HomeMy WebLinkAboutWELL-03-2022-167524.TIF Print Form
WELL.CONSTRUCTION RECORD (GW-I) For internal Use Only:
1,Well Contractor Information;
Joseph Bailey 14.WATER 7.ONES
ROM1O DESCRIPTION
Well Contrtctot Nome �_
3271 A )0 fL J NN 1 "• 5/'7ti///rs-1/ Aie
NC Well Contractor Ccrtl((cation Number 15.OUTER CASING(fur muld< eetb)OR LINER of Ikab )
B&K Well Drilling Inc FROM TOO DIAMETER THICKNESS MATERIAL
Company Name 0 it. A. ft. 6;fir. In. SUR-21 PVC
16.INNER CASING OR TUBING(geothermal timed-loop)
2.Well Construction Permit a: We/-6 3- ao - I� 'ay FROM TO DIAMETER THICKNESS MATERIAL
Lot off applicable%ell contrruriwn puma ft e.Lilt.Counts.State.Variance,etc.)
It. ft. in.
3.Well Use(check well use):
ft. h. In.
Water Supply Well: 17.SCREEN
��--�yyA cultural FROM TO DIAMETER SLOT SIZE THICKNLSS MATERIAL
L i gn aslunlctpaliPubhc R. ft. in.
•
QGeothermal(Heating/Cooling Supply) dennal Water Supply(single) rt. ft. in•
d Ind u stria VCommercial DResldential Water Supply(shared) la.GROUT
I,lmpahon most TO ,._. MATERIAL EA PLActat EYE METHOD&AMOUNT
Non-Water Supply Well: /y ft. �O 1 ft onir air- /9/5,�
44
0Monitorn6 Recovery -!! R. ft. fff!!!
Injection Well:
uifer Recharge ft. ft. 1
A
q 8 �Groundwatcr Rcmedtation
Aquifer Storage and Recov 19.SAND/GRAVEL PACK(if applicable)
('ry DSa)Inity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage D. fL
°ExpcnmentalTechnology OSubsidence Control ft. A.
a Geothermal(Closed Loop) D Tracer 20.DRILLLNG LOG(attach additional sheets if necessary)
()Geothermal(Heating/Cooling Return) ❑Other(explain under n21 Remarks) FROM I o DEtiCRIV710A(color. mint*.tO Vrock Nut.grain sox.ate.)
A ft. it,
_Ll
4.Date Well(s)Completed: I-aJ'LA3 Wel11.10 2-47*--I R. ft. t41..d1,7 j 6,-,5a.Well Location: 3 eft• 4 rt. /r'4/4 .5s4)1,5 de?l
,
S7i✓e17 ckale$nejy fi'liIfrd igra9/o hie ft. ft. Gte+/50%71f
Facility/Ow-ncrNarnc I Facility I N(ifappicable) ft. fit. , /irl/ j
3y� R rciC.1��. Sh ear;LLs F1 G - d�G_.!t —
Physical Address,City,and Zip / r ft. ft.
ariLAt34 CO_ Igo")oatii( 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,ore lat/long is sufficient) 22.Ce •ftcation: I
N w \
?2j_-____ --42."?
6.Is(are)the well(s)JPermanent or Temporary u e Cc ill Cornea, Date
Bs signing this form.1 hereh il that the wells)was(µere)constructed in accordance
7.13 this a repair to an existing well: 0 Yes or 0No trvh/j.a Nc,iC 02C.0100 or 15,4 NC.4C 02C 0200 Well Consvvcnon Standards and that a
If this is a repair,fill out known well construction information and esplmn the notate of the copy of this record liar been provided to the well Ott nee.
repair under kll remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobclDPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 2 Sl1HNIT"fAl,INSTRUCTIONS
9.Total well depth below land surface: ,J��t (L) 24a. For Al) Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdtfferent(example-3C200'and 2@l00') construction to the following:
10.Static water level below to of easin 40
P g� (fir.) Division of Water Resources,Information Processing Unit,
/fwater level as above casing,use'-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this Lorin within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rota,,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: //J / 1636 Mull Service Center,Raleigh,NC 27699-1636
v t' +
13a.Yield(gpm) 30 Method of test: /'!I�1 f i/r 24c. For Water Sunnis Injection Wells: In addition to sending the form to
1 the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Chloe Tabs Amount: 1 112
LD5 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Dcpatnncnt of Environmental Quality-DIN!mon of Water Resources Revised 2-22-2016
(.141?;-A C Case# WELL-03-2022-167524
` ' CATAWBA COUNTY HEALTH DEPARTMENT
V „ '`C` Environmental Health Section
/8 4 Z sM 06/20/2023
WATER SAMPLE FIELD REPORT
Ow tier *S!EVEN&AMANDA MEIERDIERCKS,3492 REID CIR,SHERRILLS FORD NC 28673
C:518-701-6568 STEVENRMEh GMAIL.COM (gkcl&sen I q (} gw•04 g,ca".
Site Address: 3492 REID CIR,SHERRILLS FORD NC 28673
Parcel Number: 460702783272
Driving Directions Hwy 150 to Sherrills Ford Rd,Beatty Rd,Reid Cir,Lot on Left,house will be buit in back in the clearing
Sample Collected by: Dv/ .5k' [ L i I C4 ( Date/Time Sampled: 04/" /2 3 q 5 ? it l
Sampling Point: S AMA I - (4 P
Is well head accessible? `Yes ✓ No Reason for inaccessibility
Well New or Existing? New ✓ Existing
Type of Well: I)rilled / Bored Hand Dug Punch
Does well meet adequate construction standards from what can be observed: ` 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 sealed
Other(comment)
Comment:
rsamfieldreport 06/20/2023 15:16 Page 1 of2
�A C� Case WELL-03-2022-167524
CATAWBA COUNTY HEALTH DEPARTMENT
Environmental Health Section
Eyy
18 4 /94 06/20/2023
WATER SAMPLE TEST RESULTS
Owner *STEVEN&AMANDA MEIERDIERCKS,3492 REID CIR,SHERRILLS FORD NC 28673
C:518-701-6568 STEVENRMEI/iGMAIL.COM
Site Address: 3492 REID CIR,SHERRILLS FORD NC 28673
Parcel Number: 460702783272
Lab Coliform Analysis Results: Total Colifonns: a,WWI- Fecal/E.Coli: L bct1 IT
No Collection Date Over 30 hours old
Invalid Results: Excessive turbidity
Excessive Chlorine
Lab Accident
PA
Lab Tech Initials f d, Date/Time Received 12 C c o 4/2 S/20 2 3 Date/Time Completed��
crud,- " I
RECEIVED
V ED
0 2')23
Environmental Health
rsamiieldreport 06/20/2023 15:16 Page 2 of 2