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A35 105• Person County Heaith Department Sewage System Improvements Permit Date: �� ^ �Z This Permi Void Af r 5 Years Pennit # pwn@r� Gi Wo �— SR# Lvcation/Directio . - - /3�� Subdivision Name: Lot Size: �' Type of Dwelling: Water Supply: Private: Public: Bedrooms: �_ Garbage Disposal Basement Basement F' s INFORMATJ,P�1 Ck'�tTI�IED BY _ . owner or REPAIR: `" 1 '- REEVA�,UATION: Lot # Community: Size of Septic Tank: ./Dl�D gall� s Si/ze of Pump Tank: Niiritication Line: � i�3 Depth of Stone: 12 inch�es � r • Max Depth of Trenches: Altemative System: Conv. Pamp LPP Pump Remazks: ------------------------- Date Well Approved: �� Well should be 100 R from any sewer system BY � Sanitarian Date S ge ys pprov : - BY Sanitarian CERTIFICATE OF COMPLETION Contractor. �� N• �.Q.. � ; c Sewage System location, installadon, and protection must meet state and local reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S.130 A-335F) � Z � L,ocarion of sewage disposal sewage system sketched on back. � � s �ovEx� v\ W �e � b � � SJ� � � � Person County Health �epartment Weil Permit Date: �-/-9�-This Permit Void After 3 Years �y.,�... Owner. ..a-�tV �dQ d S�, �r P . y_ SR# l��s LocadonNirecdons: � � � 3 2 Subdivision Name: ' ��— Drilling Contractor. WR�.1, c'ONS'i'RUCi'ION Distance fmm Nearest Pmperty Line Distance from Source of Pollution } Tatal Depth: Ft Yield: �� GPM Static Water L.evel F� Water Bearing Zones: Deptt� FG F�� Casing: Depth: From U to F� Diam� Inches TYPE: Steel Galvanized Steel If Stetl, does owner approve: � No �ye�g}1G Thiclrness: Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered ir► Setting the Casing? Yes No If "yes" give reason: Grout Type: Neat S emeat Concrete Annular Space Width Inches Watet in Armulaz Space: Yes No ✓ Method: Pumped Poured Depth: From � co Fc Materials Used: No. Bags Portland Cement Weight of 1 bag Ibs. If mizture (sand, grav �tdngs) - Ratio: to ID Plates: Yes No 4 z 4 slab Yes � No z � � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT THIS WELL WAS CONSTRIJCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY EP . (� �q qZ Si f C �actor ate � z7 yz Sanitarians Sien e Date Issued Sanitarian's Signature Date Complete3 Sketch well location on reverse side. _. � �� . � l � ''�.r+'ti ,� � � � � � .6� 'i � � �JS...d�.�v.�i°��L�k.�.�'i7��L�ai�i.� � ,�r''4�.�14�7LJ1 �uild'ang Additions/ Mobile �ome Replacements Tax Map #:��-� Approval Requested for: Parcel#: Mobile Home Replacement — 1� Building Addition ,Q�IP Applicant Name: /►f �f%9-�� Address: " /?4d �cL-rrf��s �L_/ /�c� Phone #'s: ,i � � Pernut Located: � Yes No Installation Date: Design �flow: 3 (oo (gpd) Current Contract with Certified Operator on file (if required): ��_ Water Supply: ✓ Well � Public or Coxnmunity Wastewatex system shows no visual evidence of failure on: � (date) (Applicant's signature if site visit is not required) �� •u ' � .�ii, / / i i .. / f 1'!i � �' , � Additio�eplacem�nt Approved Environment H a1 ecialist 11/15/OS � Date Pat McCrory Governor ,/ ,��.s� 3 � - I 6 � ��r�� .�.�.r � /� 's� o� ��_ 5�� NCDENR � North Carolina Department of Environment and Natural Resources Division of Waste Management Donaltl R. van der Vaart Secretary September 1, 2015 Peggy McDaniel 1790 McGhees Mill Road Roxboro, NC 27574 RE: Water Supply Well Sampling Results — Country Club Road (NCN000410375) 192 Country Club Road — Well ID QG 16010-005 Roxboro, NC 27574 Dear Ms. McDaniel: Please find attached the Sample Analytical Results for a water sample collected from your well located at the address referenced above, on July 15, 2015. The sample was submitted for laboratory analyses for Volatile Organic Compounds (VOCs). VOCs were detected in the water sample as shown on the attached sheets. Because one or more contaminants were detected in the water sample, a Health Risk