HomeMy WebLinkAboutWELL-08-2021-155610.TIF YLE_
L 'CONSTRUCTION RECORD GW 1
For Internal Use Only:
1.Well Contractor Information:
•Kyle C. Shaw
Well Contractor Name l4 WATER ZONES
FROM I TO DESCRIPTION
4521-A 7-12 n ° >i
NC WA Cbnrzacear Certifteatioa A+nmhe= n• ft-
Advanced Well Drilling 16.OLTERCASING{forrnelti-ceiedwels OR
-
' LLC FROM )OR-LINER fir It MAT)
70 pI,y -ER i 7ffiCFTiriSS
MATERIAL
Cglepari}';tame 0 ft. 1 Li
rt. � 6 uL
2.Well CoPermit1....1 ` K 16 INNER Cacrtig ORTLI$II�G Heavy PVC
ILStI 11CIlOR : f ll�- '" / 1— FROM TO (geothermal closed-]nap) 4Lirt all applicable 140 construction penrurs(I.e.LUC//.Caney.Srate Varian=tic) ft. ft. -AW Tess MATERIALia.
3.Weil Use(check well use):
ft. ft. in.
Water Suit Welki_
17.SCREEN -
ClAericuiNral Cf�funicipal/PubGc FROM TO DIAMETER SLOT SUE Talc>a-ess
C7CicOtllrlR]5I n• R. la )Gl7£RL3L
(Hooting/Cooling Supply) i•JResidential Water Supply(sinsde)
ft_ IOandn• al/Co nmercial OR o in.Water Supply(shared) is.FR("BOLT
Non-Water Srtpply Well: C]Vrells 100_000 GPD goat TO nra7L
EATPL,ACEatI Tlt on.EAinoravr
°MonI � 0 ft- --,1M `� Bentonite Poured
bJection Weil: CIR:�covztVft. ft
QAquiferltechar2a 1lCrronad'�aterRzmztiiation lU j I
C]Aquifar Storage and Recovery C1SflIi17ityFerric[ is..SAND/GR.17'ELPACK(If oppI tea blel_
DAquifr TestFR- TO MATERIAL EMPLACEMENT METHOD Storrnunter drainage fZ ft
0Experimental Technology °Subsidence Control
QGaothertnal(Closed Loop) DTracer
DC76othatnCl{Ileet11IE1COD1inE Return !7 'O.DRILI.INGLOG(attach addittoualsheets Irnecessary) .
} Otlter(etplain under T21 Remarks) Front ? MSCItrnTta((color,earliness.se muck ripe.vain�xr.etc)
4.Date l�rell(s)Cnrnpleted: 2,.I C.) �i(`�l li >
Well Me 4-7 IL 1 Li 2 �I� ;+CG31�{l';Sa.Well Location: it
~It ✓
�.CT!"-r1 aiJt'��, (,._. i 1;=-.;. ft. ft 3 J
Facility/Owner;Name
ff v !; Faciiiry till(if
Dppplirabte) ft. tft.! i!Gat 1,I �� �� /.C�r,Ire I "ram .w ��VC// R. ft.
Physical Address,City,and Zip--/
a. . rt.
• ` ''- ''_1.RE:�Sa112KS
Crnray
Parcel ldrntificarion No.(PIN)
Sb.la �eotld longitude in degrees/minutes/seconds or decimal degrees:
_Cif wl Vino;issufficient)
'`.,--?. S - 4-122.Certification:
it1 rs / . 1i /1_414t�'
6.is{rill)the'tell(s}: F_`lPermnncnt or CT �f Well L jC_ �'. �
£mporaty Srgna ofCertifiedWell Comma.: Date
7.Is this a rcpnir to an o-well: By signing thisfarnr,I hereby amypcharthe we!((()mar(mere)constructed in accordance-Rich
7.Is tfa s °Yes or L�iNo 15..E.C;CO'C.eJ90orI5 R'CaC 02C.C�apaWaifConrrructionStandards
repair:fill out!'»awn well conitrucifort 1 a repair rtnder#2l ranrarhssrfom at(on mid espltr a r1g nature of tF.e al this record Iran been proeided rD Me
alit o+t�e, and nra copy
section or ae a the bacf,-ojtltu form_
8.For Geoprobe/DPT or Qosed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:
construction,only 1 OW--I is needed. Indicate TOTAL NUMBERoftiaells (dd'See(her iYou may use nR marls 8ax} You back of this page to aystsoattachadditionalpagesfneovide additional wen c ssar drilled:
pages if necessary.
