HomeMy WebLinkAboutWELL-10-2021-158718.TIF Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ?
3 Ic T /^- It 14.WATER ZONES
Well R+nuaclut V:+me / et FROM r TO DESCRIPTION
C h.
,['
NC Well Cwnrjetot Certification Number 15.OUTER CASING(Cu,multi-cased welleLOR LINER(If ap licablel
_eil a ^ A 4jtr 1 FRt,M h1 /T1O--- ft. DIA,DIAMETER • SO
ntyyrR sir . ___ _
BLS r' i �5 1 14+' /& SO { 4.
Gnnpany Varna 16.INNER CASING OR TURING(geothermal elated-loop)
2.Well Construction Permit#: FROM TO DIAMETER ' THICKNESS I MATERIAL.
COI all apphrabk•well catotuction permits ri.a 1.3C.Cnun.,Sfare.Vus lime.etc.) ft. ft. In.
ft. ft. hi. ,
3.Well Use(check well use): i I
Water Supply Well: 17.SCREEN
F TO ! DIAMETER ' SU)TR17F- 1 THICKNESS MATERIAL
Agricultural DM icipal/Puhlic f ft. ft. 1 is
Geothermal(I Icating'Cooiing Supply) esidcntial Water Supply(single) ft. 1 ft. 1 IS.
Industrial/Commercial OResidential Water Supply(shared) I--8.GMW1.1. - -`-
litigation tnom TO M AIM AI. E►aPE%CEMENT METHOD&AN(Il'\T
Non-Water Supply Well: to 14 7 It CG> .v.te" rv(`t I6,1t) / No
Monitoring ORecovery ft. ft.
injection Well: • ft. ft.
Aquifer Recharge DGroundse tter Remediation f
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO M STYRIA! i EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage h• It.
Experimental Technology OSubsidence Control h. h.
Geothermal(Closed Loop) DTraccr 20.DRILLING LOG(attach additional sheets If necessary)
FROxf To DESCRIPTION(color_hardnew_wil/rock ttpe.erale Jn,te.l-„ •
Geothermal(IIcating/Cooling Return) [,Other(explain under:21 Remarks) -' ""-fr. ft.
4.Date Well(s)Completed: I I Well 1D# ; ft. Cr.
5a.Well Location: _ _ -- -------
ft. . ft. -
FaciiityOwnerNyru Fauhtytrio(if applicable) _ i -_-_a
3o la 8C,ss ch' 6L rsNs For It. 1 o h. l kist.rer' Al-
I(
Physical Address,City.and hp ft. 01.) it.
21.REMARKS
County Parcel Identification No.(PIN) 1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well lied,one at long is aullicieat) 22.(ertilicalion:
35, ( o17g3t N 8 ( :04.5.09'73 ,1. H
�6.Is(are)theweli(s)EPermanent or QTemporary Signal ! pita_a-_
407/
e.^.ifal�Vd Cotrtrrc[or Date
R)'ai,gniug this ram.1 hereby scroll that Inc well(,,was(wem constructed in orcnrdance
7.1s this a repair to an existing well: Yes or No with I5.1 N'C.1C L':e.th iNs or 15.4 CAC(12('.1121141 Well Camino fine.Standards and that a
II rho A el repair,/MN oat known well cons trio Mtn information and etplain the nature of the cum of Ma,retard has been provided to the rte•U owner.
n jsar sadder 21 remark[mentor or on the bark of this farm.
23.Site diagram or additional well details:
K.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAI.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: " 'O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple+sills lot rdl depths if different(rumple-3"420''and 2(l0(t')
construction to the following:
10.Static water level below top of casing: • 30 (ft.) Division of Water Resources,Information Processing Unit.
If rsmer lewd is above raring.use" - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 'Q (in.) 24h.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
y`C7rter t above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(r.e auger,rotary.cable,direct push.eta/
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) `) Method of test: r'�35 '%c 24c.For Water Supply&Injection Wells: In addition to sending the form to
_ the uddfess(es) above, also submit one copy of this Comm within 31) days of
GY"Ncli i1( �L
13h.Disinfection type: Amount:- � completion of well construction to the county health department of the county
where constructed.
