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A36 36� �►Rp1(catlon Dete- � ad -� � Amourrt Pald: � � t � #�� .. �a � :�,- - Pa ., S.�.o� -�� o o, �r, -�� Qr� . � . 3� �� ,57� �r.�ri `----._�_ � �]]�1C��1� � �.TN�'�'" �an...�:��.a�,�.��,.a, a�-�oc._.�.a.� l- �- . � • , ,.• ; :� � _�: !'� �%��-� t) PormR requ�sto� Owne prospeatlw �win�; � D�c�1� � t-� E'e.cQarm ��S . Hame Phone• •�`I �= 5 � Ad�ess• , 70 Busln Ph no: s - 3 03 Z� ' • -� . . . Nainsila�id �a5� � _ S g � 2 . ,.: � �. J �� n _ t+asa of aur�M ownor _ ��C � r � �� !n La�- , �. � 3� � Properh► D�cr�Ptton: Lof slze: ��,3 TawnahiP. ��8ubdhilabn:, ��" Lot ��1- Dlr�c�tona tn th� Pi�oPe�"�Y (Induding roa� names and�bers� . . _PJl�iub��. [a � � � ..�_ r_ �_ . _ .. . ... ._ 4) proposed Uaei��ure Descrlp�t[on: answerR �ch of fhe fotlowinp quea�ons: .. �/ aj Proposed ___, Existtng Type af 3truc�ure: 1� h Le.w � �� Oepth: �P D',.. b) Number of �edrooms: ,�' Number of occupents ar people to be aaved: �� c) 6as�nen� Yea_,, No ✓W�II there be pwmbing in the basament? N� ci) �rbaSe �isPosal: Yes . No 1/ . ;. t . ' . • . 5) Watsr SuPp�Y TYPe: Prlvate L/(ne�w �r eals�ng,��'Public,� Cammunity . 3prtn� _ Are any welts on adjolnlne property? Yee No ,�(f yes, ptease l�� a�prwdmato locatbci � the 'site plan. 8j Ooas yonr pr+opsr�y contaln pravfousiy td��d jurisdlctiooal vwetlar�ds? Y�s No V .. � P�ASE NOTE THE FOLLOWINa• � ,• •, � , � . ... , . , D A PU1T OF THE PROPERTY QR 9[� PLAN IIIUST BE SUBMI7TED WRH TH19 APPUCATION. ➢ PROPERIY L1NE8 AND CORI�ER3 �IyUg"I' gE C sLLARLY MARl�p. •, ' � THE PRQPOSED L�CATIOM OF ALL 8TRUCTURE.9 !IdlJST 8E 6TAKED OR F'LAGGED. D THE 9iTE 1�IUST BE READiLY ACCE3818LE FOR AN EYALlJAT10N BY THE�HEALTH DEAAR7MENT 3TA�F. I hereby make appltcatlon to the P�on CouMy Health Qepartment for a s�e �valustion iar the on-stte sewage dlsposat sysiem far iha �av�d� p�operty. 1 aQ�+ee that the cartteMa ot thta apppc�#lon ara true and represent the maxlmum faclliUes to be ced on th property. 1 ur�derstand if the alte ta altered ar tho Intended usa changes, the' permit shaU �m.....,.d.t.... .1 .. � or � 2 Date G� ' PqiD, rav. OBI27102 t/t ROALL609EE 411��H I*lu�wuo��nu3 �op uos��.� w.+ z�:en cnnzinrion May 22 09 02,25p Hamletttilennings � <� -1 2 S �+ N y N '�. / r i / � O p mma NO�z.. �,>� mo ' '" c �rn� N � � C = mN W� Z' 336 599 3019 / �� \ \ � � \ � C O N 'C S • C f1 > Z um � . �n 0 �o z A r � y Z '/r� L�£� y ,\ N , I N �" � � � � _ /�� _� /^' g�t�•�LS � �o 3i .jNf�O' y r � � N �9 yb •Yt p / � ' �' S N N N � �' � N �� ,90 /� m a 0 � ' \ • .n � I /' � � / " N � � O �C] / � �' oti � � W � �S � � = � �7 W j'� � " \ -P � 00 p,3 �� s f. ��.�� .,•' �� l l'� 7La�"II.7� ctD Si7L�]L cC�� 7t� �.�Il. � 1l Jl cC� �2SL �l'1�� Tax Map ! ►� Farcel # '' Su�bdivision Fhase Sect�ion Lot # Applicant: �a � Location: y L �,o� � Z L. -�-�5� Permit Valid for Type of Facility: . # of Occupants Lb' Proposed Wastew Proposed Repair: Owner or Legal l Authorized State Improvement Permit No Expiration ?