HomeMy WebLinkAboutWELL-03-2023-191130.TIF ct) • CATAWIIA COUNTY ,
• -t i Public health Department
Subdivision
• .,� Environmental Ilealth Division PIN# 375019600534
PO Box 389,25 Government Drive,Newton,NC 28658 LOTH rN 1
w
Site Address: 2523 CLAREMONT RD,NEWTON NC 28658
Name on Permit MICHAEL GOOD
Property Size: Acres 5.25
Directions: NC 10 AN D St,Keep straight to get on to NC 16/S NC 16 Hwy.Left on Claremont Rd,properyt on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
:04iicertify 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 R13PR-03-2023-43589,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
d Electronic 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:03/13/2023
Owner/Authorized Representative Signature c 2_
y71 C
Date _\} .7 r'/ 2 ,7j
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by_ (name Of person sending permit)
Signature____________*___ Date/Time Si II)3
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 yoxPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
rn 3 cbd Q ni t voi4,s ive bwelia• Aar / ltd L
chpcnntt 03/13/2023 16 26
I.Well Contractor Information: I I
Robert Teague «l 14.WATER ZONES
Well Conttactn,Name ft.
1 TO _ DESCRIP110N
2857-A Q . Sit. !!G ___---
ft. 1 ft.
NC Well Contractor Certification Number
15.OUtt.R CASING(for mold-cased wells)OR LINER(If apptlable)
B & K Well Drilling Inc mom DIAMETER THICKNESS MATERIAL
Company Name ft.
[ S ft. 6 118 in' SDR-21 l PVC
Lp16.INNER CASING OR TUBING(geothermal dosed-loop) i
2.Well Construction Permit it:�( —l G , ' 36 I,FROM __ TO DIAMETER THICKNESS MATERIAL
Lu:all applicable..r11 construction pc,mttstic Lit.Cnoon Stare I'artancc.a 1 ft. ft. M.
3.W'ell Use(check well use): fr. 1 ft. in.
Water Supply W ell: I a_
17.SCREEN
.Agricultural , FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipatiPublic
ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) � - — — _—_
Industn [�
aliCommerclalft. 1 ft. in.
Residential Water Supply(shared) -.--__.. L_�__-_
Irrigation IL GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -.
ft. ft..
Monitoring Recove _..____ ,
Injection Well: tt. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft.
Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO i MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
F.xperimental Technology Subsidence Control ft. — ft. -
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If eems.ry)
Geothermal(Heating/Cooling Return) (10ther(explain under 02l Remarks) FROM As______J6SC.rtlFtiON(color.b e:s foiL'roeb ntte trtia tine ere)
ft. re.
4.Date Well(s)Completed NV 42-S_ al Well IDa it• (, ' I Sr G _
Sa.Well Location: ft. ' n.
►� I CQt ,-.---ft:
M
Facility/Owner Name Fac'lity IDa inapplicable) ft. ft.
5 33 dare an4 a _se Lk n - - ft. ft.
Physical Address,City,and Zip
Calft. ft
Ac% �� 21._ REMARKS
County WW��++ Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---- _.__._._...___
(if well field,one tat/long is sufficient) 22.Certi tin
N W,
4 ,P,gp-.)1
6.Is(are)the well(s)OPeraneat or Temporary Signature of Well Con for Date tn
8,1 agning Mi,fume. 1 hurl, ccrnfr that Mr nrll(t)MILT(..ere)mutt—lotted in accordance
7.Is this a repair to an existing well: Yes or No orb I3.1 N('4C-02C 0100 or 15A NCAC 02C 0200 Wall Construction Standards and that a
Ifthu!s a repair,fill mu An0Kn well construction information plain rhr nofurr u/rhr t tW�'of Oil record hat been provided to►e well under.
