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Home My WebLink AboutSAM-02-2023-188616.TIF • NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES • VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS: PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300 WATER SUPPLY WELLS UNDER 15A NCAC 02C.0107 All water supply wells not considered"Private Drinking Water Wells"and including irrigation,industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or Ore information. Illegible submittals will be returned as incomplete. DATE: . (3 , 20 PERMIT NO.: (to be completed by DWQ/DPH) A. WELL OWNER— For single family residences list the property owner(s)_ For all others, list name of the business, organization,or government agency and person delegated signature authority: 46 (t 1 �,,�r4 & I kJ Mailing Address: `1�r &a6n•t I S City: 54{rr,tit f'OJ4 State: /t/ Zip Code: ((o7}County: ( 44 .L‘Gt. Day Tele No.: g( -"?a 3- (9(90 1 Cell No.: EMAIL Address: e,a.r • Ceo-t Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number(PIN) of well site: [ La 01 4 3 y 3 6?`— County:CC,f G cam, GL (2) Physical Address(if different than mailing address): City: State: NC Zip Codc: C. WELL DRILLER INFORMATION (if known) Welt Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person; City: State: Zip Codc: County: Day Talc No : _ Cell No.: EMAIL Address: Fax No.: Fonn GW-22V Page 1 Revised February 2013 D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is being requested; description of how the alternate construction will not endanger human health and welfare and the environment; and reason why construction and/or operation in accordance with the standards is not technically feasible and/or provides equal or better protection of the groundwater. C . 11 ln 11 4°,_ 9 t/p �M 1 /�lw lry�/�.'f�'+11• E. ATTACHMENTS—Provide the following information as attachments to this application: (1) A map showing general location of the property (including road names, NC State Route Number, distances, any key landmarks,etc.)sufficient for finding the well location. (2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building foundations,property lines,water bodies,potential sources of contamination,other wells,etc. (3) Submit a copy of the local well permit application and site evaluation map(if applicable). (4) Any other information relevant to the variance request such as a well construction diagram showing proposed well liner or atypical construction materials/methods. F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional construction requirements beyond those specified in ISA NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application. Approval of a variance will not be considered in cases where the specified minimum additional construction requirements cannot be met. G. SIGNATURES Signa re of P eResponsible fur Well Construction(typically the well driller) (AI`7f Print or Type Full Name of Person Responsible for Weil Construction (typically the well driller) l A(Ldeil (EIS Sigoatu e o County Environmental Health Specialist Pik(i(1ik Print or Type Full,lme of County Environmental Health Specialist Per 15A NCAC 02C.0118 the Secretary of the Division of Water Quality or the Division of Public Health may require submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as described in G.S. 1508-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 • Please submit this forum along with a Well North Carolina Variance Application for an existing Department of Health and Human Services private water supply well. Division of Public Health Well Site Location: 51,,r r ti Fts J N C— L b o 0 3 N 3 03 ri c (Town,camnarnitv,sr/division and Lot e1 Address; c 5-1- County: City/ST/Zip: Is t;-7,1 Date of SiteVisit: 3 / ( 2-3 1° I. q ' Ac 11 , ll I id ( iUntltictiott 1\ v'11 ( onstruclion Date of Well Construction: _ .11 7 Is the well head 12"above land surface E-S r NO If unknown, was it drilled before 1972? YES. or NO If no,what is the height of the casing; _inches If unknown,was it drilled before 7/112008? YES dr NO Is there a sanitary well seal? YES r NO What type of well is it: Is the sanitary well seal in good repair? YES o NO (Dri ed Bored Hand Dug Jetted Other Are the following items present at the well head? Does the well have a cement slab? malor NO Vent NI 0 Sample Tap V it S Well Tag f\I Q Pump Tag NI Q Does the well appear to be grouted?cYE) or NO I'(ticnlial Si,ttrcrs c,l•C(tttt:tntill:lliun? Does the well currently meet separation requirements with known sources of contamination? YES o NO If no,please provide distances to those it does meet: _ - j-o S a.,p+1, c Y'-I� . Sy is t1A 4 r kit,vv.