HomeMy WebLinkAboutWELL-01-2022-163793.TIF Print Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
SQcc'r / "4.e.5 le 14.WATER ZONES
Well Contractor Name' FROM _ TO DESCRIPTION
'���4 90 ft. i0uft• 1A.5t►"e
rt. rt.
NC Well Contractor Certification Number IS.OUTER CASING(tor mold-cased weW)OR LINER(It abk)
L' Ilcrr+.o�ti- b� ) j FROM TO DIAMETER THICKNESS MATERIAL.
Company Name C+1ip R. 1'__IL / tee. Si/1+1 ' /�y„G
2.Well Construction Permit 4: 0( ]i^C 4 a I 6 3 7 9 3 FR�R CAO OR TU DIAMETER THICKNESS) MATERIAL
List all applicable well construction permits(i.e.V1C,County,State,Variance,etc.) ft, ft. la.
3.Well Use(check well use): it. ft. In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
()Agricultural DMunicipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) 'esidential Water Supply(single) fL ft - in
Tndustrial/Cexnme refer! Residential Water Supply(shared) lE.GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD.AMOUNT
Non-Water Supply Well: ,}ky(t ft. ',z�' ft. ac.6 nt ifs t .O (�-y5,y
Monitoring DRe covery rt. ft.
Injection Well:
it. ft.
DAquifcr Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalllllty Darner FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
Experimental TechnologySubsidence Control ft. TO
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets ifseexasary)
FROM TO DESCRIPTION(enter,hardness,taWroca type,ante are,ate.)
Geothermal(Heating/Cooling Return)r Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1 CV-I J'a, a Well IDa# rt. R.
Sa.Well Location: f+I ft. ;1.j" it. 3r'='`'t-
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
4 050 Iletirview tr a tG,0 fL 1"G R. in,4ter z-nc,
Physical Address,City,and Zip rt. 120. rt.
tiVN.S2 tde ` I\C- 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
3 , ( ., 4%1 El t y 3
N W - j /Ic ter
6.Is(are)the well(s) ermanent or DTemporary Sigma o ified wc1 onerazmr Date
8P sig ng this form,1 hereby certii i.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or giNo with 1SA NCAC 02C.0100 or 154 NCAC OW.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the cops'of this record has been provided to the well owner.
repair under v21 remarks section or an the back of this farm.
23.Site 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I X0% (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200•and 2@100') construction to the following:
10.Static water level below top of easing: i,f (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (L) (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method:
e tr..f,y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i a Method of test: P re")SO i e. 24c.For Water Supply&iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �k-4 C/I ih O. Amount: q Q t. completion of well construction to the county health department of the county
where constructed.
Form Ci W-I North Carolina Department of Environmental Quality-Division of Water Resnunxs Revised 2-22-2016
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: Marisa Oaida Sample ID Number: 163793
Location: 4050 Fairview Dr, Maiden NC 28650 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
SIM is Private Well Information
. a. and Use Recommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba ; Name:I Marisa Oaida—4050 Fiarview Dr, Maiden NC 28650
Sample ID#: 163793 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 on(v.
❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium ❑ Copper ❑ Fluoride ❑ Iron
❑ Lead ❑ Manganese ❑ Mercury ❑Nickel ❑Nitrate/Nitrite ❑ Selenium _ ❑ Silver
❑ Zinc
3. 11 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. n 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 on(v, 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/I. 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 only.
❑ b. Your sodium level exceeds 30 mg/I and may pose aesthetic issues such as had 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.
LOQ WPDT Report
Area of Interest (AOI) Information
Area : 3,134,508.7 ft2
Jan 27 2022 9:34:50 Eastern Standard Time
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1.4.614
0 003 006 012rn
Knew.Recesses dt Conterrneeon Otte,System Roads 1 t S N. A- 1. .- ti .1
Underground lanai hubris —Ramps Rest Ares!Hor,rte+rime 0 0.05 01 02 km
Plvaeb(Potygov)•Paroeb ' PrdORed Route
Non-System Roads —Otnet State Agency Route
fatkeret Route — Srxnnoary Route w_dut 615 U.4 n+r 4 we. I....... stw a WA,
[r,.... MI 4. ltrwe.a 4 p WA." i..^ .4R4 G....,
Non-System Prima).Rows sra.0..uvcRtS(M o 444TIW.A VS,G$ CPA WPs+!s Cerny.
