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HomeMy WebLinkAboutSAM-07-2016-074730.TIF 4$A C Case# SAM-07-2016-074730 � ,y CATAWBA COUNTY HEALTH DEPARTMENT mammin ape r7 Environmental Health Section 1842 SM 07/I9/2016 WATER SAMPLE APPLICATION Applicant RONALD UNDERWOOD, 3605 RIDGETOP RD, SHERRILLS FRD NC H:7044837454C:7047376015 Site Address: 3605 RIDGETOP RD, SHERRILLS FORD NC 28673 SELECTED SAMPLES Bacterial Name of Subdivision: Inorganic Parcel Number: 368702864932 Lot: 21 Block: Specific Directions Description: Bacteria and Inorganic Chemical Reason for Sample: Type of Well �l G�ltr' +!! l"'.ilDiilled y;jl�ila Is the well on this same property? Mites'1l Is outside spigot available to collect sample? +...Yestl*'11' Is power on? {IIYes.C}dll I-las well been tested before? I pkYes;,��i1jj Results ?pr b em s;Ck2",:. ,.1571111,111EN, Does the plumbing come out the top of the well through a sanitary well seal? �t,`'°'YeS Does the well ever become cloudy or has there ever been a problem with taste and/or odor? L:ia Ng. ,, Explain Does the well top extend twelve (12) inches above the ground or well slab? L,,atiYes 11111 The well is in: 'IMI 1'" tRear l(tm t �.!��liill J.I�., Does this well supply water to more than one home? E No"/:'il't,,`] Water samples will be drawn from an outside faucet unless otherwise specified. Please note that all water samples are taken during one visit. The processing laboratories have different protocols and timeframes for reporting results; therefore, you may receive several different reports concerning your water sample. For questions or more informat e , please contact Catawba County Environmental Health at(828)465-8270. Date /� Signature or Owner or Age , - � Area 1 I] FEIIE�iDESCRIPTIttcOIN L_� _�_. ty'r`yt i- --- tDtATIEtF. i i`I(IYuaLh FEE AUNT . . t. Bacteriological Sample Fee 07/19/2016 558.00 Inorganic Chemical Sample Fee 07/19/2016 $114.00 tl;' j'%fOTALIFEE$ I1;11IllP' 111 i kIy11 60111 II`. la t iuue� t alu liiLV' r LELA rsamapplication 7/19/2016 Page 1 of 2 1Print4Form .) cATAc„, Catawba County Public Health '--a - °' COUNTY "• s yy www.catawbacountync.gov/environmentalhealth —��� Environmental Health North Carolina P.O. Box 389, 100-A South West Blvd., Newton, NC 28658 Phone(828) 465-8270. Fax (828) 465-82762l /� ' Water Sample Application Ce/( 7e f4 - 237-70/f Sample Requested By - e,,/ % r eA' cc_'o ' d Home Phone <, Y` frec7 cy r / fzi-ei Property Address 346A-1- "P! ci ®G CZ-9- C • Business Phone S'Ae 4el // /C© ,gr cl Mailing Address cct/fi4( C —r1 �/ A J Driving Directions /6 �C 4/ /h /2-7(,&�r"t /" L°� � • I vpPA/ / i 4.4ev Kai/ i %`ry Twee Fr( c%f f� ep7 v.✓' eed //} 4 . /�4 r / ,,a t / err- �, -i 4 /o�j�e 72;.-- ' Sample mple Requested: Bacteriological //1/Inorganic Chemical Otthher i'1977 a cl �f e Sample reason: J !s tec�eve/ C7 j/C Ae/'�� - (Cee � 7,1`4fc) Type of Well: Drilled t� Bored Dug Other C Is the well on this same property? Yes No Is outside spigot available to coll4 sample? Yes No Is power�/ on? Yes �Noo Has well been tested before? Yes S1� /y No Unknown Results U /17,‹/17,‹U//e/yf Does the plumbing come out the top of the well through a sanitary well seal? Yes ✓/No Unknown `.