`� l�tl+ IDS l� S1 't'h�� 7-r �- LX r 00 . T r G r-f' Other comments: A I F,_ V r ,� P� m. ,a 1 PPY • � v S Name of person completing this form(please prim): J� j t� . • Catawba County Environmental Health 0 ,lob i' 0 % Jill • 49 li 1 2.3- v'. .7458 4 Is 40, 4 A. t 416 illik„ ,... qi., # c-4r� / 5.96 Be r68�s 14. a 2a` ♦ti f I A Parcel: 460703430795, 7458 GABRIEL ST lin=40ft SHERRILLS FORD, 28673 This map/report product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2023 Catawba County NC 04/06/2023 Catawba County Environmental Health k J . ' Li • ,.` • • I ..i ,:...•+1...0,% ,lifile-4 ''''' -,4,,,.,-.1.--4, „ , . , ,, , , ,,,,P, ,,,,, .,;,„ N,....,.14•.,,;...4 •. :Nolo• , f .1 d" - , 7458 ,,ea .' l , '• F 'M r J ' II- '' ••1•7 , t 51 • 4‘iv•• ii!i iff—.' ••' • �/+ , IF Ii FLU, f•- P 1 s - 3`- j + r • it - . I''.-"-,.. 1%, I N f fr ,M i .' .,t Is .. i ! • •' ' • Parcel: 460703430795, 7458 GABRIEL ST lin=40ft SHERRILLS FORD, 28673 This map/report product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2023 Catawba County NC 04/06/2023 • K& W Laboratories Results Report ; 1121 Hwy 24/27 W Midland,North Carolina 28107 AI Tel(704)888-1211 Fax(704)888-1511 Client: Miller's Lakeside Well& Pump Date: 17-Sep-21 7673 Pink Dogwood Trail Order ID: 21091416 Denver,NC 28037 Project: Drinking Water Collect Date: 9/14/2021 Location: 7458 Gabriel St Sherrills Ford,NC 28673 Collect Time: 12:18:00 PM ANALYSIS SAMPLE# PARAMETER RESULT UNITS METHOD DATE 21091416-01 E_Cali Absent colony/100m1 SM9223B 9/14/2021 21091416-01 Lead <0.003 mglL SM3113B 9/17/2021 21091416-01 Nitrate <1 mglL SM4500NO3D 9/14/2021 21091416-01 Nitrite <0.05 mg/L SM4500NO2B 9/14/2021 21091416-01 Total Coliform Absent colony/100m1 SM9223B 9/14/2021 EPA Maximum Contaminant Level Nitrate 10.0mg/I Nitrite 1.0mg/I Lead 0.015mg/I NC Certification:559 Certified ByNC Certification:37767 /L/ Sc Certification: 99051 G.Kraska Lab Director ,STArE cr i ,, : a�",,,Y,•.,,,� d,,,, ROY COOPER• Governor %`�4,, �' ., NC DEPARTMENT OF i 1 �-- �; KODY H. KINSLEY • Secretary `_- ` is HEALTH AND`� ° HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health ^^•z MARK T. BENTON •Assistant Secretary for Public Health Division of Public Health Onsite Water Protection Branch April 11, 2023 Robert and Sandra Wilks 7458 Gabriel St Sherrill's Ford,NC 28673 Re: Approval No. JMB2974 Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C .0107(a)(2)(P)] Property location: 7458 Gabriel St Sherrill's Ford,NC 28673 Dear Mr. and Mrs. Wilks: On April 6, 2023,the On-site Water Protection Branch received your request for a variance from the Well Construction standards, Title 15A North Carolina Administrative Code Subchapter 2C .0100. The request for the variance concerns a water supply well on the referenced property. A structure is proposed to be within twenty-five feet of the well. Specifically, the variance request grants you permission to use a water supply well at a distance closer than the twenty-five-foot setback to a building perimeter. Achieving the twenty-five-foot setback would be difficult given the challenges of the property. Based upon information provided by you, and the Catawba County Health Department, it is my finding that based upon current conditions as the site exist today (as well as the current proposal for use of the structure) you meet the conditions necessary for approval of a variance as specified by 15A NCAC .0118 (a) (1) and (2). On that basis and if the following conditions are met, the requested variance is approved: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road,Raleigh,NC 27609 MAILING ADDRESS:1642 Mail Service Center, Raleigh, NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 1) The well/wellhead shall meet all current 2C. 0100 standards, including but not limited to being properly grouted, terminated at least 12" above land surface, properly sealed, and having a thread-less sample tap etc. 2) The well shall be sampled for the same parameters required of a newly constructed well. If samples indicate contamination, further repairs or treatment will be necessary. 