9.Total well depth below land surface: 24.SUBMIITTa.T,h1STRUC:1I NS
Fox multiple wells list all depth;i ale event ova < o P f t 'e- -Of]'and 2 6P 1 { } Submit this GW-1 within 30 days of well completion per the following:
10.Stafic'waterle�'eI below top of eosin,
24a. For :',II Wells+ Oriainal form to Division of Water Resumes
Ijuru,:rlerel is above e ctasirre1 are (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ��R�
2a
i1.Borehole diameter. $_For Injection Wells: Copy to DWR_Underground Injection Control(TUC)(in.)
Well construction P , I636 MSC,Raleigh.NC 2 76 99-1 63 5
Cie aim,rmethod: i 7 i `.t
gray,cable,direct posy�, ) 24c.For Wafer Snook and Open-Loop Geothermal Return Wells:Copy to the
FOR WATER 3C�PLYcounty environmental health department of the county'where installen
WELLS ONLY:
1311. eld-( ) r r� 2-Id.For Water Wells producing (xl over 1 000 GPI)_ t
•Method of test: Air PermitProrrr._ara 1611 X S .halergh,NC 2➢699-161 f Copy o L}WR CCPCCJA
13b Disinfection type: HTH
Amount: / //
=:.7 --t
y.1BA CD Case# WELL-08-2021-155610
([7.4 '�" CATAWBA COUNTY I IEALTH DEPARTMENT
., Environmental I Iealth Section
4_ S"^ 06/21/2023
WATER SAMPLE FIELD REPORT
Applicant *CORNERSTONE III PROPERTIES INC.8008 COPORATE CENTER DR,CHARLOTTE NC 28226
C:7043013229 S'IAN a,CORNERSTONE3P,COM
Land Owner LINDA ENNIS,221 S SCHOOL ST,(i11313STOWN NJ 08027
Owner 13ULLER RIVER DEVELOPMENT PARI NERS LP,259 TIX"I ILL WAY S'I'E 102, FORE MILL SC 2971:
PAM@BRDEVELOP.COM
Site Address: 7160 ROLLING I!ILLS DR.SIIERRILLS FORD NC 28673
Name of Subdivision: A L ROBINSON
Parcel Number: 460703038341
Driving Directions I I WY 16 S/TO H WY 150 EAST/TO LITTLE MTN RD/2ND LEFT IS ROLLING HILLS
T
Sample Collected by: 1 vd I skk �-ytk em I Date/Time Sampled: v74 ila.9 /?'.50 pt'
Sampling Point: 5.
4.t'KN 14. CAP
Is well head accessible? Yes "' No Reason for inaccessibility._
Well New or Existing? New '• Existing
Type of Well: Drilled / Bored I land Dug Punch
Does well meet adequate construction standards from what can be observed: Is!Yes No
Items of non-compliance: Evidence of improper grouting or no grouting
Well does not meet a required setback(comment)
Improperly constructed sanitary well seal
Well head not term at>= 12" above finished grade
Well head missing vent
Well head does not have a threadless tap
Well missing identification plate or pump tag
Wire conduit opening not sealed
— Other(comment)
Comment:
rsamfieldrepon 06/21/2023 10:42 Page I of 2
-- -- -- ---- - -- --._- 1
4111
Case# WELL-08-2021-155610
(�, 'f" CATAWBA COUNTY HEALTH DEPARTMENT"1",_*
0-3
—4 AIM ' AI
Health Section
1g42 SM 06/21/2023
WATER SAMPLE TEST RESULTS
Applicant *CORNERSTONE III PROPERTIES INC,8008 COPORATE CENTER DR.CI IARLO l l-E NC 28226
(':70430I3229 STAN6i'C'ORNERSTONE3P.COM
Land Owner LINDA ENNIS,221 S S('I IDOL ST,GIBBSTOWN NJ 08027
Owner 13(ILLER RIVER DEVELOPMENT PARTNERS LP,259 TEXTILE WAY S fE 102, FORT MILL SC 297I
PAM@BRDEVELOP.COM
Site Address: 7160 ROLLING HILLS DR,SHF.RRIL,LS FORD NC 28673
Name of Subdivision: A L ROBINSON
Parcel Number: 460703038341
Lab Coliform Analysis Results: Total Colilbrms: preAtot- Fecal/E.Coll: A bC 4 t{'
No Collection Date Over 30 hours old
Invalid Results: Excessive turbidity Excessive Chlorine
Lab Accident
Lab Tech Initials N Date/Time Received 10 b Date/'Time Completed DI-."' / °4
�r
I l l! 2 j 2023
L:nvironmental Health
rsamfieldreport 06/21/2023 10:42 Page 2 of 2