�,�CP. New 'Addition � - // . • ' /l�': Date: � �'7 —� Date: � 2—�i' 'The issuance of this perxnit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewa,�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (�. � � Propos�ed% �astewater System: �Z (n„] ar �,��t�cn`-�"►'� Typei �ii Wastewater Flow , �.p.d. New V Repair E pansi n_ Soil LTA�: = g.p.d./ ft 2 Type of Facility: Pv�. �.Q, P 5► f)� P. P. �� R Basement _ Yes _ No Wastewater System Requirements Tai►k Size: Septic T�nk: dD gal Pump Tank: ~--'�al ' Grease Trap: `--�gal Drainfield• Total Area: �D sq ft Total Length 3d0 ft Maximum Trench Depth Z 7 in ' 7 � o, C'., Trench Width J f Minimum Soil Cover: �Q in Minimum Trench Separation: _�_ ft Distribution: V Distribution Box �Serial Distribution Pressure Manifold SpeciGcations: s� �' ��ct � o r �� Authorized State Agen Permit Expirati n Date: The type of system permitted is entional " Accepted permit. ��y-c Jl Owner/Legal Representative Date: (a - �-G`� Alternative. I accept the specifications of the Date: '' � � PCHD r v. 11/10/OS ' , • `��,,/� �� . . � f �` � � �� 1� �-.� u- � �.�..� m.�.11 1HC � � � Narne ��' � h ca v� Sub n � Authorized State Agent �ITE S)�ETC� Ta.z Map # A3� ,Par�e1 �3� Section/Lot# _ � 0 3-09 � Date . System camponents neprefent approxima�ra �contours o�ly: The con�ractor must fTisg the system prior to . beginriing the installrttion to f�sure that propergmde is mc�iratairied , ` __ y i � �1 = Y y N � /� ��\ 1 � \ ✓ \ / I \ \ oA mar mo N 0 rZ. o,ym mo � C �m� -d � q C = o� y� � y � y*•0� �� 6S� �� — I S s�eF� _ 1 n�{�a t - 31�� ,�,13 be� �P � — 360� /��e�� Q �-boX or Ser�'a � " �,1L„ �.ej�C6� hc�'�r�5 7 �Ji� ��b°K (Y1ltr�l�qrn Je,� � 1�'„e5 �.q,u.a� � j' -�Y � � � ` � _ \oo Q �`� (o' '__� Q ��A : 'S- �� ! `££ ,, � �"" o _� 0 � � �o� _ S �Z /' S�,L�'�VS � a o � � ;N = / i .. ._ �9 ,4 r,�,� . . w . �J u Z � yp• � tn W � N / ' � ' ' y � � / J � a /' o / � � ' ^ � Z � V�}''/7 . / � ' 1!1 / � ' 0 N N N / � V � 1 O�, V r � �1 �S / t .N.. , P� /V L/'� / ' m V � 00 SCiL� � I � � _ �e�� 0 , �� '��bJ � � � - Y � + � I �� -�� 1L.�0 li�dZJ%. � .�+ �'T"R"'1 fL.:. �ii. �c�l.� � �. �..1L�� J�e l°��irC�l� i� �� '� � � ��OGu ��:�o�� W � � ^ n a 0 3 . ,'�r�pficant: � . . Location: �a �e — o �, ao —� i Lo�- o L � �. �. :'` r -� � _ ' r � - it E �: � - - . S�fst�m Type (in Accordance 1Nith Table Va): �� r, THIS SYST�:1f1 F�AS �E��9 i�4�TALL�s7 lP� COI67I�Ll�� 1flltT�i �PP�ICA�LE .I�ORTH G'AROLIt�IA GE��§�L ST�TUT�S, �3UE.�S �OR Sc1�1tAG� TREAZiViE�(T ,3,�iD DISPOSAL, AND - ALL CO(V�ITIONS GF � T]-3E IiV��R�V�i�ENT PEi�fV11T �� CONSTRUCT1Qf� AIiTHO�St�,T �N. - � � . . . . Ce `�S —� � . P, orizAd State Agent Daie . Installed. By: � � � . Date: �- �S :� � ' � � a y'� /a 3'8 /z 2'�0 �ii�/t ` 10� . : ,. � �uSc l5'fa � rfc� ��rz . �c� � . � / p,D d�" CYA»� /,S 1 �,., Sqr� e �S � f' °r- �ji1 Gt rf? � r' =CHC�, 1'�v. G i 12�1'Q�� 0 ��G ��,s�� 9�e'�� i��s��..AS a �9��' �B � �� i ax NI�p ��3� Parcz! �� Sys�te:� Type (Table Va) C�,a,�, �� O�rr�e�,A�piicant � � Subdivision Address/Loc�tion SecfPhas� L�t # � ve��. ��r�� State �ID/date Ca aci — � Tee and Filier - Baffie Sealant Riser (ifi applicabie) Tank Outiet Sead � Permanent ii�ar�er i�u�ap T�nk ct�+o �a�+o _ Waterproof /Sealan# Riser Water Tight � . � � P�am� Che�ic VaivelG2te Vaive �farm visahle and audi�ie Electrical Components Rate ( m A rove� Pum iVioded Bloc� Under Pum - Pum Remova! �Rope/Cnain . �D'as�vH�aa�aon:Sy��an � Serial Distribution �ressure f�an�roa Low Pressure Pi e A r. �ip� Niate�iai and Grad� , .