the abandonment of any private well governed by this chapter, or any private well abandoned as a condition of a permit issued under this chapter, shall be administered by the Department of Health in conformance with this section. B A temporarily abandoned well shall be sealed with a water-tight cap or welli head seal. Such a well shall be maintained so that it will not be a source or channel for contamination to ground water during temporary abandonment. :. Permanent abandonment. The object of proper permanent abandonment is to prevent contamination from reaching ground water resources via the well. A permanently abandoned well shall be abandoned in the following manner: 1. All casing material may be salvaged. 2 Before the weil is plugged, it shall be checked from land surface to the entire depth of the well to ascertain freedom from obstructions that may interfere with plugging (sealing) operations. 3. The well shall be thoroughly chlorinated prior to plugging (sealing). 4. Bored wells and unçased wells shall be backfilled with clean fill to the water level. A two-foot- thick bentonite plug shall be plaçed immediately above the water level. Clean fill shall be placed on top of the bentonite plug and brought up to at least five feet from the ground surface The top five feet of the well casing. if present, shall be removed from the bore hole. In an open annular space IS present around the well casing, the annular spaçe shall be filled with grout to the maximum depth possible, but less than or equal to 20 feet. A one-foot-thick cement or bentonite grout plug that completely fills the bore void space shall be placed a minimum of five feet from the ground surface. The remaining space shall be filled with clean fitl which is mounded a minimurn of one foot above the surrounding ground surface. Bored wells or uncased wells abandoned in this manner shall be treated as welis with respect to determining the minimum separation distance to sources of contamination listed in Table 3.1. The location of these wells shall be permanently marked for future location. 5. Wells constructed in collapsing material shall be completely filled with grout or clay slurry by introduction through a pipe initially extending to the bottom of the well. Such pipe shall be raised, but remain submerged in grout, as the well is filled. 6. Wells constructed in consolidated rock formations or which penetrate zones of consolidated rock may be filled with sand or gravel opposite the zones of consolidated rock. The top of the sand or gravel fill shall be at least five feet below the top of the consolidated rock and at least 20 feet below land surface. The remainder of the well shall be filled with grout or clay slurry. 7. Other abandonment procedures may be approved by the division on a case by case basis. 8. Test and exploration wells shall be abandoned in such a manner to prevent the well from being a channel for the vertical movement of water or a source of contamination to ground water. 9. When bored wells are bored and a water source is not found, and the casing has not been placed in the bore hole, the bore hole may be abandoned by backfilling with the bore spoils to at least five feet below the ground surface. A two-feet-thick bentonite grout plug shall be placed at a minimum of five feet from the ground surface. The remainder of the bore hole shall be filled with the bore spoils. oe 6 A V 1 K 6 9 - a 6 a 9A 04 Ac. / * 02 Ae . A. la SOLD well - a - 3 - a . N 6 - - & 100 - N l- I6AP 93 ' - - 63 ls 25/ DREES 1 AA Commonwealth of Virginia VDH Use only Application for: Sewage System/Water Supply Health Department ID# 3-28-0355 Due Date Owner Keviy OCohnell Phone 751-181-16015 Mailing Address 3342Chesthkt Point Lahe Phone Hyes, VA 23072 Fax Agent Phone Mailing Address Phone Fax Site Address Same A5 above Email Slahne gmail.com Directions to Property: Subdivision Oyster Cove Section Block Lot 15 Tax Map 51812)-15 Other Property Identification 12597 Dimension/Acreage of Property oL Sewage System Type of Approval: Applicants for new construction are advised to apply for a certification letter to determine ifland is suitable for S sewage system and to apply for a construction permit (valid for 18 months) only when ready to build. OCertification Letter Construction Permit Voluntary Upgrade Repair Permit Minor Modification Proposed Use: Single Family Home (Number of Bedrooms 2 Multi-Family Dwelling (Total Number of Bedrooms Other (describe) Basement/Ov-No Walk-out Basement? Ye No Fixtures in BasemeniOye-@No Conditional permit desiredOYe:No Ifyes, which conditions do you want? Reduced water flow Limited Occupancy Intermittent or seasonal use Temporary use not to exceed I year Do you wish to apply for a betterment loan eligibility letterOye@No *There is a $50 fee for determination ofe eligibility. Water Supply Will the water supply beOPublic orPrivate? is the water supply@Existing or OProposed? Ifp proposed, is this a replacement well@YesONo Ifyes, will the