HomeMy WebLinkAboutWELL-07-2022-176185.TIF 44 . • CATAwt3ACOt1N'fy Case# WhLt.-07-2022.176185
``• Public Health Department Subdivision GABRIEL J LITTLE UNREC
Environmental Health Division PIN# 460701155319
PO Box 389,25 Government Drive,Newton,NC 28658 1.U'I'# 2
..
Site Address: 3775 LANDMARK DR, SHERRILLS FORD NC 28673
Name on Permit: CARL ERIC DAHLQUIST
Property Size: Acres 0.32
Directions: Hwy 150 to Little Mountain Rd, left onto Landmark Dr, house is close to the end of street
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-06-2022-41444, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
jElectronic Image'Transmittal/E-mail (Return receipt required)
• As the property owner or authorized representative I have reviewed and understand the specific conditions
of the permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Construction Standards(15A NCAC 2C.0100), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 07/21/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature_ i .
Date-Time 1 1 XI)?
Method: Fax y Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto compiette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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Print Form
WELL CONSTRUCTION RECORD (CW-I) For Internal Use Only:
I.\fell Contractor Information: ,/
i d- e 4 e I Q _2 -- II.WATER ZONES
Wel C'amracior Nan,c FROM TO ; ns('talrTION
Lta 1 DA ft. ft. i
ft, n.
II('omnrtnr('enllication Number
t c,L, 15.OUTF.R CASING(for multi cued wells UR LII NF.R(If rpplkrble)
>��C(�took
o yule ( ( Jn l and ` I•5.O AS OIA ai Ert:n Tf111CK1 11. - T A I(IAI,
JJ ����(( / I I6.INNER C'ASING'OR.T.UBING .conc�rtnal closed-Itwp)
2.well Construction Permit#L04,1 f J' -4 .2-1 / ( FROM To AMI:I Eli •I III(KNESS MATERIAL_
Lett,diappbe.thfrurllettuvtrnr' permits(i.eLW;C'nunty..trare, rierl�rnrr.r8'_1 ft. ( m
fl. ill. 1
3.\Veil Use(check well use): ft. I ri. ill.
Water Supply Well: 17.SCREEN
Fl(o\t jilt__ DIAMETER 5LU'1'SI't•: "DI('KNESS h1A'rt:RI,li.
0Agricultul'al DMJttnicipaliPublic ft, -ft, In.
❑CientherntaI Bleating/Cooling Supply) Bit Water Supply(single) ( rt, fl. • in.
❑lnuIustrial.'Cnntmer:ial 0Rrsidentiul Water Supply(shared) Is.GROUT
IlIrrieation mom 11 t:To I Ut 11lnl. 1•:11 11 %(t MV'('t rli(m .k%10(l1'h"
Non \\aier Supply Well: ft. I ft. rh_ _/ • ` _.(_ d
°Monitoring EDRecovery rt. rt. I(�!Y/� {Q
Injection Well: --- t I ft. -- V�
Q.\quiler Recharge D(irnundwalcr Rclnediation l _
19:'SAND/GRAVEL PACK(If applicable) _
\quitcr Storage and Recovery Salinit Barrier J
�^ y FROM TO MATERIAL t:?1PL,tC FMt:YI)IF:Inuu
°Aquifer Test DSutnnwatcr Drainage n. B.
plispernnental Technology OSubsidence Control ft. ft.
Of ieuthernial(Closed Loop) DTracer 20.DRILLING LOG(attieh.iddlilonal sheets if necesary) •
eotlscrinal Ile:rtin'� FIt0111 TO �ntsciair'IC)N Icoh,r.haninr..- iilVnek IMn. rain Sift.01%1
(i ( '(ailing Return) ❑(Alter(explain under 1/21 Remarks) It n.
4.Date\1'cll(s)Completed: Well ID# L
ft. 1
•
n. n.
Se.Well Location:, ' f
Czid tic lqu.l5-1- _ �---rt. n.
Far ilityit t uii r Name Facility Ills Of applicable) Ii• I It
1,l r SI:1 iiiil`Cyr
I'In•'.•al A. rCa:,('a5.and'Lilt 1'1. IL !
