HomeMy WebLinkAboutWELL-08-2021-155915.TIF 11;1�l 1 U !ON RUt' N L('l,�„1►((,\N'-li 1.,,, liileilinl jar(Iti
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1.Well Construction Permit N;.011.1.,- _ycc^^K_ 1S 'rAM _uu n,(t,
fW nil pplcadl.will cawmrcdou Peronirt•1. LA (nrom Shift, I n.•...nq, o.r —_. n
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lh arrr Supply Wt A: rN6:1. I tli---� i pia'aVrn ] f i ri_or al-rkg I ivi Mt43,_„
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COcothcitnal(Hem ingA:ooling Supply) ftdurnal Watel Supply(stogie) — p. I U. i In,
C dLI trial'Conutlelcial ORcsideutial Wale;Supply(slioredl llL te'ROtl7
\Ttafiil I�Ir.��NP�T 4LT1iryD a 1��fOM
OlrnyaPon OWells>1U0,000GPD O OH M
fl 20 a. Bentonite Pour
tiun-Water Supply Well:
°Nlaritonng l7Ra.occly ft, ft.
Infection Weil: n. I O. —
❑Aquder Recharge O(irnuodwalm Remedletlon :ITArtiO W fi fy PPird,1
❑Aquifer Storage and Recovery OSelintty Darnerraa\I Ty atATERIAi, ra7nl-ICLWrl'rr MI Itt
°Aquifer Test OStortnwater Drainage ft. 1 ft.
Oi?xpenntcntal Technology °Subsidence Control ft. ft, _.—.I-T_,___._,.-
°Geothermal(Closed Loop) °Tracer 20•> 9 a �t 'P % tlaary�
FROM TO DSCRIITIax(color.►ard r,_,-,..k.._j_____..—
°Geothertml(Hosting/Cooling Return) °Other tetplain under 021 Remarks) t� rt- /r ft. Q�''5,D J
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4.Date Well(s)Compler2d:S191�-7" -Well lDx r' It. fb /in V
5 ft. ii- ft. 1( V /Me
Sa.Well Location:
I / ;ok i et. A.
Facility er Name Facility Mt of policlinic
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yb�s��hy>tl,f a, ll 3rRd - fr. j n.
Physical Address,City,nod Zip
LI ^ IS
ell.REMARKS
Count) ParcelIdctar Elution No(PINT
Sb.Ladtude sod longitude In degrees/minutes/seconds or decimal degrees: 1
(f•.vll tab,at:tadlona it,ulfaienti 12.Certiflea on:
Striatum Centtied Well Cooncnor Cala
6.Ware)the well(s): °Permanent or °Temporary
Sys/ping,thlone.)hereh leaf'rho inn.:rills)..ni(..rro),onun.t'rdInamv,kme,uh
7.11 this a repair to an existing well; C Yes or nNo .!•a VCAC 02C OW"or 15.1 ACelC 02C.010f R"dl Coruavaiwl Srandar&and that a type
(f thrr L.a .fell aye h00%n wr/.nnrrnrt aan;gfonna:inn and rrla'aln the mangy n U., elk.,rrcnrf hne horn p m iced in Ow nr/)owner.
rape r wider all remarks senor or on the bock ofhis form 23. 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 construction info
construction.only I GW-I is ntedod. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may slap attach additional pagett if necessary.
drilled: f „^ 24.SUBNITF L INSTRCCTIQNS
9.Total well depth below land surface:,.�!S (t ) Submit this C W t within 30 days of well completion per the following
fin ne/rep.'.•.rib lilt rdl depths iIitieeirnn(cenmple.3(ald0-,o. cipitin'1
24a. For All Wells: Original form to Division of Wata Resource (DWR).