-0"/ Does the water ever become cloudy or has there ever been a problem with taste or odor? Yes No Explain Does the well top extend 12 inches above the ground or well slab? Yes �No Unknown The well is located in front rear left side right side of the house. Does well supply water to more than one home? Yes No ✓ Date 7 - /Y - /‘ Signature of Owner or Agent(40^'r « / /t2 of /I /, /-(e 4;7 a e rWeze / tAe e- / oY c-o-fpc' 61t7- Armor e 7Ad47e/ . 41- ems 4irer zki ed-it e At Tv "Leading the Way t94 Mrommunity" PPublik �.��, Y� / �� °Health , /-t e 7---k- ` r c int i$ DATE:8-10-95 INSTALLER: JEFF STEELE WELL COMPANY, INC. 16579 COOL SPRINGS ROAD CLEVELAND, NC 27013 ************************ * PUMP RECORD * ************************ NAME: RON AND ELAINE UNDERWOOD C/O WILLIS SPIVEY ADDR: 8033 HWY. 150 E. , TERRELL, NC 28682 TELP: 478-5771 1 . PUMP IN WELL:7EH10422 SERIAL #:AA430231 2 . WIRE IN WELL:480' 10-2 + GROUND 3 . PIPE IN WELL: 480' 1" SCH. 80 PVC 4 . TANK:WM-6 LAWN HYDRANT: SLAB: 5 . Valves: X Well Seal : X Tank Tee: X Pop Off: X Spicket: X --- --- --- --- --- 6 . TRENCHING: WELL COVER: 7 . PIPE TO HOME: 8 . WIRE TO HOME: 9 . COMMERCIAL FILTER: SMALL FILTER: CHARCOAL FILTER: 10 . ELT. EXTRA: 11 . LABOR: INCLUDED SUB SOURCE: P225199 13 . EXTRAS: 14 . WELL DEPTH: 505' GAL/MIN:4 CASING DEPTH:105' GALV. 15 . TOTAL PUMP JOB: $2241 . 00 ALL TAXES PAID BY STEELE WELL CO. , INC. TO SUPPLIERS . 16 . SERVICE RECORD: ***NOTE: A FILTER MAY BE NEEDED WHEN THE HOUSE IS COMPLETED. THE DRILLER NOTED THAT THERE WAS IRON CONTENT IN THE WATER:**** NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND camam DEVELOPMENT *************FOR OFFICE USE ONLY************* DIVISION OF ENVIRONMENTAL MANAGEMENT-GROUNDWATER SECTION * * P.0. BOX 27687-RALEIGH, NC 27611 PHONE (919) 733-5083 *Quad No. Serial No. * *Lat, Long. Pc * WELL CONSTRUCTION RECORD *Minor Basin * *Basin Code * • *Header Ent. GW-1 Ent. * ********************************************* DRILLING CONTRACTOR: STEELE WELL CO., INC. STATE WELL CONSTRUCTION DRILLER REGISTRATION NUMBER: 780 PERMIT NUMBER: 1. WELL LOCATION: (Show sketch of the location below) Nearest Town: DENVER Count?r: LINCOLN OFF 1846 BEVIAH DEPTH Drilling Log (Roar, Community, or Subdivision and Lot No.) From To Formation Description 2. OWNER: RON AND ELAINE UNDERWOOD C/O WILLIS SPIVEY 0 10 BOULDERS AND SILT ADDRESS:8033 HWY. 150 E. TERRELL NC 28682 Street or Route No. City or Town State Zip Coae 3. DATE DRILLED: 8-10-95 USE OF WELL: HOME 10 30 SAND 4. TOTAL DEPTH: 505' CUTTINGS COLLECTED _ Yes x No 30 90 RED SHALE • 5. DOES WELL REPLACE EXISTING WELL? _ Yes X No 6. STATIC WATER LEVEL: 100 FT. Above X Below TOP OF CASING, TOP OF CASING IS: 2 FT. ABOVE LAO SURFACE 90 105 SOFT, LAYERED GRANITE 7. YIELD (ape): 4 METHOD OF TEST: AIR 105 505 GRANITE 8. WATER ZONES (depth): 195-455 9. CHLORINATION: Type GRANULAR Amount 1 CUP 10.CASING: If additional spacepis needed use back of farm. Wall Thickness i********************************************** Depth Diameter or Weight/Ft. Material LOCATION SKETCH Eos 0 To 105 Ft. 6 1/4 .188 GALV. (Show direction and distance from at least two State Roads, From To Ft. or other map reference points). From To Ft. 11.GROUT: X Depth Material Method From 0 To 20 Ft. BAG WASHED From To Ft. 16 BEVI.AH 12,SCREEN: DIRT 1846 Depth Diameter Slot Size Material LINEBERGER 1851 From To Ft. in. in. From To Ft. in. in. PLEASANT 1849 From To Ft. in. in. 150 13.GRAVEL PACK: Depth Size Material From To Ft. I-77 From To Ft. 14.REMARXS:SHOWED HIGH IRON WHEN RODS WERE PULLED. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY—OF—I - RECORD HAS BEEN NPPROVI�DE,D TO-- THE WELL OWNER. ( — //SIGNA ' i CONTRACTOR OR AGENT— DATE GW-1 mit original to Division of Environmental Management and copy to well owner. f/ 7C-1 :!(3: Fax: 70-1:483-9179 Innovative Conunercial'Industrial Technical Design :Aon-Chemical Hater Treatment for Farm, Home& Industry 1-l:,zl.ronic Heating- Hot (Vater Supply-Generic Cadd&.dutoCAD-Elite RHI!1C ii�nlJlolt Engineering - BioTHERNI - Seahorse -Triangle Tube - Dime Water Ednards Engineering - Bosch Instantaneous - \'R\' Products The Harley A. Payne Agency,Inc. 5150 Glenwood St. Sl:crrills Ford, NC 28673 P. O. Box 930 Denver,NC 28037 whom the dekv i Inii.lymir a'':e!j'c: i.vhen moved the office to my home, and misplaced your identification, so could not you. i ()Lou :Li.t: -IA tl) CLEAR t'DOR NONE 1.\RD\I S`,. (;PAC\.5 Pltl; I;,\I.L( 4 IPO.\, 1'})\ 0 rIl 7.85 'IDS PPM 110 SILICA 0 :\03 PPM 0 Mu PF\I 0 Oil prrserrr NO Suspect Bat ei in NO Sr, trentr eui is reconnnended For this water. UN Dime AA iter, L.t. Sincerely, Hai ley Pn)ne • sp= 1c, CATAWBA COUNTY (3,.(; 5 �t I00ASOUTHWESTBLVD a NEWTON, NORTH CAROLINA 28658 RECEIPT ,jds PHONE: 828.465.8399 Tuesday, July 19, 2016 N.4.8 4 2, 94 www.catawbacountync.gov PAYOR: Underwood, Ronald PAYMENTS TRANSACTION NUMBER: TRC-740967-19-07-2016 PAYMENT DATE : 07/19/2016 PAYMENT TYPE: Credit Card 168332093 INVOICE NUMBER FEE NAME FEE AMOUNT 07-16-330633 Bacteriological Sample Fee $58.00 07 1:6D306331i1!IiEW- "7MM;u' InorganiET emical,ISampel Feet'" 31ill�ll "(,,',„,„511„4700] TOTAL PAYMENTS : $172.00 SAM-07-2016-074730 CASE TYPE: Water Sample WORK CLASS: Multiple Different Samples SITE ADDRESS: 3605 RIDGETOP RD, SHERRILLS FORD NC 28673 Applicant RONALD UNDERWOOD, 3605 RIDGETOP RD, SHERRILLS FRD NC H:7044837454C:7047376015 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 07/19/2016 11.55 Page 1 of 1 e4'A C case# SAM-07-2016-074730 H ;; G CATAWBA COUNTY HEALTH DEPARTMENT d =TEA 4 Environmental Health Section �8 42 SM 08/09/2016 WATER SAMPLE FIELD REPORT Applicant RONALD UNDERWOOD, 3605 RIDGETOP RD, SHERRILLS FRD NC H:7044837454C:7047376015 Site Address: 3605 RIDGETOP RD, SHERRILLS FORD NC 28673 Name of Project: Parcel Number: 368702864932 Lot: 21 Block: Specific Directions Hwy 16 S, pass Jones Fish Camp, left on Mt Beulah Rd, 1 mile-left Ridgetop, 1st home on left 3605 on mailbox Initial Collected by: /2- P Date/Time Sampled: g--/—/ 6 ( /2 :10 ron Type of Sampling Point: 45'o) .4tf iri /tear o6 .