HomeMy WebLinkAboutSAM-02-2023-189370 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 dearly or type information. Illegible submittals will be returned as incomplete.
DATE: L/2-/6. , 20 PERMIT NO.: (to be completed by DWQ/DPH)
A. WELL OWNER — For single family residences list the properly owner(s). For all others, list name of the business,
organization,or government agency and person delegated signature authority:
ifit,i
Mailing Address: 5t)ZS' ( /^ pe
City: 4X6� State: 4k Zip Code:��' County: C44775: 1419-
Day Tele No.: 152e -3 zv -53o Cell No.:
EMAIL Address: _€1'14e tJef/Ier@3 fti 4 /t c - Fax No.: •
B. PHYSICAL LOCATION OF WELL SITE �j
(I) Parcel Identification Number(PIN) of well site: az5 7 4145—749
County: e-4 Q.QA.-
(2) Physical Address(if different than mailing address):
City: State: NC Zip Code:
C. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
Form GW-22V Page I 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.
JD1770fr,/ ?o tt E (.5-Z..NEooicti /7j sc Af-r ,W.
Z/ ` recv, LI
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 MINLMUM CONSTRUCTION REQUIREMENTS
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and
Piedmont and-Mountain region wells arc referenced on-Attachinetit-s A-and B 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
1 ' r
Signature of Person Responsible fur W unstruc (typically the well driller)
Ahnt Aq -
Print or Type Full Name of Persln Responsible for Well Construction
(typically the well driller)
6 „.
$gnatt re of County En iro mental Health Specialist
U s �,��� �2 � Fs. / o
Print or Type Full Name of Count}'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. 150E-23 within 60 days after receipt of the decision.
Form GW-22V Page 2 Revised February 2013
North Carolina Please submit this form along with a Well
Department of Health and Human Services Variance Application for an existing
Division of Public Health private water supply well
;;; - sExistin Well:.Variance Inspection-Repo •`:';
Well Site Location: lit I c k a r,i NI 6 C-c•--6. .) Co , 3 7 z S ( H LI Li 5 7 ej r,
Town,community,subdivision and Lot#)
Address: j E, i-_s' I 10-7-1-, 10) r N t ' County: C ---1-,,..,•1-„ ,
City/ST/Zip: 1..1 i z;�-r.) N G 7,75-6 0 1 Date of SiteVisit:__ 3 / i t / 2.3
15 _.t^ _ —"..`.:t'•21 '.•'C'i i:1::-:f1:' '-f•'i:.N.:;:ii:,7. ::r. 5'..: ..q.
r r. "r��.: -.d.
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TK
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,� ��;J� 'Well��'Constructron:�:.; .•;.' ,<
.r,. 'gyp
Date of Well Construction: _ N ) A Is the well head 12" above land surfac or NO
If unknown,was it drilled before 1972? YES oz( U ) If no,what is the height of the casing: inches
If unknown,was it drilled before 7IlI200 . r NO Is there a sanitary well seal? YES or NO
What type of well is it: Is the sanitary well seal in good repair(YES)or NO
Dle Bored Hand Dug Jetted Other Are the following items present at the well head? 1
Does the well have a cement slab? OYESor NO Vent N o Sample Tap
o
Well Tag f\to Pump Tag G
Does the well appear to be grouted. YES o NO
.Potential Sourcesrof Contammation?
