HomeMy WebLinkAboutWELL-08-2022-178035.TIF 1 ,ty$' . CATAW BA COUNTY ___
h `" Public Health Department Subdivision STORYBROOK PH 1
Q --, '"1Environmental Health Division PIN# 369701193297
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 3
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Site Address: 3464 STORYBROOK LN, SHERRILLS FORD NC 28673
Name on Permit: *D&E PROPERTIES, LLC
Property Size: Acres 0.92
Directions: Right off of Little Mountain Rd onto Storybrook Ln. 3rd lot on left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
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 RBPR-07-2022-41691,bythe followingmethods :
( )
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
•
/4As 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: ::/2::ative
(cr,...Q .7..z<
Owner/Auttthof ed Signature
/ Date u ..26__
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson sending permit)
Signature C.rE Date/Time 12'202
Method: Fax 1 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 complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 70 fL 200 rt.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
Russell Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 70 ft. 6.25 In. SDR21 PVC
Company Name WELL-08-2022-178035 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM , TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.U1C,County,State.Variance,etc.) ft. ft. ie.
3.Well Use(check well use): rt. rt, la,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. rt. is.
❑Geothermal(Ileating/Cooling Supply) IEResidential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATERIAL £MPLACF:MF,NT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 rt. Grout Poured
❑Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remodiation
l9,SAND/GRAVEL PACK(If applicable)
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(robe,hsrdaess,rolVrock type,groin slit,etc.)
0 ft. 65 ft- Dirt
4.Date Well(s)Completed: 12-14-22 Well ILO( 65 ft. 200 ft. Rock
ft, ft.
Sit.Well Location:
D & E Properties Keith Estes it ft.
Facility/Owner Namc Facility IDN(if applicable) ft. ft.
3464 Stony Brook Lane, Sherrills Ford NC 28673 ft. R.
Physical Address,City,and Zip it, it.
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
35' 59.972' N 081' 04.845' W C.. 1/12/2023
6.Is(are)the well(s): LelPcrmanent or OTemporary Signature of Certified Wet Contractor Date
8r signing this form,!hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 17No 154 NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a cops
If this is a repair,fit!out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under'121 remarks section or on the hack of this fimm.
23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft.)
Far multiple asps list all depths if different(example-il.4200'and 2(411007 Submit this GW-I within 30 days of well completion per the following:
(ft.) 24a. For AB Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: 70
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For injection Wells:Copy to DWR,Underground injection Control(IUC)
II.Borehole diameter:6.25 (in)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 0 Method of test:Air Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 3/4 cup
Form OW-I North Carolina Department of environmental Quality-Division of Water Resources Revisal 6fi 2018
Analytical Results sTATF Vilr," F.:
ANALYTICAL
Catawba County Public Health
PO Box 389
4100
Newton, NC 28658
Receive Date: 07/18/2023
•
Reported: 07/19/2023
For: James& Mary Stansberry 3464 Storybrook Lane
Sherrills Ford NC
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
230718-34-01 Nitrate 08-2022-178035 1.35 mg/L 3537 07/18/2023 CL
230718-34-01 Nitrite 08-2022-178035 <0.1 mg/L 353 z 07/18/2023 CL
Respectfully submitted,
>
Melissa Myers
NC Cert#440,
NCDW Cert#37755,
EPA#NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 2
122 t'ourt Street Stir V.-%ilk.
704-8724697
NI I RATEINI I RIFE ANALYSIS
W.1."FER SYSTEM II)#: 0_ - 128 0 35 Count): Catawba
N Mt?Of atcr System: 73, RA1 1, S'+ap,s c t .nail ill I:kit\ S:tr. r
Sample 11 y pc: n Entry Point (SpeciarNon-compliance
Location Where Collected: 3114'91 Sturybrobt". L lr 11,5 F rJ A/6 .2 b)C73
1•acilits 11)No. 1) 0 3 5-
Sample Point: T p (:olleetion Date collection 1 tine
Collected/-1 : ptot,,k-k- /VI:k 01 ! (7. ).3 / q , p
Mail Results to(staler system represent alive
CATAWBA COUNTY PUBLIC HEALTH Phone a: (828)465'8220
ENVIRONMENTAL HEALTH Fat (828)465..8276
PO BOX 389 Resporstiblr Person's
EHAdmin@catawbacountync.gov
NEWTON,NC 28658
1,Aii014:‘FORS II)tt: 37755 ii SAMP1 I. 1 'I( 10141 D REQUIRED
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1,1-111 11: .1;1. I 35liii 11111' 1.s,
1,1 I I'q! I 1 NI
SI\CItC It%suit eNceedh allocable!IMO.,the labilf.litlr) must i analytical resillt,to the State on day lest completed
1)-N 1 1:: TIME:
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ANALN Si S 1111:4.1 N: 0 1? [13.) 2 5 5: 0 t P1
1,D41111,11 Nrortp,r1 1.4
.‘N‘i.1 St COMP(I. I 1..1): 01! 1 7 , 3 4:06 •
haborator:, log 2 ()7 I B):
(SOMNIF.N1 S: ..
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Laboraturr shoahLylguRsuLtuo;
Yesizer Sestio:.Arn Data En:re.1104 Matl Scr.l.st I 122.1c:gh.:s( 2)04161'
Fos,914.,11.6.6.3.
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 2
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: James Stansberry Sample ID Number: 178035
Location: 3464 Storybrook Ln, Sherrills Ford NC 28673 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
Private Well Information
1,- )
,,,
NC DEPARTMENT OF and Use Recommendations
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba Name: James Stansberry—3464 Storybrook Ln, Sherrills Ford NC 28673
Sample ID#: [178035 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 only.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 inor,anic chemical results only.
❑Arsenic ❑ Barium El Cadmium El Chromium El Copper ❑ Fluoride ❑Iron
0 Lead El Manganese ❑ Mercury ❑Nickel ❑Nitrate/Nitrite El 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. El 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.
El Chloride El Copper ❑ Fluoride ❑ Iron ❑ Manganese
❑ pH ❑ Silver 0 Sulfate ❑ 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 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.
D 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.