repair under 021 remarks section or on the back of thisform 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 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dulled. / SUBMITTAL INSTRUCTIONS
9. led (-4well depth below land surface: (ft.) 24a. J•'or All Wells: Submit this form within 30 days of completion of well
For mu/np/e n rl6 kit all depths i/dif Brent(example-yg200'and 2&l00) construction to the following:
10.Static water level below topof casing: 40
C (R•) Division of Water Resources,Information Processing Unit.,
1f%.aur/eve/u above canny.use'•.. 1617 Mail Service Center,Rakigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this forth within 30 days of completion of well
12.Well construction method: construction to the following:
fir auger,rotary,cable,direct push.etc)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t b ) Method of tut: Air Flow 24c.for Water Sugplt& Injection Well{: In addition to sending the forth to
the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection Chloe Tabs Amount: 1 1t2�° completion of well construction to the county health department of the county
type:
where constructed
Fort GW-I North Carolina Department of Environmental Quality-Di%wswon of Water Resources Revntit 7.22.7016
Analytical Results 4,;," STATESVILLE
ANALYTICAL
Catawba County Public Health A
PO Box 389
Newton, NC 28658
Receive Date: 10/24/2025
Reported: 10/27/2025
For: Michael Good:2523 Claremont Rd, Newton NC
28658
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
251024-16-01 Nitrate 191130 <1 mg/L 353.2 10/24/2025 CL
251024-16-01 Nitrite 191130 <0.1 mg/L 353.2 10/24/2025 CL
Respectfully submitted,
Melissa Myers
NC Cert
NCDW Cert#37755,
EPA#NC00909
PO Box 228 • Statesville,NC 28687 • 704/872/4697
Page 1 of 3
trr.ter,;
r
•
122 Court Street Statesville,NC 28677
704-872-4697 www.sa-nc.com • '
•
NITRATE/NUMITB ANALYSIS .
Ncu:fyj7 inf na$oa crust bent pU 1 tueor.91:L=a ca&.
WATERSYS3EMID WELL-.0 3-a0-3" 191.1 1 County: Catawba
Name of Water System: fli'`[:I,c,e-( �
Sample Type:•-•- 0 Entry Point ) 'Special/Non-compliance
Location Where Collected: aS23 C(.Arcv r4 (, NeW1-bh /1`e 286..'8
Facility ID No. Pi//3 a
Sample Point:' WGl'/ `7&ad� j1 Collection Date I, Collection Time
Collected By: )2W/sL.1- 1'1y 1. 1 _ /d /23 j2.S ' 12. L, P M
(NunPtiei) CalaDarrq ZS Eb Alcaeuq
Mail Results to(water system representative): .
CATAWBA COUNTY PUBLIC HEALTH Phonen:i,($28)465-8270
ENVIRONMENTAL HEALTH Fax#: !(828)465-8276
, PO BOX389 Responsible Person's email:
•EHAdmin@catawbacount-1.nc.gov
NEWTON,NC 28652
•
LABORATORY ID A': 37755 . 0 SAMPLE UNSATISFACTORY I]•RESAMPLE REQUIRED
• i
CONTAM •
• EEQIIIRED j�OT DETECTED QU.4NTlrtt t • ALLOWABLE
F CONTAMINANT CODE REPORTING LIMIT (.e.<RILL} R?SULTS' LIMIT CODE (R RL} (%}
, _..........�.,......—...._._....
1040 ' Nitrate 353.2 1.00 mg/L • ----- mglL 10.00 mg/L
1041 Nitrite 3532 0.10 rng/LX
----- mg/L 1.00 mg/L
*No :If result exceeds allowable limit;the laboratory must fax analytical results to the State on day test completed.
DATE: T.BME:
• r o 2 /25 2:S
i ANALYSES BEGUN: 4 .. __ . �i42
gmin �t =�5rr�z
; ANALYSES COMPLETED: �O /Z(-J /Z,S�. _ 3:14 2 Eifi
I accawrzt'— tao.'yst.rrn4•
1
Laboratory Log 4: .251 COQ • 1(8-0 I Certified By: 04z:L.
COMMENTS: '
ZOOS
Laboratory should Mail Results to: •
Public Water SupplySeaticn,Atct:Data Entry,1634 Mail Service Center,Raleigh,NC 27699-1634
PO Box 228 • Statesville,NC 28687 • 704/872/4697
Page 2 of 3