-�- -_- .. �� o�¢�a�ac�a�oca �� - � re�cfi Wid'fh � �. � Trenct� Dep�h �, in. Tre�ci� Lenaih � �t. � Tre�cfi G�ade � Tre�cf� S ac�n � Roc�C De th and Quali � Da�nslSf� dovvr�� etc. Pressure Laterals � Hole Soacina � Pi�e. Sieave T�m-upslProte�tors F��qui�d' Se�a�� From� We!!s � " �rom Prape9iy lines � Structures/�asamenis � � �tc, es / ramage W.�ys Sur#ace Waters Public V1later Suppiies Ve�icai Cuis (>Z ft.) 1lt0ater Lin�s Ve�iicle �Tr�ffic � � � • �EasementslRi ht of V�l . Other -�s- Easemenis Recard�d e � e perator on Tri-Partate A�re��nent Cr��as�en� 0 �c:�d ��. 31i 31C1 � ��;�, S� � l� ��.� � � l � : �.� �; � � �� I�'..�:�.��:m-�.�-�� .�.11 �'�C � �.1-�I�. ��I��,� �� 1�/1Ii'T (ii�e•av_�e�a�� : A � � ��L�: 3 � �uiIl�D(,�3�flSnmE1: �tD$: ��Ilc��'s 1�``1��e: l� rna �un�ar� l�i��i�an� Ad��ess: " �'E�on� i'�daaffia�es-�: �.�c��io�a o� u L aK� Lo3� Q�I -�-� Lo-F a h��`�"��7�3 ��at �o��: �� c� N� ��.� 1� See attached siie plan for p�oposed tivell location. L� "i� 2� All cr�plicable State and Coatnty �e�nrlatians governing constrzcction and setbacks a�ply.� 3� �ernzits e�pipe s years from the date of issue. �t3asr C',�ndi8avn�/��aaa�aen8s: irt(11 Q[r1 � S�-' ^ c,C ��r�an� ;s§a�ed k�?�: �a��e: � - � —D'� �� g��n�a�: Location: Grouting: Well Log: . Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: ��'��C��'� �� i�l��+ �� EHS/Date Z "D� �.,aa�� i�5��o�n: EHS/Date Installer: Depth: Grout: ��1� A��d��a�e�a�: EHS/Date �Completed: 1Vlethod/Nlaterial(s}: _ ��1 ��i�9e�: �QfnB� Pump Installer: , � ��fl �p�r��e� Date S2anp�e Colleci�d: FS' y�b� /� %3' °e:son C�unt�� Enviro:unental i�ealth =�� S. l�Ioro-an St.; Suite C Roxboro. NC �7573 �a�� #: .32l� 7 i,icense#: � /r Date R esults Mailed: Phone: 335-�97-1790 r�t: .30-�97-7303 8/1/08 � t North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section BIOLOGICAL ANALYSIS REPORT Private well water information and recommendations County: -�fb� Name: �� Sample Id-Number: �/ �%� Location: Reviewer ��"`il' Your well water was tested for biological contaminants (total coliform and fecal coliform bacteria). The results were evaluated using the federal drinking water standazds. � 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 aze found in animal and human waste. Total colifortn or fecal coliform bacteria in well water indicate that the well may have structural problems or that the well was not properly disinfected. BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR P ATE WELL WATER (These recommendations are based on biological analysis onl . No coliform bacteria were found in your�well water. Your watar can be used for drinking, cooking, washing dishes, bathing and showering. Total coliform attd/or fecal coliform bacteria were detected in the sample which indicates that harmful bacteria &om human or animal waste could enter the well. Do not use the water for drinking, cooking, washing dishes, bathing or showering unless you boil it for at least one minute. 