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HomeMy WebLinkAboutWELL-09-2022-181175.TIF \C.• CA\TAIVBA COUNTY r • ,.1.� Public Health Department Sutxlivisiun log • Environmental Health Division PINK 368702869549 PO Box 189,25 Government Drive,Newton,NC I8658 LOTH 3 Sit.Addr.ss: 3639 MT BEULAH RD,SHERRILLS FORD NC 28673 Nam.on Permit: 'LEMON BOWL RENOVATIONS LLC Property Six.: Acres 1.06 Directions: Right off of Little Mountain Rd onto Mt Beulah Rd.4th lot on right after Lineberger Rd. Owner/Authorized Representative Acknowledgement of Permit Receipt )(1Wil I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of (the property described above. X1'(\L.As the property owner or authorized representative,I have received the above referenced permit(s)as requested in the application for service RBPR-07-2022-41545,by the following method(s): Received in Person _ Facsimile Transmittal(Return form with signature required) f Electronic Image Transmittal/E-mail (Return receipt required) Pi Asthe 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(I5A NCAC I8A.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:09/27/2022 • Owner/Authorized Representative Signature "Aka-6,-,AAI p� — 7 Date � 1 �2-� Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) SignatureqC Date/Time 9130/)) Method: Fax " 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 yosPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EHCusttomerService (Nip() t:1-4(1 i SQAof rx4t• eml MW1 .1.1,u+,1 09R7/022 13 33 Created With Tiny Scanner pc:A � WPDT Report Area of Interest (AOI) Information Area : 3,134,508.7 ft2 Sep 28 2022 15:53:16 Eastern Daylight Time / ,,,(,, i( i _ ___ _ N 7 -`j -----_____ hi ''.--- , i ti_____/: ..:: 41114.\\ —.77 /, i I w ,` ti j tt 11 / t..(-____ r 1:4,514 Eli Puce is!Polygons)-Parcels Projected Route 0 0 03 006 U;2 m. l 5 1 t it ti ti ti r Non-System Roads — Other State Agency Route 0 0.05 0.1 02 km - Feder8r Route — Secondary Route Non-System Pnmary Roads Other System Roads — IMnstate e++Cow+wt'rc+Cu+,wors vw,a ca,.+y sir N Pine,h(:NNN OUr u ar,.,st..etA una,at Lan „ENE. cum., saNbs,n - Ramps.Rest Areas.Non-Mainline — US Rote oemea.oown.In.usn.skss,USGS.SPA.wS US Coots,0 . USDA NCOOT Gr5 Un0 So , Esn A•wr DS USGS NGA.NASA — NC Route 3639 Mt Beulah Rd,Sherrills Ford,NC All North Carolina Department of Environmental Quality(NCDEQ)GIS data Is expressly provided"AS IS"and"WITH ALL FAULTS".The NCDEQ makes no warranty of any kind,express or implied, concerning this information, including but not limited to any warranties of merchantability or witness for any particular purpose.The NCDEQ assumes no responsibility or legal liability concerning the Data's accuracy, reliability,completeness,timeliness,or usefulness.The data is not intended to constitute advice nor is it to be used as a substitute for specific advice from a professional. Users should not act(or refrain from acting)based upon information in the Data without independently verifying the information and obtaining any necessary professional advice.Users are solely responsible for ensuring the accuracy,currency and other qualities of any products derived from or in connection with the NCDEQ's Data.The Data is collected from various sources and may be modified over time without notice to improve spatial andattribute accuracy.The NCDEQ disclaims responsibility for the spatial accuracy and attribution of GIS features and makes no warranty concerning same. Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Michael A Brook 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 4210A ft. 100 ft' 4apm; 225ft-8gpm NC Well Contractor Certification Number ft- 210 ft 28gpm 15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable) Rockwater Well and Pump FROM TO DIAMETER THICKNESS MATERIAL Company Name 0 ft. 55 ft. 6.25 in• PVC WELL-09-2022-181175 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.UIC,County,State,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17..SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural DIMunicipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) ©IResidential Water Supply(single) ft. ft. in. Industrial/Commercial fIResidential Water Supply(shared) 18.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft. ft. Bentonite 37 bags Monitoring ORecovery ft. ft. Injection Well: ft. ft. Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0 Stormwater Drainage ft. ft. Experimental Technology fl Subsidence Control ft. ft. Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail rock type Rraln size etc 0 ft' 20 ft- red dirt 4.Date Well(s)Completed:1/28/25 Well ID# 20 ft. 45 ft• tan dirt 5a.Well Location: 45 ft• 240 ft• blue rock Lemon Bowl Renovations ft. ft. Facility/Owner Name Facility ID#(if applicable) ft ft. 3639 Mt Beulah Rd, Sherrills Ford, 28673 ft. ft. Physical Address,City,and Zip ft ft. Catawba 368702869549 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one latllong is sufficient) 22.Certification: 35.592069 N -81.055494 W 6.Is(are)the well(s)0Permanent or MITemporary Signature of Certified Well Contractor Date By signing this form,I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or XONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: 8.For Geoprobe/DPT 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 240 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths(f different(example-3@200'and 2@100') construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, If water level is 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 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 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm)40 Method of test:air 24c.For Water Supply&Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: 1.5 lbs completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 t6; catawba county public health Memorandum November 25, 2025 To: Michael & Cynthia Gray From: Megen McBride, Environmental Health Administrator Re: Well Samples Required Permit Number: WELL-09-2022-181175 Site Address: 3639 Mt Beulah Rd, Sherrills Ford NC 28673 The North Carolina Department of Health and Human Services requires all new private drinking water wells be sampled for bacteria, nitrate, nitrite, and a number of naturally occurring inorganic minerals. Our office has made several attempts to contact you to schedule the water sample collection and have been unable to reach you. Please contact our office so that we can schedule a time, at your convenience,to collect the required samples. The fees normally charged for these samples were included in the cost of your well permit, so there is no additional charge for this service. The samples will be taken from an outside source.The sample test results will be sent to you when they are received by our office. Typical process time is 6-8 weeks. 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 MAKING. LIVING. BETTER. Analytical Results Ar STATESVILLE _, ANALYTICAL yfit- Catawba County Public Health `- PO Box 389 Newton, NC 28658 Receive Date: 12/05/2025 Reported: 12/08/2025 For: Michael &Cynthia Gray:3639 Mt. Beulah Rd, Sherrills Ford NC 28673 Comments: Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst 251205-09-01 Nitrate 181175 1.85 mg/L 353.2 12/05/2025 MD 251205-09-01 Nitrite 181175 <0.1 mg/L 353.2 12/05/2025 MD 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 Court Street Statesville,NC 28677 704-872- 697 www.sa-nc.com . • • INFIRAIT NI'ERI`E ANALYSTS • Netr.Ailiaft tiea=a:beat-Adto oto iI=e cxr&. WATER SWIM.Da# t f 1 L 0 c1-2Q 2')--1.�1(75 County: Catawba Name of"Water System: MiCk(A•e;( cl' CA!Afhia Gray . Sample Type: ©Entiy Point SpecialINon-compliance Location Where Collected: 3C33 fit 1• $ewla.h eol, S1,,s'r,ils r`/ /Ye C7.3 Facility ID No. t R l 1 r Sample Point: We i+ 11 Collection Date iti Collection Time Collected By: Lto1 cik Pi;K_ept,I /2/04 /d.S' s /i : 31, i M (WM(DDIYY) — t=P.ttr'Aic PM) Mail Results to(water system representative): CATAWBA COUNTY PUBLIC HEALTH Phone fro ($)465-8270 ENVIRONMENTAL HEALTH pax&, l(8281 465-8276 •, PO BOX 389 ResponsiblePerson's a naf: •EHAdmin@catawbacauntync.goV NEWTON,NC 28658 LABORATORY ,'sr: 37755 . El SAMPLE UNSATISFACTORY 0•RESAMPLE REQUIRED 1 REQUIRED NOT DETECTED QU/.2 TW1.BD AI LOWAH[5 ' CQDE CONTAMINANT CODEbETHOD REPORTING LIMIT' (i.e.<R.R.L) RFSUI TS,- 1' RJt i.) CX) 1040 ' Nittate 3532 1.00 mg/L ej . . mg/L 10.00 mg/L 1041 Nitrite • 3532 0.10 mg/L mg/L 1.00 mg/L, *Note:If result exceeds allowable limit;the laboratory must fax analytical results to the State on day test completed. DATE: MS: I ANALYSES BEGUN: L2 /0 9/2 67 • /12: f Q, I —1M A G „I / ts ,_QY,� , ANALYSES COMPLETED: /2 /O 5./2 ! 7 :VP___, 1 L Laboratory Lo 1: S1 Lj� mil•t I l Certified By: -*_ a `�J I,abo ry 8t 2 1/5'O COMMENTS: • . 2008 . Laboratory should Man Results to: Public Water Supply Sectioa,Attn:Data Ent};1634 Mail Service Ceate,Rae eh NC 27699-1634 PO Box 228 • Statesville,NC 28687 • 704/872/4697 Page 2 of 2