Fnmt C,,W-I North Carolina Deparinecnt of Fmiromnenlal Quality-Dn irion o:Water Re.uureec Rct twit 2-22-2016
$A C1111 Case# WELL-10-2021-158718
t Ga CATAWBA COUNTY HEALTH DEPARTMENT
V ,�, Environmental Health Section
Ig 42 SM 02/13/2023
WATER SAMPLE FIELD REPORT
Applicant SAME AS OWNER,, _
Owncr NATHAN MARION TRUSTEE,220 GLEN ALLEN RD,MOORESVILLE NC 28115
C:8282348756 OURPHALTaGMAIL.COM
Site Address: 3086 BASS DR,SHERRILLS FORD NC 28673
Parcel Number: 369804910156
Driving Directions Hwy 16/Hwy 150 intersection head East on Hwy 150,Left on Little Mtn Rd,Right on Ingleside DR,Left
on Bass DR,lot on Right
Sample Collected by: UW Date/Time Sampled: 0 / t/ 3g- lla:: 3Sampling Point: � e t,al.p
Is well head accessible? Yes / No Reason for inaccessibility
Well New or Existing? New / Existing
Type of«ell: Drilled V Bored Hand Dug Punch
Does well meet adequate construction standards from what can be observed: t/ 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 scaled
Other(comment)
Comment:
rsamfieldreport 02/13/2023 12:20 Page 1 oft
,y.BA Ilk)
Case# WELL-10-2021-158718
IEE t CATAWBA COUNTY HEALTH DEPARTMENT
lv . Environmental Health Section
\8 42 SM 02/13/2023
WATER SAMPLE TEST RESULTS
Applicant SAME AS OWNFR..
Owner NATHAN MARION TRUSTEE,220 GLEN ALLEN RD,MOORESVILLE NC 28115
C:8282348756 OURPHALT@GMAIL.COM
Site Address: 3086 BASS DR,SHERRILLS FORD NC 28673
Parcel Number: 369804910156
Lab Collin Ent Analysis Results: Total Coliforms: D M 1 Fecal/E.Coli: VlIT'M r r
No Collection Date Over 30 hours old
Invalid Results: Excessive turbidity Excessive Chlorine
Lab Accident
Lab Tech Initials Date/Time Received u�� J '� '' 1 )I U Date/Time Completed V✓ . IJ ' rJ '7) `t ""04
RECEIVED
FE=
Environmental Health
rsvnfieldreport 02/13/2023 12:20 Page 2 of 2
Analytical Results STATESVILLE
ANALYTICAL
Catawba County Public Health
PO Box 389
Newton, NC 28658
Receive Date: 02/22/2023
Reported: 02/23/2023
For: 10-2021-158718: Nathan Marion, 3086 Bass Dr
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
230222-38-01 Nitrate 158718 <1 mg/L 3532 02/22/2023 CL
230222-38-01 Nitrite 158718 <0.1 mg/L 353.2 02/22/2023 CL
Respectfully submitted,
>Zth (L. J. .d)zlLigJ
Melissa Myers U
NC Cert#440,
NCDW Cert#37755,
EPA#NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 2
• ' STA'FSVO,I_r
AN A,r'le:Al
122 Court Strcct Statesville,NC 28677
704•872-4697\4NN., 1_I?1...(.l?1.]
NITRATE/NITRITE ANALYSIS
NA*Ai:•tehreza•cen mat 1r t.�1 aE Sat c•arepLrncr o.d t
N 1 11•k S1 N I F\I I I)a: _`,• .;_p")-1 _ 15-a t)1 g County: Catawba
Name of N a ter No stem: '1•, 1., (V\'•.YI
\ample l)pc: H F.ntr) Point ie7 Special/Non-compliance
1',cation%1 here Collected: 9 V''31a .;';S I)r S h e,t t t t F.,f'.4 NC- c�.U'3'?3
I acilitt II)No. 1 r' U
P
Sample-Point: �.__;1,
('olleclion I)xtr Collection Time
Collected lit; , .�. I' . . ', t d i I I 3'' S
LL
_ ,rev . _ Mt�:17ry .. -[4, L_ -
%lail Result%to Inver ttstein repretcntati%ei:
CATAWBA COUNTY PUBLIC HEALTH (828)465-8270 .
Phone u:
ENVIRONMENTAL HEALTH Fat p: (828)465-8276
PO BOX 389 Rrgmuriblr Pre•nl.'•rnuil
NEWTON,NC 28658 EHAdmin@catawbacountync.gov
s
i
I %It(UR%Mi " II)it: 17755 1.2 s 5511'I.1 I Ss s I1Sf U( 1010 r i ttl'%NIP{1 1411,11 11t1.1)
. ... ' •' \II iJi:. AIIi.R 1;i,,
•. 1A' NI.KiRi(NI,L 0.111 ewl.}
(.1J1)i. IRR1,) \ RI t '�• LI%tl1
III III \Itrute 1412 100 mIr/L __.._... mgil. 10.00 mglL
,
' 'H I \. trt:e :: 0.10 mg'l. ntg.l 1.00 mg'l
•.\r.lr. It tr.uu e1;rc,ts all.•u.t:'ie Iv7111,:hc laboratory must fax analytical%molts to the State on day test completed.
+�
%N,LI 11I.N HI l:l .: OZ L2 23 3 3�. P nt
%N.%1 %\F.\(051P1.F I F1): ' 02 22- i 2-3 is 4. ( -_M..• t
r
2 f I
Laboratory Log a: 2d�1,z�......St, ...... Certified By: -- —._1_ .._,?