3) No potential sources of groundwater contamination shall be stored near the well-head. 4) No termite treatment shall be applied to the structure within twenty-five feet of the well unless alternative methods are approved by Catawba County Health Department. The granting of this variance is for the well location only. It in no way relieves the owner or agent from other requirements of the North Carolina Well Construction Standards including, but not limited to the requirements in 15A NCAC 2C .0113(b)to repair or to abandon any well which acts as a source or channel for the migration of contamination. This approval does not imply sufficient water quality. Further,the approval does not relieve your responsibility to comply with any other applicable Federal, State, or local laws or regulations. If you have any questions regarding this variance, please contact me at(828) 713-3335. Sincerely, John M. Brooks R.E.H.S, MS 2 N 0 R T H C A R 0 L I N A il,';i S(A7f n • • - + °T Private Well Information t 4l,.l .. and Use Recommendations NC DEPARTMENT OF HEALTH AND HUMAN SERVICES Division of Public Health For Inorganic Chemical Contaminants County: Catawba Name: Robert Wilks—7458 Gabriel St, Sherrills Ford NC 28673 1 Sample ID#: 188616 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 on(v.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 inorganic chemical results on(v. ❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium ❑ Copper ❑ Fluoride ❑ Iron ❑ Lead ® Manganese ❑ Mercury ❑ Nickel ❑ 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. ®The following substance(s)exceeded aesthetic drinking water standards. 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. ❑ Chloride ❑ Copper ❑ Fluoride ® Iron ❑ Manganese ❑ pH ❑ Silver ❑ Sulfate n 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. ❑ b. Your sodium level exceeds 30 mg/land 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. - anganes Exposure to Manganese has the potential to harm your health. Contact with any hazardous substances can cause health effects and the occurrence and nature of the effects depend on how much,how long and how one comes into contact with the substance. What is Manganese is an essential nutrient that occurs naturally in the environment. It occurs in low levels in the air,water, soil, and food,Manganese can be found in Manganese? grains and cereals, and is found in high amounts in other foods,such as tea. People can be exposed to manganese by ingestion or inhalation. How could I be What are the sources? Some people are exposed to eating food or exposed to supplements containing manganese. The way manganese gets into your Manganese? body is by eating food,drinking,swimming or bathing in water or breathing in workplace air contaminated with manganese. Workers in the welding or factory industry may be exposed through air in the workplace. Manganese is used in a variety of products such as fireworks,dry-cell batteries, fertilizer,paints and cosmetics. Manganese is also found in the environment in soil and water after release from the manufacture,use and disposal of manganese based products. What are the health effects of Depending on the concentration,manganese exposure may cause neurological Manganese effects on the most vulnerable populations, which includes infants,children,and Exposure? pregnant women. • Avoid manganese exposure sources. How can I limit • Test your well water on a regular basis. or prevent my • Workers with potential for manganese exposure should remove contaminated clothing before getting in car or entering your house. exposure to • Weld objects in a well-ventilated area and use an appropriate respirator to Manganese? reduce inhalation of fumes. Is there a Manganese is an essential element in the body so there will always be medical test to some present. Levels can be measured in the blood, hair, feces,and show if I have urine. Increased levels in your in your body may not indicate the health effects experienced from the exposure. been exposed to manganese? Manganese Fact Sheet 1 February 2015 Additional Call the N.C. Department of Health and Human Services, Division of Public Health at(919) 707-5900 for additional information. Information Agency for Toxic Substances & Disease Registry(ATSDR). Manganese. March 2011. Available at: www.atsdr.cdc.gov/substances/toxsubstance.asp?toxid=23 References Agency for Toxic Substances&Disease Registry(ATSDR). Public Health Statement for Manganese. January 2015. Available at: www.atsdr.cdc.gov/phs/phs.asp?id=100&tid=23 Agency for Toxic Substances&Disease Registry(ATSDR).ToxFAQs for Manganese. March 2014.Available at: www.atsdr.cdc.gov/toxfaqs/tfasp?id=101&tid=23 &tid=23 State of North Carolina• Department of Health and Human Services Division of Public Health www.ncdhhs.gov www.publichealth.nc.gov N.C.DHHS is an equal opportunity employer and provider 2/15. NCH odeperlmont fhiudih ad North Carolina human lmrkM Public Health Manganese Fact Sheet 2 February 2015