Does the well currently meet separation requirements with known sources of contamination. v of T
If no,please provide distances to those t does meet: \/g .c;,c.� .>e. ...(e ,,2- 3'-1- F- —
s.�v1 r V 0 J.... 1 1 t r'a n.. -a.c-l‘/ p t^ Pe.i c: :) .5 n r:i e>
- 1
Other comments:
�1 er —• Complete`be!ow —
Name of person completing this foam(please print): . .-. _5.z, "--\ 13 v V c) R i
Sa STATFa•� ,,
„., , ti•a',,PT ROY COOPER•Governor
NC DEPARTMENT OF
_ e � HEALTH AND KODY H. KINSLEY•Secretary
1 ,r.r
HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health
• "' ,.::= MARK T. BENTON •Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
March 17, 2023
Anne Wepner
5025 16th Dr NE
Hickory, NC 28601
Re: Approval No. JMB2948
Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C
.0107(a)(2)(P)]
Property location:
5025 16th Dr NE
Hickory, NC 28701
Dear Ms. Wepner:
On March 17, 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.II.S, MS
2
` 0 4312 District Drive
'-l'i ,,1 '' North Carolina State Laboratoryof Public Health MSC 1918
'6"'4 , '. g Raleigh,NC 27699-1918
illi I. .c1�0 g Environmental Sciences http:llslph.ncpublichealth.com
c; vo Phone: 919-733-7308
Inorganic Chemistry Fax: 919-715-8611
Certificate of Analysis FINAL REPORT
Report to: ENVIRONMENTAL HEALTH Name of System:
CATAWBA COUNTY ENVIRONMENTAL HEALTH Anne Wepner
P 0 BOX 389 5025 16th St Dr SE
NEWTON, NC 28658 Hickory, NC 28601
EIN: 566001814EH Delivery: NC Courier
StarLiMS ID: ES230317-0007 Date Collected: 03/16/2023 Time Collected: 10:40 By: Jason Boyd
Date Received: 03/17/2023 Time Received: 07:33
Sample Type: Raw Sampling Point: Outside spigot on home Well Permit No. SAM-02-2023-189370
Sample Source: Well water Receipt Temp. : GPS Number:
Profile: Inorganic Chemical+ Metals I
Analyte Test Result Allowable Limit Unit Qualifier(s)
Arsenic <0.001 0.010 mg/L
Barium <0.1 2.0 mg/L
Cadmium <0.0005 0.005 mg/L
Calcium 13 mg/L
Chloride <5 250 mg/L
Chromium <0.02 0.10 mg/L
Copper <0.01 1.3 mg/L
Fluoride <0.1 4.00 _ mg/L
Iron 1.66 0.30 mg/L
Lead <0.003 0.015 mg/L
Magnesium 1 mg/L
Manganese 0.112 0.05 mg/L
Mercury <0.0004 0.002 mg/L
Nickel <0.01 0.1 mg/L
pH _ 6.9 N/A
Selenium <0.005 0.05 mg/L
Silver <0.01 0.10 mg/L
Sodium 3.2 mg/L
Sulfate 9.7 250 mg/L
Total Alkalinity 37 mg/L
Total Hardness 39 mg/L
Zinc 0.26 5.0 mg/L
Report Date: 03/28/2023 Reported By:
Ft. EIVE Marc Komlos
MA ? 1 '`'23
Environmental Health
Page 1 of 1
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: Anne Wepner Sample ID Number: 189370
Location: 5025 16th St Dr NE, Hickory NC 28601 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 he 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
J
�� � and Use Recommendations
NC DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Division of Public Health For Inorganic Chemical Contaminants
County: Catawba J Name: Anne Wepner—5025 16th St Dr NE, Hickory NC 28601
Sample ID#: 189370 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 inorganic chemical results on(v.
❑ Arsenic ❑ Barium ❑ Cadmium ❑ Chromium (T Copper ❑ Fluoride ❑ Iron
❑ Lead ❑ Manganese ❑ Mercury El Nickel ❑ Nitrate/Nitrite ❑ Selenium n 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. Your water can be used for drinking,
cooking,washing, cleaning, bathing, and showering based on the inorganic chemical results on(v, 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.
❑ Chloride ❑ Copper ❑ Fluoride ® Iron ® Manganese
❑ pH n Silver n Sulfate ❑ Zinc
6. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's(USEPA) Health Advisory level for sodium of
20 mg/I. 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/1 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.