Evaluation (HRE) of the water supply was performed by our toxicologist. The HRE, which is enclosed, compares the concentration of detected contaminants to acceptable concentrations and provides a recommendation for acceptable uses of the water. Our records indicate you had previously declined and offer made by the Environmental Protection Agency (EPA) to install a carbon filter system to treat the contaminated water from your drinking water well. NCDENR would like to extend the offer to have a filter system installed. Should you wish to reconsider the offer for a filter, please contact me at Vincent.Antrilli(a),ncdenr.gov or (919) 707- 8353. If you have any questions regarding the Health Risk Evaluation, please contact Hanna Assefa at (919) 707-8351 or me at (919) 707-8353. Sincerely, Vincent Antrilli, Jr. Environmental Specialist Inactive Hazardous Sites Branch Superfund Section Enclosure CC: Person County Health Department 1646 Mail Service Center, Raleigh, North Carolina 27699-1646 Phone: 919-707-82001 Internet: http://portal.ncdenr.orglweb/wm An Equal Opporlunity 1 Affirmative Action Employer — Made in arl with Recycled Paper t :- ,�,,,.- August 31, 2015 , �. , •- " '" MEMORANDUM TO: Vince Antrilli Inactive Hazardous Sites Branch Superfund Section FROM: Hanna Assefa, Industrial Hygiene Consultal�'� Inactive Hazardous Sites Branch Superfund Section RE: Health Risk Evaluation Country Club Lane Site 192 Country Club Road Roxboro, Person County NCN000410375 A water sample was collected from the subject well on July 15, 2015. The concentration of tetrachloroethene detected in the well water exceeds applicable standards. The standards used to determine if the water is suitable for drinking and cooking are the federal drinking water standards (USEPA MCL), or where there is no MCL, the health based North Carolina Groundwater Quality Standard (15A NCAC 2L)/ Interim Standard (IMAC). If the USEPA MCL and health- based North Carolina 2L/IMAC are not available, a health-based concentration is calculated. If contaminant concentrations exceed the applicable standards for using the water for drinking and cooking, the contaminant concentrations are further analyzed to determine if the water is suitable for other household uses, such as showering, bathing, washing dishes, flushing toilets, and hand washing. Therefore, based on this evaluation, the water from this well is not recommended for drinking and cooking. The water from this well can be used for all other purposes listed above. The table below compares detected contaminant concentrations with the applicable standards: US EPA Calculated Concentration NC 2L Health Based Sample # Contaminant �ug/L� �M�� ug/I,� Concentration (ug/1) QG16010-005 Cis-1,2-Dichloroethene 0.91 70 ** ** Tetrachloroethene 9.1 5 ** ** Trichloroethene 0.65 5 ** ** ** Not Applicable ug/L= Micrograms of contaminant per liter of water. � Volatile Organic Compounds by GC/MS Client:NCDENR - DWM - DSCA Laboratory ID:QG16010-005 Description: 192 COUNTRY Matrix: Aqueous Date Sampled:07N5/2015 0953 Date Received:07/16/2015 Run Prep Method Analytical Method Dilution Analysis Date Analyst Prep Date Batch 2 5030B 8260B 1 07/21/2015 0359 JJG 80161 CAS Analytical Parameter Number Method Result Q PQL Units Run Acetone 67-64-1 82606 ND 10 ug/L 2 Benzene 71-43-2 82606 ND 0.50 ug/L 2 Bromodichloromethane 75-27-4 82606 ND 0.50 ug/L 2 Bromoform 75-25-2 82606 ND 0.50 ug/L 2 Bromomethane (Methyl bromide) 74-83-9 8260B ND 0.50 ug/L 2 2-Butanone (MEK) 78-93-3 8260B ND 10 uglL 2 Carbon disulfide 75-15-0 82606 ND 0.50 ug/L 2 Carbon tetrach�oride 56-23-5 82606 ND 0.50 ug/L 2 Chlorobenzene 108-90-7 8260B ND 0.50 ug/L 2 Chloroethane 75-00-3 8260B ND 0.50 ug/L 2 Chloroform 67-66-3 8260B ND 0.50 ug/L 2 Chloromethane (Methyl chloride) 74-87-3 8260B ND 0.50 ug/L 2 Cyclohexane 110-82-7 8260B ND 0.50 ug/L 2 1,2-Dibromo-3-chloropropane (DBCP) 96-12-8 82606 ND 0.50 ug/L 2 Dibromochtoromethane 124-48-1 8260B ND 0.50 ug/L 2 1,2-Dibromoethane (EDB) 106-93-4 82606 ND 0.50 ug/L 2 1,3-Dichlorobenzene 541-73-1 8260B ND 0.50 ug/L 2 1,2-Dichiorobenzene 95-50-1 8260B ND 0.50 ug/L 2 1,4-Dichlorobenzene 106-46-7 8260B ND 0.50 ug/L 2 Dichlorodifluoromethane 75-71-8 82606 ND 0.50 ug/L 2 1,1-Dichloroethane 75-34-3 8260B ND 0.50 ug/L 2 1,2-Dichloroethane 107-06-2 8260B ND 0.50 ug/L 2 trans-1,2-Dichloroethene 156-60-5 8260B ND 0.50 ug/L 2 1,1-Dichioroethene 75-35-4 8260B ND 0.50 ug/L 2 cis-1,2-Dichloroethene 156-59-2 82606 0.97 0.50 uglL 2 1,2-Dichloropropane 78-87-5 8260B ND 0.50 ug/L 2 Vans-1,3-Dichloropropene 10061-02-6 8260B ND 0.50 ug/L 2 cis-1,3-Dichloropropene 10061-01-5 8260B ND 0.50 ug/L 2 Ethylbenzene 100-41-4 8260B ND 0.50 ug/L 2 2-Hexanone 591-78-6 8260B ND 10 ug/L 2 Isopropylbenzene 98-82-8 82606 ND 0.50 ug/L 2 Methyl acetate 79-20-9 82606 ND 1.0 ug/L 2 Methyl tertiary butyl ether (MTBE) 1634-04-4 82606 ND 0.50 ug/L 2 4-Methyl-2-pentanone 108-10-1 8260B ND 10 ug/L 2 Methyicyclohexane 108-87-2 82606 ND 5.0 ug/L 2 Methy�ene chloride 75-09-2 8260B ND 0.50 ug/L 2 Styrene 100-42-5 8260B ND 0.50 ug/L 2 1,1,2,2-Tetrachloroethane 79-34-5 82608 ND 0.50 ug/L 2 Tetrachloroethene 127-18-4 8260B 9.1 0.50 ug/L 2 Toluene 108-88-3 8260B ND 0.50 ug/L 2 1,1,2-Trichloro-1,2,2-Trifluoroethane 76-13-1 82606 ND 0.50 ug/L 2 1,2,4-Trichlorobenzene 120-82-1 8260B ND 0.50 ug/L 2 1,1,1-Trichloroethane 71-55-6 82606 ND 0.50 ug/L 2 1,1,2-Trichloroethane 79-00-5 82606 ND 0.50 ug/L 2 P�L = Practical quanlilation limit B= Delected in the method blank E= Quantitalion of compound exceeded the calibration range H= Out of holding time ND = Not detected at or above the PQL J= Estimaled result < PQL and > MDL P= The RPD between two GC columns exceeds 40 % N= Recovery is out of criteria Where applicable, all soil sample analysis are reported on a dry weight basis unless flagged with a'W' Shealy Environmental Services, lnc. Page: 13 of 55 106 Vantage Point Drive West Columbia, SC 29172 (803) 791-9700 Fax (803) 791-9111 www.shealylab.com Volatile Organic Compounds by GC/MS Client:NCDENR - DWM - DSCA Laboratory ID:QG16010-005 Description: 192 COUNTRY Matrix: Aqueous Date Sampled:07N5/2015 0953 Date Received:0711612015 Run Prep Method Analytical Method Dilution Analysis Date Analyst Prep Date Batch 2 50306 82606 1 07/21/2015 0359 JJG 80161 CAS Analytical Parameter Number Method Result Q PQL Units Run Trichloroethene 79-01-6 8260B 0.65 0.50 ug/L 2 Trichlorofluoromethane 75-69-4 8260B ND 0.50 ug/L 2 Vinyl chloride 75-01-4 82606 ND 0.50 uglL 2 Xylenes (total) 1330-20-7 82606 ND 0.50 ug/L 2 Run 2 Acceptance Surrogate Q °/, Recovery Limits 1,2-Dichloroethane-d4 96 70-130 Bromofluorobenzene 94 70-130 Toluene-d8 106 70-130 PQL = Practical quantitation limit B= Detected in the method blank E= Quantitation of compound exceeded the calibration renge H= Out of holding time ND = Not detected at or above the PQL J= Estimated result < P�L and > MDL P= The RPD between two GC columns exceeds 40 % N= Recovery is out of criteria Where applicable, all soil sample analysis are reported on a dry weight basis uniess flagged with a"W" Shealy Environmentai Services, Inc. Page: 14 of 55 106 Vantage Point Drive West Columbia, SC 29172 (803) 791-9700 Fax (803) 791-9111 www.shealylab.com M PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant I � �d '`.�1 L L�� 5 Coun � � `�� Address + � t3' �� 1 � " � , Collected By_�,� ' � � Date Collected � � / �`a'" �� Time Collected_ Source: Well ❑ Spring ❑ Other Location: ❑ House Tap ❑Well Tap ther o Charge ❑Charge �'`r '' � � �`"`� �J 7'�S� �e _ �/''�- S�0 � � � �*��*�**��,�**��*��**��*�*��*�*��*��*��**��*�*��***��**�*�*��*�**��**��**� **��**��*��*��*��*��*��**��*�*��*�*��**��***��**�***��*�� Results Total Coliform FecaVE. Coli Present � ❑■ Reported By :�- bactreport Absent �