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A36 12!�: ���i?3� �' �c°. � � - ,. � � fi �-%G�':� �2T�:o % � O O ^4��'t',"s�a �o �'� ��....--�-�--- � � . _ � � �� aQP ����� e �} ��r���a "���= ��,.; �f � i �- :d� � ���n� i+Isn�: �oL� �� �� (warki A.ddras� �n �S � :`r�:1�,n.�, �r� � � r � � S� �r �� n,. t "'. ��itTs���s �� F�i�e a..� �d��s a��L g� (� �'�� �� = _ Phon� i�� ' � � ci�ress: ` `� �c , - , n � �o�s Lo� Si�e:..,.. � .,.--�u�dF,�isio,�: ; �_o�s���� i� �dd�e�s andlardire�ia�.s� �P�'= (� yes Ei t�a sJ�� u,� z,�....N......_ � y— �tasie�t�rs�stems? G{ yes � ao Daes �e sit� �oma�� �� �rat�d aa �� 5it� oth�r ma� i g�es II r�o Is �.y r-rasr�va�r � �{ y� II no Isthe �ite s�wje�m approv�i bY �.Y �t�rpub�ic a�n��2 p pes II[to Ai? t�i8F8 ffi13� ��ID� 4FYI� � u' � OII �U5 ��. C���' is �h�r.ked, pleas� P�i'id� suppo� docum.e�) ' `�'�� �.a� t���' � � ���'F3�i."K.L'�.� ��.l�� �� � J e . p��s#ee��l ��� ntua�y�r a� b�aom5: — t7 i�Iet�r �inale Fam3�Y R�s�d�c� � ���; �� �Er or"bedmor� C� �:cnansion �r"��' 'n� �� Witl t�ierab� a6a�eme�T �1 y� fln� �! CI Repa�rt�o ivt_�If�nc�iorim� SY� [3Tvo� �.�de��A_= ± �,j Sc�ttar� #flof'a; lypC 4��,BS-�S: !Y�lU� IIiaui�e� '1\�m"'-'-'='stri Sli�2�� ��••`Y�"y�' ,.w n-_ Q rTe�+r tveil II E�sring �eII II Cflsr-aun�Y �iei1 1'�' Fubli �� �ta�e� ��.�� _�- t�..��ere a�y����elIS= s�i�n�: 4r ��'ts�n$��teriin�s on� S ���..�� � �*���7 �"�e�����-=��� �} �� a��t��� �€r- � � C.i o�r — � Car��►ect�ional II Accepted II T�m.avative II Ai�r�a�� ,i cer�y Flzat tke above ir campi.de �I c�rec� 1�rlso �e !y atte�d, or �he �Ye�ded �� ct�ut�s, atf �.�, _ � _ ��p��tiac�et����� . ��� �..�� �� e'�°� � �c�� a�' �� ��a���g����? � „ � s?��� '0?t iiirss"'i 2��g3 "�'%3 .�is"�.� `-+'_���� �Fl� g a3s +� �— ..���3 �R o.oa dr�ao 00 --_------- � ___.- �6' �.. � n,�-tr ; s��� �:�� � �,�° � � . i �it � u��'.; i3i� : i! � ±i ; af BniicIi�� ____:_ i sG�8�5' i i i; 1�iT2bs Q Sp� . L�-�`"�' �C� Tax Map: � Subdivision: ���.sf ���.��� �--�- � � ���� ��ca.�-a�c-�aa�rnao�ra�am.�. ����fl�Ila Parcel: � WELL PERNIIT (New_ Repair� Applicant's Name: I�q►,�Q u.�,� nr► Mailing Address: L p, � X�noro nlc �7s y Phone Numbers: 33t �- 59q - roA 4 5 Location of 7 Lot: 7 Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years frotn the date of issue. 4.) Issuance of a permit does not guarcrr�te a potable water supply Other Conditions/Comments: �� rn, r-�� -�r, ,'�� s�, lI l i h r� r Permit issued �Tew WeU: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Date: �1�2� /S Certificate of Completion J �lLiner: EHS/Dat Depth: 0� � �_ Z�t _� S Grout: 5 Well Driller: � ,� ; •Zar�S Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C o..,.ti�.� n�r ��c�a DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 „hcN, I'1:LtSUN (:l):ifV'I`Y ►:NV11tUNMl:N'I'Al, III:AI.'l'll WELL LOG . Date:�1� �.1qW6 � Owner: T�C�l�S� �' �� E �)l:.l� TO�J � SR# Location/Directions: Subdivision Nzmc: , � Lot # Drilling Contractor: kiN K1►J E�i tu..l �MSOjJ .'ttilG. _____ WEL.L CONSTRUC'I'ION Distancc from Ncarest Property Linc Distance from Sourcc of Pollution Total.Dep.th:_ Ft. Yield: 6 GPM Static Water Level Ft. Water Bearing Zones: De th � Ft. F� Ft. �t. Casing: Depth: From�to��Ft. Diameter: � Inches TYPE: Steel � Galvanized Steel ✓ If Steel, does owner approve: Yes No Weight: Thickness: . i� Height Above Ground: Inches Drive Shoe: Yes No . Were Problems Encountered in Setting the Casing? Yes No I: "ycs" givc :•cason: Grout: Type: Neat Sand/Cement Concrete Arulular Space Width 12 Inches Water in Annular Space: Yes No Method: Pumped Pressure Foured Depth: From � to � Ft. Materials Used: No. Bags Portland Cement If mixture (sand, gravel, cuttings) - Ratio: ID Plates: Yes ✓ No � 4 x 4 slab Yes�—No ✓ Weight of .1 bag_lbs. to I HEREBY CERTIFY THAT THE ABOVE INFORM�'I'ION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. . . .. � -Z3- Signature of Contrac : Datc