(Y)%1M.N I S:
Labaralorr a6tsid:Nall A•fdu t9i
. H,x.•„ply Sector,.Ann Data Entre,16)4 Mail Service Center.Ratop.NC 276'$.16)1
Fat:919.115.1437
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 2
North Carolina Division of Public Health
Occupational and Environmental Epidemiology Branch, Epidemiology Section
BIOLOGICAL ANALYSIS REPORT
Private well water information and recommendations
County: Catawba Name: Nathan Marion Trustee Sample ID Number: 158718
Location: 3086 Bass Dr, Sherrills Ford NC 28673 Reviewer: Megen McBride
Initial Sample X Confirmation Sample:
BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR
PRIVATE WELL WATER(These recommendations are based on biological analysis only.)
X No coliform bacteria were found in your well water. Your water can be used for all purposes
including drinking, cooking, washing dishes, bathing and showering.
Total coliform bacteria were detected in your water sample. Total Coliform are a group of related
bacteria that are(with few exceptions) not harmful to humans. A variety of bacteria, parasites, and
viruses, known as pathogens,can potentially cause health problems if humans ingest them. EPA considers
total coliforms a useful indicator of other pathogens for drinking water. Total coliforms are used to
determine the adequacy of water treatment and the integrity of the distribution system
It is recommended that your well water be re-tested to verify that the result is accurate.
Fecal coliform bacteria were detected in the sample. Do not use the water for drinking,
cooking,washing dishes,bathing or showering.
If the re-test shows contamination by bacteria contact your local health department for assistance. There
may be a problem with the construction of the well,the groundwater source, or operation of the well. The
well needs to be inspected by the local health department or a local well contractor to determine the
problem with the well and to give guidance on how to correct the problem.
Your well water was tested for biological contaminants(total coliform and fecal coliform bacteria).The
results were evaluated using the federal drinking water standards.
Drinking water may contain substances that can occur naturally in water or can be introduced into water
from man-made sources.Total coliform bacteria are found in soil and fecal coliform bacteria are found in
animal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well
may have structural problems or that the well was not properly disinfected.
If you have been drinking the well water and are pregnant, nursing, have a child in the household under 5
years of age, or immunocompromised (such as an individual with AIDS,cancer, hepatitis,dialysis or
surgical procedures) inform your physician of these results at your next visit.
If the contamination continues,you should investigate the possibility of drilling a new well or installing a
point-of-entry disinfection unit which can use chlorine, ultraviolet light, or ozone.
For further information please contact your county health department or the Occupational and
Environmental Epidemiology Branch at 919-707-5900.
N 0 R T H C A R 0 L I N A
4rt "°�y Private Well Information
?
and Use Recommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba i Name: 'Nathan Marion Trustee—3086 Bass Dr, Sherrills Ford NC 28673
Sample ID#: 158718 Reviewer: Megen McBride
TEST RESULTS AND USE RECOMMENDATIONS
1. ® Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for
drinking,cooking, washing, cleaning, bathing,and showering based on the inorganic chemical results on(v. You may
have other water sampling results that are not taken into account in this report.
2. ❑ The following substance(s)exceeded federal drinking water standards or the North Carolina 2L calculated health
levels.The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorganic chemical results only.
❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium ❑ Copper ❑ Fluoride ❑ Iron
❑ Lead ❑ Manganese ❑ Mercury ['Nickel ❑Nitrate/Nitrite ❑ Selenium ❑ Silver
❑ Zinc
3.❑ While your lead levels do not exceed federal or state standards,the North Carolina Division of Public Health has
concerns with any detection of lead. Should you have any questions please contact the NC Private Well and Health
Program at(919) 707-5900.
4. ❑ Re-sample for lead and/or copper. Take a first draw and 30-second flush sample inside the house(preferably the
kitchen sink)and a first draw and 4 minutes flush sample at the wellhead to determine the source of lead and/or copper.
5. ❑ The following substance(s)exceeded aesthetic drinking water standards. Your water can be used for drinking,
cooking,washing,cleaning, bathing,and showering based on the inorganic chemical results only, but aesthetic problems
such as bad taste,odor, staining of porcelain,etc. may occur. You may want to install a household water treatment system
to address aesthetic problems.
❑ Chloride ❑ Copper ❑ Fluoride ❑ Iron ❑ Manganese
❑ pH ❑ Silver ❑ Sulfate ❑ Zinc
6. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or low sodium-restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
the inorganic chemical results on(v.
❑ b. Your sodium level exceeds 30 mg/I and may pose aesthetic issues such as bad taste, odor, staining of porcelain, etc.
7. ❑ Re-sampling is recommended in months,to reinvestigate
For more information regarding your well water results,please call the North Carolina Division of Public health at 919-707-5900.