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PIU,icaI IAIJ.1rcss.C ay,bad lop 31.REMARKS
CC1 kGl.L — Nord likdiIkation No.'PIM
County
Sb.Latitude and longitude In degn eci nninutcslseconds or decimal degree: 22.Coll n:
tuwrlltield.a^e�u"►aalfw.enu) `' ,/Lllv'( '
N w ivmum of 0:n16 v Well Cooling6.Wort)On wel10)0Permanent nr ()Temporary !h.toms ran from I hereby cern&Au Me wrlh.+l tow rwrrel Owrrwrrd IN afro. Dove
\o WM 1l.1 ACM:I;`(U100 or1 SA NC AC 02C 0100 Mill lwrr+
) nmar Sranddrd)and that a
7.Is this a repair to an a dging well: ❑Ves or coin.ddu ref ud lw+Mrn pr•s+drJ nn rAr trig aware.
if dW
u is I re PIP'.Oil Mil tt.t+ nw
%VII,., .rr 'urw 10nW1r•ri + Iriain Me natter.ide
23,Site diagram or additional well details:
.r1Mrr i.oJ. el mitt..its fh R,N W.�n Ow l+r+t of Mti Armwell
You may use the hack of this page to pn+l ide addinon>•1 well site details or
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells busing the same construction details. You may also attach additional pages if nccaaaTY•
coustmcnon.only 1 G -I is monied Indicate TOTAL NUMBER of wells
drilled -.--- '?h
J y (R.) 24a.):Q�L11eIhh Submit this form within 30 days of completion of well
9.Total Hell depth ow land surface: !,i yp,a+d s41ar) corrstnlcti00 to the following:
For wYlry>lr tell,l.vr a!1 drfvAr,f d�flrrrnr frnany�l Unit.
rYlr.
(py) Division of Water Resources Information Processing
10.Sr water kwel below lop of easing:40 lo17 Mail Sertice Center,Rakigh.NC 27699-1617
tor.rl a dhow rnu+ll,foe-•
23b.For Inl d N•ells
n : In addition to sending the fonn to the address in 24a
11.Borehole diameter. 6 Imo—lin.l abate.also submit one copy of this form within 30 days of completion of well
Air Rotary construction to the following
t,a ate,mug, Division of Wain Resources,Underground Injection Control Program,
106 Mail Service Critter,Raleigh,NC 27699-t63s
FOR WATER SUPPLY WELLS ONLY:
n Flow 24e.EyrN'ater SUIWLY t Inieeriff Nelh: In addition to sending the from to
lln Yleld(gpn►) �� Method of nesn:.A the a.kltessiesl goose, also submit one copy of this lion within 30 days of
Chios.labs "'''tns completion of well construction to the county health depantuao of the county
t, Amount: _:---- when:wnsnuctal.
Ob.Disinfection ,pe:_------
Kurth Cooling Deponaem of Ennronmrnul Quality•Dnsvwo of WART RavrmYl
Revisal:.±-.±tit o
Form(7tF'•1
Analytical Results STATESVILL
ANALYTICAL
Catawba County Public Health 0
PO Box 389
Newton, NC 28658
Receive Date: 11/08/2022
Reported: 11/10/2022
For: Vlad Baloiu 8381 Paso Fino Lane Catawba NC
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
221108-29-01 Nitrate 12-2021-162668 <1 mg/L 353.2 11/09/2022 CL
221108-29-01 Nitrite 12-2021-162668 <0.1 mg/L 353.2 11/09/2022 CL
Respectfully submitted,
Melissa Myers
NC Cert#440,
NCDW Cert#37755,
EPA#NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 2
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ra.Y7lcit
122 Court Surat Statesville,NC 2B677
704472.4697 SS•af:R5:3
1 KATF�I1TIU ANALYSIS
o I b r 6 b f� County: Catawba
WATER SYSTEM ID#: I .-.�.tl
Name of Water System:.,•._ U 1�,_�__2(23,Y=-{"t--•.--`""".---'"""_"-
Sample Type: f2 Entry Paint arCta sl(Nostt•mPilance
i Location Where canceled: __.
�FJi;rie10 1,, !anti« 111 _...___.-._..._
Facility ID No. ,16i .
{� ::. CalteeiioO�L c. ectiegTinu
Sempk Point: •�IY"-".. w. a
(J�'� t $r?s— t Ca:Ga�', M
�1 ...n ,µk«""6+a
C•ifectedHy:,,,,, tit^kt [� � ���_.�.-.�
Mail Results to(water rystem representative): '10
CATAWBA COUNTY PUBLIC HEALTH .__ mon*it...(Bag) g_82
___. .. .. _...
(82$}465 8276
ENVIRONMENTAL HEALTH Faa�: - —
-_ ... Rsrpsnalrk Pettee't aua:
PO BOX 389 _ - ----•- EHAdminecatawbacountvnc.6ov
NEWTON,NC 28658 _.._...... _
L:AB<)RA•1 OKI,11)n: 3775S 0 SAMPLE UNSATISFACTORY 0RUSA•MPLE REQUIRED
..,.^„M"'••-'•"."` ..•• ~IM MIMED KR DETECTED QUANTIFIED ALLOWABLE
METHOD NEFORTLNG Limn ;it<0.RL'i ResaleI.:MTT
=C(Y."4AM Cty�:AsAiNAHT {`ODE nt.a.L7 Po
t C.ODE
toga. 19.00 mg&L
- [QdO... �hJ7l! I772 1.00 mgii. ---.._�.._
f 104i Nitrite 35)2 0,50 m lam {.., 1AD mg'L
g-1. ... �1 "--.." ....�..,.......,"r
vapre �"••`�� � � results to Stec on day lest completed
�' .Note If result exceeds allowable limit,the laboratory must fax analytical
DACE TIME:
4--.Y 1 t r 2 -Z r.Sb. M
AItiALY5E88EGllN:? — CAI.aaWiri — a,.,,•a.M.
ANALYSES COMPLETED: le It IJ't t 2Z _ ._. z4+tuM
/� ill
(} .�1.�.�.._..._:.—;:'—fir,.
v. Ni'U U• ll °I Certified By:•___.._... J ..
L,sboraroryloR.• y,,.. .._... 1�����_ ,._....-..-........,...................
COMMENTS:
4: Loos w t . t...,..al., atm.afore:AM Mal Salvias Calla,Itaidaa, C276yk-16ys
..., .
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 2