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 physictan of these results at your next visi� There may be a problem with the construction of the well, the goundwater 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. You should re-sample your water after proper well inspection and disinfection to make sure that the problem does not continue. If the contanunation 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. Contact your local health department for more informatlop or go to htta://www.eai.state.nc/eai/oii/hsfactsheet.html. March 10, 2009 Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES080509-0006001 � �� ES Microbiology ID: 7845 GPS Number: Sample Description: Comment: Name of System: Perry Duncan P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://sloh.state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 913 Chub Lake Loop Rd Col lected: 08/04/2009 11:30 Received: 08/05/2009 08:26 Sample Source: New Well Sampling Point: Well head J Smith Angela Heybroek Well Permit Number: A36-36 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 08/O6/2009 E. coli, Colilert Absent � ° Susan Beasley 08/06/2009 Report Date: 08/07/2009 .... Reported By: Susan Beasley � Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. . . . . Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits� 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits �ron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 � North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section INORGA1vIC CHENIICAL ANALYSIS REPORT � Prtvate weA water information and recommendations County: ��°�' Name: ,�)i�'� � k Sample Id Number: 9 3'Z3 .3 Location• Reviewer �'�"1� ANALYSIS REPORT Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinking wat�r standards. The pH is a measure of the acidity of the water. Drinking water may cont ' substances that can occur naturally in water or can be introduced into the water from man-made sour es. (These recommendations are based on inorganic chemical analysis onlv.) TEST RESULTS AND USE RECONIMENDATION5 Your well water meets federal drinking water standazds. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering, but aesthetic pmblems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatrnent system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride Iron Maneanese Selenium Silver Sodium Zinc The following substance(s) exceeded federal drinking water standards: We recommend that your well water not be used for drinkin� or cookin�, unless you install a water treatrnent system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing, and showering. Arsenic Barium Cadmium Chromium � Copper � Fluoride � Lead � Iron ManQanese Mer�curv Nitrate/Nitrite Selenium Silver Sodium Zinc _ pH Re-sampling is recommended in months. Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. Contact your local health department for re-sampling assistance. OTHER CONSIDERATIONS Routine well water sampling for the above substances is recommended every two to three years. 5ample your well water when there is a known problem or contamination in your area, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. Contact your local health department for more lnfortnatlon or go to htta•//www eal state ndepUoii/hsfactshee�htmi March 10, 2009 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM ,_._. Name of System: Duncan, Perry _, =:::�r� "�.� .