10.Static water level beton top of casing:40 (IL) Information Processing Unit,16)7 MSC.Raleigh.NC 27699 1617
if eater laveLeoh+rMtn:burr '•
-
6 1/8 24b.For Injection Wells:Copy to DWR.Unuery�round Injection Control(TUC)
11.Borehole diameter: (tn.) Program.1636 MSC.Raleigh.NC 27699-1636
12.Wea construction method:Air Rotary 24c For Water Supply and Open-Loop Geothermal RetarR Wefla Dopy to the
•
ire.not.rotary.cable.&mei ousk etc.I county environmental health department of the county where iustalkd ,
FOR WATER SUPPLY WELLS ONLY: 24d For Water Welts producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpw) 6.4) Method of teat:
Air Lift Permit Program,16i I MSC.Raleigh.NC 27699-1611
13b.Dlsinfccdon 4Tx:Chlor, Tabs Amount 1 112 Lbs
Farm GW-I North Carolina Dtpenmcxtt of Ent iraomental Quaiui -Dt>isms of Wu=Itctietircat Remised 6.t•X101
Analytical Results * STATESVILLE
*At, * ANALYTICAL
Catawba County Public Health
PO Box 389
Newton, NC 28658
Receive Date: 08/31/2022
Reported: 09/01/2022
For: Gaynell Foster: 4053 Cheviot Hills Rd, Sherrills Ford,
NC
Comments: Acceptable limits for drinking water are:
Total Coliform =Absent, E.CoIi =Absent, Lead <0.015 mg/L,
Nitrate<10.0 mg/L, Nitrite<1.0 mg/L
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
220831-33-01 Nitrate 155915 <1 mg/L 3532 08/31/2022 CL
220831-33-01 Nitrite 155915 <0.1 mg/L 353.2 08/31/2022 CL
Respectfully submitted,
> (the L . ✓i11L/
Melissa Myers (�
NC Cert#440,
NCDW Cert#37755,
EPA#NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 2
•fit' STATESvII,t°
ANALYTICAL
klitip,
122 Court Street Statesville,NC 28677
704-872-4697 www.sa•I:c.com
NITRATE/NITRITE ANALYSIS
Note:AB information rten.be repelled Et compliand ends.
WATER SYSTEM ID#: O rl - ADZ( _ tr-rti if County: Catawba
Name of Water System: 6e,y et r J 1 F6•.1. P P^
Sample Type: 0 Entry Point i1741ccial/Noe-compliance Location Where Collected: Li 0 5 3 Gh r v 1 ct �L
r I(S f>2 ,1-As ry)11,1 174,0, 4'C "_
r
Facility ID No. /3?is
Sample Point: 4 Collection Detc � Collection"time
Collected By: ,1GL-" Ai'b.,„ •
,/•J 0 I ,:2. / 9 • Ad, , M
(rims Ibteb - — (LN�6F/Pe— .— -- —7,40,6 AMm PMI
Mail Results to(water system representative):
CATAWBA COUNTY PUBUC HEALTH Phone#:,(828)465-8270
ENVIRONMENTAL HEALTH pas II: (828)465-8276
PO BOX 389 Responsible Person's email:
NEWTON,NC 28658 EHAdmin@catawbacountync.gov
LABORATORY ID#: 37755 0 SAMPLE LNSATISIAC i oul iJ Rl.SAMPLE ItFt)1 Ili I'If
- CO.rk. l MGTHOD REQUIRE( (�DETECFED QUAN I IFII:D
CONTAMINANT REPORTING LIMIT (i e c R R I.) ALLOWABLECODE CODE RESULTS° I.IMfI
TR-R-I..) (X1
1040 Nitrate 353.2 1,00 mg .._ mg/L mg 1. 10.00
/L ll
1 G41 Nitrite s{; 0.10 mgil. mg/I. 100 mg/L h
'Note:If result exceeds allowable limit,the laboratory must fax analytical results to the State on day test completed. =S
DATE: _.. TIME:
ANALYSES BEGUN: 1 08/3I 122 !3: 2S . 1 NI '
µDAIWA) 1pal r PM;
ANALYSES COMPLETED: 93/'51 /2-e — 'y_—:52', M
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Laburatory Log C:X.20B, 1•,33 Certified By: --.--
COMMENTS:
zoos —------ ---- - ---
laboratory should Mall Rasalta IQf
Public Water Supply Saviun,Men.Data Entry,1634 Ma11 Service Center,Raleigh.NC 27699-1AM
Fat:919.71 f.f6J7
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 2