HomeMy WebLinkAboutWELL-04-2022-169755.TIF May31 23, 10:41 a p.2
WELL-CONSTRUCTION REOORD GW l
For Internal Use Only:
1.Well Contractor information:
Kyle C. Shaw .
Well Contractor NameI4•Iti'+ITER'L0iNIES
FROM
F TO DESCRIPTION
4521-A 19- 371n
a ��rlts:rtl (Ave
�rC tti'cli Contractor Ccrt ficotiar.NumberR LLC IS.OUTER CASIs�G(for multi-cased i ells)OR LINER VTuppllmble) -
Advanced Well Drifting
FROM TO�� a 1 D1.41rLL`7ER I
TR'tChTi&SS I \1,�7£RfAI.
Cempom Name 0V in 1
Heavy I PVC
16.INNER CASING OR TUBING(geothermal closed-bog)
2•Well Construction Permit I ? FROM TO DIiETER THICK-WAS
\A7EaLLLList o!I aPdiea5te xr 11 construction permit;ri.e
7c^oor.n.Si .:t i orinace.a;e 1 R
R. in.
3.Well Use(checktrell ate): R. is I
1 water Supply Well: -
17.SCREEN
°Agricultural ❑\IUnicipal.Public F FROM To DIAMETER SLOT SIZE 1 THICFNES5 ' NL+1TERt,1L
OGeoth� 3 Supply)l(Healinzeoolinn R la !I
�rrltesidential Water Supply(single)
❑IcduslriaUConinttrcial re, rL in. i
DRJasidential Water Supply(shared)
❑Irieation Dwells>100.000 GPD TRo ROL'C TO �uTERt u
Non-Water Supply Well: EIIPLrCE\J 7.1rETNOD S \fOCRT
D-Moniranne C) n- a a itBentonite Poured
Injection Well: •
GRacovcn a ft -
11uifer Recharge ❑GrotIndcntzr Rzmtxiiation a tL I
OAquifer$IOrap2 and Rarovart QSalinih l3ar'iar 19.SAND/GRAVEL PACK(if p9p114We) t
°Aquifer Test FttOJI TO \LITERLIL EMPL4C£a]E�rJMEIFIOD
05tornmatzr Drainage It 2
❑Experimental Technology °Subsidence Control
�Ge:odtatnal(Closed Loop) ❑Tracer rt. P
DGeothermal(HeatingiCoolinn Return) COther(explain under=2l Remarks) DRILLING LOG(attach Welkin nil sheets 1f thorsin horsiness.
s -
1, FROM TO t DESCRIPTJ( feeler,bardgerr,,.Wreck type.met sin.eel
4.Date Well(s)Completed: fL �� 1t ' ��
3a.Well Location: f i`b R6^ Rr �/
`16' rt ft. �ey Lf�
Fact1ityiOract :amc ��^" /
Fac]in•lD=iifapp:iccblei rt 2 '/
S 13 S r; c e `. aRtA13 I I
Physical Address,C' and Zip (I. fe
21.PENL-1RKS
Count_
Parcel nti:cation No. i
Sb.Latitude and longitude In degrees/rninutcstseconds or decimal dcgi ees:
(ifnell field,one Iet loner is sutlieien:}
�S e 7�� O y J r� + 22.Certification
"ice� .1 � 1 r i � �'f i 1 �\• i��1��i/2•tN +� �
G.Is(arc)the well(s): ± `.reBe !'t "(-) Pclrrranent or GTemporet� Sign of Certified Well Contractor
Date
7.Is this a repair to an C�75ti 3r slgntrg this Arm,;hereby terrify that the well's)r:os(were,coustrncredirn accordvtce city
well: EYes or n\o 1S.-1\C.IC 02C.0100 or13.a eVC.dC 02C.0200 waif Constmetfor,Standards aid that a colt
.Pf this is a repair,fill carwen brown weninformation and=plain the nature of the of tins record has been provided to the creel outlet. •
'epltr under.'21 rat+arts sect ion or at the hack of this form
S.For Ceoprobc1DPT or Closed-Loop Geothermal Wells having the same
23.Site diagram or additional well details:
COIISlflJe jOD,only 1 Gar_ You may use the back of this page to provide additional Hall construction info
1 is nxd d, Indicate TOTAL\1l•IBER of t�zl Is (add'Sae Over'in Remelts Box).yea may also attach additional loges if necessary,
drilled:
4�`i 24.SCIBS IITTAL 1 STRt CTIOi\S
9.Total well depth below land surface: •�-r7
For multiple wells list aft depths lfdf et err{exam*.3 2 (ft') Submit this GW-1 within 30 days of well completion pet the following:
P b' { P DO'cad_a100';
10.Static water level below top of casing: Ca 24a. For AD Wells Original form to Division of Water Resources (DWR),
ll-Hate r kW)s obLrrcnsYng,use =^ (1') Information Processing Unit, 16I7 MSC,Raleigh,NC 27699-1627
I11.Borehole diameter: 6 on.) 2-lb.For Inicction Wells:Copy to MVR, Underaroturd Injection Control (IGC)
Program, I636 MSC.Raid sit.NC 27699-I636
12,Well construction method: A
F
(i c auger,rotary,cable,direct push etc) 24c.For Water Supplyand Open-Loon Return Wells:Copy to the
count' -Ivtronmental health department of the county where installed
FOR WA TER SUPPLY.WELLS ONLY:
2dd.For Rater Wells producinc over 100,000 GPO:Copy to DWR-CCPCUA
13a.Yield(epm) Method of test: Air Permit Procter,161l\dlSC,Raleigh \rC 27699-16]1
13b.Disinfection type:-.4 HTH 1 `65
Amount: f
No:th CaroLna Department of EnlVDnlnenLat Quality-Division el•lvater Resources
catawba county
public health
Memorandum
August 7, 2023
To: Randy Hullette
7751 Valley View Ct.
Hickory, NC 28602
From: Megen McBride, Environmental Health Administrator
Re: Well Head Inspection Not Complete: Permit: WELL-04-2022-169755,
Site Address: 5613 Springs Rd, Conover NC 28613
Catawba County Environmental Health permitted a private drinking water well at the above
address. Our records indicate the well was drilled on or about 7/19/2022. We have not been
notified that the well has been put into use and is ready for water samples to be collected.
If your well is ready for final inspection and collection of water samples, please notify our office at
the contact information below.
There is no need for you to be present for our inspection. The water samples are collected from
an outside spigot. Please note, however, that the well head needs to be accessible. Please
remove any locked well covering or insulation barrier so that we can visually inspect the well for
compliance.
The fees for the well inspection and water samples were included in the cost of the well permit,
so there is no additional charge for this service. The water sample test results will be mailed to
you once they are received by our office. Typical process time is 4-6 weeks.
Please contact our office if we can answer any questions or provide additional assistance. You
may reach our office at (828) 465-8270, or by e-mail at: EHAdmin@CatawbaCountyNC.gov
catawbacountync.gov
Environmental Health
Catawba County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270
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