old well be sbandoned@y-ONo Will any! buildings within 50' oft the proposed well be termite treated? OYes QNo Well Type (e.g. domestic use, agricultural, irrigation, etc.), doweshc All Applicants Is this property intended to serve as your (owners) principal plaçe of residence? GYesONo All applications must be accompanied by private sector evaluations and designs, unless aj petition for VDH services is approved. Isal Petition for Service form attached? Yes No In order for VDH to process your application for a sewage system you must attached a plat oft the property and a site sketch. For water supplies, a plat oft the property is recommended and a site sketch is required. The site sketch should show your property lines, actual and/or proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines, building location and the proposed well and sewage sites must be clearly marked and the property sufficiently visible to see the Ig topography. give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of processing this application and toj perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil Evaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and approved. (Wiar O'comsr 917122 Signature of Owner! Agent Date This form contains personsl Information subject to disclosure under the Freedom of Information Act. Revised 7/1/2019 SITE PLAN SKETCH Or attached scaled site plan (if available) Atuched Owner/Agent Signature Ckan 62 Date 9h22 COMMONWEALTH OF VIRGINIA VIRGINIA DEPARTMENT VIRGINIA DEPARTMENT OF HEALTH OF HEALTH Gloucester VDH County Protecting You and Your Environment 1882 Main Street e P.O. Box 663 Gloucester, VA 23061 Kevk Petition for VDH Services Form 3 1, Cillian O'Comell am petitioning VDH to provide evaluation and design services based on (select one): Means test (household income at or bel low 100% of the federal poverty guidelines) VDH Hardship Guidelines If you selected VDH Hardship Guidelines, please check all of the following guidelines that apply: Qualify for fee waiver pursuant to 12VAC5-620-80.A. Replacement we!l Well abandonment Safe, Adequate, and Proper Evaluation Onsite sewage system repair or pit privy fee waiver Insufficient number of private sector service providers Other: If other, please provide a detailed description of your hardship in obtaining private sector evaluation and design Services along with any relevant documents that you believe supports your request. Please provide the names of the Private sector service providers you contacted, prior to submitting this petition. (Detailed description can be attached) Gilvian DCGmne Rl 9/7/22 Owners / Agents Signature Date (OFFICE USE ONLY) Petition, for services: & APPROVED DENIED Chud Banx 09.07.2022 Reviewed By Date Pllwshwhigelmwswwwyaasaé.uang-hephate-awl CUPpdrcmare 51 Pet for VDH: Serves.docx 0701/2019 DREDGED CHANNEL TO. LOT 2. LOT 3 "SARAH'S CREEK" ELooo E66 $74007'20"w 1 100.33' * < 61 - LOT 14 1.0a AC. 3. M LDI 4 M / A noy E Posodosd : M 3 - C 3 bpu3 N Pas W o 1 e 100.00 a 0.24 Mi.t To * N78045'00"E * ST RT. * G 42 STATE. ROUTE NO. 715 25' TO CENTERLINE 6 PLAT T,B.M. - MANLECAP SETIN H, SHOWING LOT 14 a -VEPCO POL6 à TG32 +11.04 OYSTER COVE" TOPOF MAIL MEAO GCEV. AND BEING THE LAND OF CuE.ceG s. DATUM) FLOYD JR. & MABLE W. BRADD LOCATED IN THE YORK DISTRICT OF GLOUCESTER COUNTY. VIRGINIA NOTE SCALE: "":60' AUG. 3,1982 I. PROPERTY REF.- D.B.2428P6.409 CPB.4 & PG.78 Documentation Required for Sewage System OP &/or Record of Inspection for well Tax Map #: 51612)-15 HDID#: 3i0- 22 - 0255 Sewage System Construction Permit Minor Mod New Construction Repair VU Needed Received Date Action/Paperwork Description Inspection by EHS Inspection by Private Sector (OSE, OSEIA, PE) Contractor Completion Statement Reçorded Notice for Recordation Recorded Deed, or easement, or other Signed Survey Plat Waiver form (attachment B): EHD Updated Repair Log Updated SDS GPS Coordinates: Date OP requested: Date OP needed: Date OP issued: Date OP to building official: Private Well Construction Permit New Construction Replacement a Abandonment Only Needed Received Date Action/Paperwork Description As-built for Geothermal Well System Statement: 50' setback not met, alt treatment used Inspection by EHS - 1-35-33 Inspection by Private Sector (OSE, OSE/A, PE) 12.04.2022 Satisfactory Water Sample 12..0L. 2022 Water Well Completion Statement - new/replacement 12.04.2022 Water Well Abandonment Slatement EHD' Updated Installed? EHD Updated with construction info? Abandonment: does action qualify for refund? Yes No Not primary residence or property is commercial Well Driller abandonment documentation on file Refund form Received Refund approval obtained Refund processed to payee EHD Updated Abandoned? EHD Updated with construction info? Well GPS Coordinates: Date ROI requested: Date ROI needed: Date ROI issued: (-26- 23 Date ROI to building official: NA 3 - € 5 a o 8 @ 8 6 e e - o e Powse Ehe das 12f+ Eyishng e? deck G yaa Qx21' peenuN Pwl L MA Ipb' 4o Savalh cinck