+DVJ.+- Well New or Existing? New Existing Type of Well: Drilled ✓Bored Dug Spring City Does well meet adequate construction standards from what can be observed: ,----"Yes No Reason for non-compliance: Defective well cap and/or seal Piping does not exit through top of well by approved cap and sanitary well seal Evidence of improper grouting or no grouting Opening in the well casing or cap Supply too close to source of potential contamination Notification: Existing well owner notified that well does not meet adequate construction ? _Yes No Date of Notice: E9 - rsamfieldreport 8/9/2016 Page 1 of 2 $A Cc case# SAM-07-2016-074730 CA At ' , $ CATAWBA COUNTY HEALTH DEPARTMENT U -� Environmental Health Section 842 sm 08/09/2016 WATER SAMPLE TEST RESULTS Applicant RONALD UNDERWOOD, 3605 RIDGETOP RD, SHERRILLS FRD NC H:7044837454C:7047376015 Site Address: 3605 RIDGETOP RD, SHERRILLS FORD NC 28673 Name of Project: Parcel Number: 368702864932 Lot: 21 Block: Lab Coliform Analysis Results: Total Coliforms: V1b5t/m Fecal /E. Coli: Q r1')LnT No Collection Date Over 30 hours old Invalid Results: Excessive turbidity Excessive Chlorine Lab Accident Lab Tech Initials DI'' Date/Time Received QS t WI 1 L0 t C ° Date/Time Completed 0(61 WI RI9 t 540 RECEIVED AUG 11 2016 CATA i✓, ENVIRONMENTAL HEALTH E9 - rsamfieldreport 8/9/2016 Page 2 of 2 t'a`a STn7E o'+'. ., North Carolina State Laboratory of Public Health 47 4312 DistrictDrive Environmental Sciences Raleigh, 28 27611-8047 ,� a _ htto://sloh.ncoublichealth.com `,, !ll��� """, ,�,`/ Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 - — Certificate of Analysis Report To: Name of System: CATAWBA CO ENVIRONMENTAL HEALTH RONALD UNDERWOOD P 0 BOX 389 3605 RIDGETOP RD NEWTON, NC 28658 Courier#09-70-01 SHERRILLS FORD, NC 28673 EIN: 566001814EH StarLiMS ID: ES081116-0006001 Date Collected: 08/09/16 Time Collected: 12:10 PM Date Received: 08/11/16 Collected By: RP Sample Type: Raw Sampling Point: Spigot back of house Well Permit#: SAM-07-2016-074730 Sample Source: Well Temp. at Receipt: GPS#: Sample Description: Comment: Inorganic Chemical + Metals I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 . 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 18 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 6 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L pH 7.6 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium < 1.0 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 68 mg/L Total Hardness 69 mg/L Zinc 0.38 5.00 mg/L Report Date:08/22/2016 Reported By: Xennet/i Greene RECEIVED SEP 01 2016 CATAWBA COUNTY ENVIRONMENTAL HEALTH Page 1 of 1