HomeMy WebLinkAboutWELL-02-2022-165499.TIF J Print Form
WELL CONSTRUCTION RECORD (GW-l) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES -
Well Contractor Name FROM ] TO ] Rlrt toy
2857-A 2L G tt (j ft. Cy
NC Well Contractor Certification Number ft. ft.
B &K Well Drilling Inc 15.OUTER CASING(for malt)-aced weds)OR LINER(If applicable)
FROM TO DIAMETER i THICKNESS 1 MATERIAL
Company Name 0 ft. 1 i n ft. 6 115 In' SOR-21 PVC
/`'� - , G el r ) CS 'C7 16.INNER CASING OR TUBINGM(geothermal cloud-Mop)
THICKNESS
2.Well Construction Permit# d't1' W! FROM TO Dl xETER rHICK�Ess MATERIAL
List all applicable well construction permits(i.e.WC,County,State.Variance,ere.) b ft. S ft.•f-(1j C, in.
Pfil3.Well Use(check well use): ft. ft. in.
Water Supply Well: . 17.SCREEN
�Agicultutnl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Municipal/Public ft. ft. is
()Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single)
ft ft In.
fJlndustrial/Commercial
()Residential Water Supply(shared)
Il krigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: re. ft.
aMonitoring ()Recovery
Injection Well: R• ft.
()Aquifer Recharge ft. ft.
()Groundwater Rcmcdiation
Aquifer Storage and Recovery ()SalinityBarrier 19.SAND/GRAVEL PACK DI-applicable)FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Teat ❑Stormwatcr Drainage ft. rt.
Experimental Technology ()Subsidence Control R. ft.
DGeothennel(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets If anorer.ry) 1
Geothermal(Heating/Cooling Return) [Other(explain under 021 Remarks) FROM TO hiCRIPTIOA(color.hard Ifrock Type.anor wa.K)
6R. (�
4.Date Well(s)Completed(V.-2t�2 . Well 1D# I 1 es ��1 lk
L Well Location: ^S t'IL .3c)s rt.rt. L (/L <I scrpf
. 1)rc d .�essccl, -fi , -tr�.y VV 0-6.c
Fa"'ty/OwnerName Facility II Ds(if applicable) ft. R
3 706 i k) c st- H id (3)-y « L
PhysicaMddress,City.and Zip '
ri 21.REMARKS
County Parcel identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field.Onelat/long is sufficient) 22.C�c•tllryca��
N W J�
6.Is(are)the well(s)laPermanent or ()Temporary Signature of Certified Well C for Date
Nv signing this form.1 hereby e•rniJi•that Me eel/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes Or No with 13A,VCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!filar is a repair,fill our kno»n well cntu(ruclian Infrtrntarin an plain the nature of the eupv(Oka speed has been provided m the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only l GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �f 03 ,SUBMITTAL INSTRUCTIONS
9.Total well depth-G> ow land surface: tom) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-.f;120f•and a 1001 S P
construction to the following:
40
10.Static water level below topof in
casing: (ft.) Division of Water Resources,Information Processing Unit,If-water keel is above caring,we"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (In.) 24b. For lniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Air Flow
Method of test: 24c,for Water Sootily& injection Wells: In addition to sending the form to
Chlor Tabs 1 1rz Ltd
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Rcsourcm Rolled 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: Samuel Sanchez Sample ID Number: 165499
Location: 5700 Elaine St, Hickory NC 28601 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 arc 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.
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: Samuel Sanchez Sample ID Number: 165499
Location: 5700 Elaine St, Hickory NC 28601 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 arc 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
I ST�fry o* Private Well Information
%,.4 -VI
~ � and Use Recommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba Name: Samuel Sanchez— 5700 Elaine St, I lickory NC 29601
Sample ID#: 165499 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 ono,.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). I-Iowever, it may be used for
washing, cleaning, bathing and showering based on the inorganic chemical results on(v.
❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium ❑ Copper ❑ Fluoride n 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 on(v, hut 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. n a. Sodium levels exceed the U.S. Environmental Protection Agency's(USEPA) I lealth 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 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.
N 0 R T H C A R 0 L I N A
I ST�fry o* Private Well Information
%,.4 -VI
~ � and Use Recommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba Name: Samuel Sanchez— 5700 Elaine St, I lickory NC 29601
Sample ID#: 165499 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 ono,.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). I-Iowever, it may be used for
washing, cleaning, bathing and showering based on the inorganic chemical results on(v.
❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium ❑ Copper ❑ Fluoride n 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 on(v, hut 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. n a. Sodium levels exceed the U.S. Environmental Protection Agency's(USEPA) I lealth 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 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.