(tLA)bct L( 3~1b1lI21.REMARKS
( root) Parcel Idclttiticalion No.II'INi _ _. _ ._. ___.--_-.._ _......._........I
Sb.Latitude and longitude in degrees/minutes/seconds nr decimal degrees:
(if..ell field.one Iat:long is.orbs feel) 22.Certification:
./e.,,,,(----
6.Is(are)the well(s) Permanent or Ore nporury Signature al(ciii Well l'nnlrnclot Date
11c signing ihia(.uvi. I Ilei'eiti.rerii/F that ill-nr/ll..r MIS inrrrl rnn..h'urled is aerurdanue
7.Is this a repair to an existing well: Yes or �No with 15:1 N(',I('(,2(' 0100 or l5.4 N(il(•WC 0201i Well Coitsiriiclin,,lauchuti.e and Mai a
1/rlti..Pt✓regxni'./ill t+at( •n nrli cnu.rrnrNnn inliu•inutuui and r,plain ihr nano,ctfth,• ropy,.1 this retard hoc been provided in the nrn owner.
repair air 1•r#21 re Li serli,io n;an vitt'ti tr1 nl ibis/w•ni.
23.Site diagram or additional well details:
S.For Geoprohe/OPT or Closed-Loop('enthenurl Wells having the same You may use the hack of this page to provide additional well site details or well
constniclion,only I CW-1 is needed. Indicate TOTAL NUMBER of wells construction details. Von may also attach additional pages if necessary.
dulled:___ -_ . SUBMITTAL.INSTRUCTIONS
9.Tidal well depth below land surface: ,. 0 (ft.) 24a. For All Wells: Submit this titan within 311 days of completion o1'well
F..r ati.bpd,•ur1L.list oil depths.th.it,6l/ereai I.ample-i,d'(Ill curl 2(ii,!100•) (.'ousimetion Icl!he Ii,Ilow'lI1L`:
10.Static water level below lop of casing: Lk() 01.) Divisinu of Water IResnurces.Information Processing Unit,
rf•,✓1.•.it.d;.::n„I, ,•,.a.tg,ties ' ' 1617 Mail Service Center,Raleigh.NC 2 7699-1 6 1 7
I1.!Sorchnle ilia meter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of continental of well
12.Well coustrucuou method: construction to the tidlowing:
.I.S.;lager,rotary,cable,direct poodle etc.)
division of Water Resources,Underground Injection Control Program.
FOR WATER SC•I'I'I•Y WFI.I.S ONLY: 1636 Mall Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) \lethal of test: 24c. For Water Sunnly & Infection Wells: In addition to sending the corm to
the address(esi above. also submit one copy of this form within 31) days of
I3b.Disinfection type: amount: completion of well construction to the county health department of the county
where constructed.
Form(iW•I North Carolina Dcpanntcnt of Environmental Quality-Division of Water Resources Revised 2.22-21116
r
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: 0 01,(04v►s3" C-r-1 Sample ID Number: l- Z� I7618c
Location: 1115 k O r rr 1113 l . r) Reviewer: ass,,A 130-13
Initial Sample Confirmation Sample:
BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR
PRIVATE WELL WATER(These recommendations are based on biological analysis only.)
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 coliformbacteriawere detected in your water sample. Total Coliform are a group ofrelated
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 colifoiui 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 bybacteria contact your local health depai linent 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 depaituient 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 occurnaturally in water or can be introduced into water
from man-made sources.Total colifoinibacteria are found in soil and fecal conform bacteria are found in
animal and humanwaste.Total colifoiun 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,orimmunocompromised (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.
1
w ,Private el l 1 . orm ti
i �
fff
= ,v., a andRecommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
1
County: Catawba Name: Gcr( iO'ct c�<'s-i- 37 15 1..-.nan,•Q.rkOr z.pe iU Fc.r)
•
Sample ID#: 11 C 1g S Reviewer: Jason Boyd
TEST RESULTS AND USE RECOIVIMENDATIONS
1. Your well water meets federal drinking water standards for inorganic chemicals.Your water can be used for
dr' ng,cooking,washing,cleaning,bathing; and showering based on the inorganic chemical results only.You may
have other water sampling results that are not taken into account in this report.
2. n 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 only.
n Arsenic I I Barium ❑ Cadmium ❑ Chromium l I Copper n Fluoride n Iron
❑Lead I I Manganese n Mercury n Nickel n Nitrate/Nitrite n Selenium ❑ Silver
n 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..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 only,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.
U Chloride n Copper ElFluoride I I Iron I I Manganese
_pII ❑ sin � " 'dte _Zinc
6. ❑ a. Sodium levels exceed the U.S.Environmental Protection Agency's (USEPA)Health Advisory level for sodium of
20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or Iow 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.
•
n 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.