Dau.,V;dA io.-es tar All.OS LSO!.%CA PH..A MAR n
—Intersratt
4050 Fairview Dr,Maiden
Known Releases of Contamination
Site ID Site Maas alto Type Data Current As Of Count
1 15322 FIRST STOP/LAST Underground Tank 12/18/2019 1
STOP#2 Inicidents
2 15693 MUSTANG#15 Underground Tank 12/18/2019 1
Inicidents
3 36798 E-MART Underground Tank 12/18/2019 1
Inicidents
4 40271 e-mart-diesel release Underground Tank 12/18/2019 1
Inicidents
All North Carolina Department of Environmental Quality(NCDEQ)GIS data is expressly provided"AS IS"and"WITH ALL FAULTS".The
NCDEQ makes no warranty of any kind,express or implied,concerning this information,including but not limited to any warranties of
merchantability or witness for any particular purpose.The NCDEQ assumes no responsibility or legal liability concerning the Data's accuracy,
reliability,completeness,timeliness,or usefulness.The data is not intended to constitute advice nor is it to be used as a substitute for specific
advice from a professional.Users should not act(or refrain from acting)based upon information in the Data without independently verifying
the information and obtaining any necessary professional advice. Users are solely responsible for ensuring the accuracy,currency and other
qualities of any products derived from or in connection with the NCDEQ's Data.The Data is collected from various sources and may be
modified over time without notice to improve spatial andattribute accuracy.The NCDEQ disclaims responsibility for the spatial accuracy and
attribution of GIS features and makes no warranty concerning same.
UST Section
Description of Dataset
The Underground Storage Tank(UST)Section's data presented here is representative of two different
programs within the Section;the UST program and the Aboveground Storage Tank/Non-UST(AST)
program.While the UST data specifically relates to UST systems,the AST data may be related to a
variety of release sources,I.e.AST systems,fuel tanker spills,Illegal dumping, etc.Whereas,the UST !.
data Is specific to releases of regulated substances from USTs.All UST Section features presented In this
tool represent locations where the latest reports document confirmed or assumed exceedance(s)of the
NC Groundwater Quality Standard and/or the Soll-to-Groundwater Maximum Soil Contaminant ,
Concentrations (MSCCs).
Contaminants Potentially Present
UST and AST Program Sampling Recommendations:
• Volatile Organic Compounds
• Semivolatile Organic Compounds
• Metals(Cr and Pb)
Contact Information
To request additional information from the UST Section please contact the NCDEQ Regional Office
assigned to the area of interest and ask to speak with a member of the UST Section.A map of the UST
Section's Regional Office coverage areas and phone numbers can be viewed by following this link,The
UST Section's Regional Office contact Information is also presented below.
UST Section-Regional Office Contact Information
Asheville(ARO)—2090 US Highway 70,Swannanoa,NC 28/78(828)296-4500
Fayetteville(FAY)—225 Green Street,Suite 714,Systel Building,Fayetteville,NC 28301(910)433-3300
Mooresville(MOR)—610 East Center Avenue,Suite 301,Mooresville,NC 28115(704)663-1699
Raleigh(RRO)—1628 Mail Service Center,Raleigh,NC 27699(919)791-4200
Washington(WAS)—943 Washington Square Mall,Washington,NC 27889(252)946-6481
Wilmington(WIL)—127 Cardinal Drive Extension,Wilmington,NC 28405(910)796-7215
Winston-Salem(WS)—450 West Hanes Mlli Road,Suite 300,Winston-Salem,NC 27105,(336)776-9800
Guilford County Environmental Health,400 West Market Street,Suite 300,Greensboro,NC 27401,(336)641-3771