% Source of Water: Address: 913 Chub Lake Loop Rd "� � Source of Sample: Zip: r ��09 C, ��"� �� Type of Sample: F Count : PERSON "� Y - �� Type of Treatment: Report To: Person Co. Health Dept. ATTN� Type of Analysis Private 325 South Morgan Street Ste C (336) 597-2371 Roxboro, NC 27573 Courier: 02-33-15 Collected By: J SMITH Date: 8/4/2009 Time: 11:30:00 AM Location of sampling point: Well head Remarks: Permit # A36-36. Parameters Results Units Date Analyzed: Silver <0.05 mg/I ` 8/5/2009 Alkalinity as CaCO3 95 mg/I 8/5/2009 '` Arsenic <0.005 mg/I 8/5/2009 Barium <0.1 mg/I 8/5/2009 Calcium 23.9 mg/I 8/5/2009 Cadmium <0.001 mg/I 8/5/2009 Chloride IC 26 mg/I 8/5/2009 Ch rom i u m <0.01 m g/I 8/5/2009 Copper <0.05 mg/I 8/5/2009 Fluoride <0.20 mg/I 8/5/2009 I ron <0.10 m g/I 8/5/2009 Hardness as CaCO3 (Ca,Mg) 102 mg/I 8/5/2009 Mercury <0.0005 mg/I 8/5/2009 Magnesium 10.2 mg/I 8/5/2009 Manganese <0.03 mg/I 8/5/2009 Sodium 12 mg/I 8/5/2009 Nitrite as N <0.10 mg/I 8/5/2009 Nitrate as N 1.23 mg/I 8/5/2009 Lead <0.005 mg/I 8/5/2009 pH 6.5 Std. units 8/5/2009 Selenium <0.005 mg/I 8/5/2009 Sulfate <5.0 mg/I 8/5/2009 Zi nc 2.97 m g/I 8/5/2009 Date Received: 8/5/2009 Report Date: 8/21/2009 Reported By: Today's Date: 8/21/2009 Ref: 10950 Login Batch �g��p��, '��; Sample Number: A693233 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 Jun 15 09 02:02p Keith L. Barnette 336-598-9275 TO'�.Y' ''� � �' R' � . �u.r�L i f . � RES.�DENTXAL «`I.LL CO3VSTRUCTIOLY i2ECpRU North Caroli�a Dcpamnent of Environmeni and Nat�{ Ruoucca- Divisi<m af �4a�er Qiralii; ♦t'EE,L C�N`CRACTOR CERTTFECAI'!ON it i. WELLCOMRAC3oR: T�c�„�IS Qa��.c N� wes ca,cr�« ��aMa�� N� - Bametbe Well Driliing Inc. Wel! Co�tractor Comparry Name STREET ADORESS 611 Bamette Tingen Rd. Roxboro NC 27574 Cityo►Tawn Siate �v� � 336 �_ sss-�a15 Area oo4e- Pnone �umder 2 W£LL1PfFaRMATfON: SiTE W�l[. tD R{if applicahle) N/A STATEWEiLPERM1iA�(dapp6cabte� N/a DWQ or OTHER PERMIT S('d applicable) NIA wEc.1 use �cr,eck �►pPr�we ao�: ��a�,aa� wac�r suapty p� QATE ORt(.LED �j' //S' � � TItN E COM PL�TED I�� AM ❑ PM [� 3. V1fEL1L0 Tl N: . �}� crnr: �o � courrsY Y�'S � � �[� b �-�ft4 f LPi �—eD r•P � (S�eee t�anse, ��. Cocmtun4y.�.ision. la i:o., Paccel, bA �N raPo�wwHtc r v,r� s��uG: a� ov�r � n�se ❑ou,� (d�eck aPWopiale 6ox) . �3 � � �� iAT17UaE 3 _ ��s« L�NGTi1J�E in adcciaul farmsc i.atitude/tongitude soiace_ QGPS pTopographic map (bcalion of we8 mast be shox+n on a USGS lopo map and attached to Ciis larm inot us;ng GPSj 4. WE1L OWNER OWNER'S NAME ✓�' G,, l STR�T ADD�2ESS _��Lu l�=A� �O�D �A K,��o�� /1/_ C- 2?�'�„� Cily a ToKm �'Slate Zip i',ade L.�.3� 5"� `7 .� 5 S � � Area code - Phane numl�et 5_ WEI.L AETAILS_ � a 7U7AL DEPTH= • b. OQES WELl. REPLACE EX(ST1NG WF_LL? YES ❑ NO k� c. WATER LEVQ B�t7op af Casirty- 25 F7'- (Use -t• if Aba� Yap pF Casin9) d. 7QP l)F CASING IS _ �.� F7'. Abwe Lacd Surface' F 'Top of tasing Lecminated aVor belaw land surface may requite a rasiance in acardanoe with 15A h1CAC 2C .011 B. e. YfElO (9Pm): � METFlQD OF TES'f B�OW 20 1'lllft � p,1 L OLSItdFEGTlON: I'ypa HTH Amount_ .25 Cup g. WATER ZONES (deptli): From�_ To 1�1 � From Ta Frar�,y ro� From io From� �s Ta L$� From To 6. CASING: Thitknc.•ss/ Oeplh Diame{er YJeig1�! i�Aateria{ Fram O To�_Ft.�,�_ .189 Galv From io FL From To Ft. 7. GROUT: Pepth MaEetia{ Method From D To Z 7 Fc Gravel/Cement Paured From To Ft Fran % Ft. 8. SCREEN: De�th Orameler Sbol Size Material Fram �o F� in_ icL �fAFrom To F4 in, in. From Ta Fl in_ in. 9. SAhI01GRAYEI_ PACtC: Depth Size Material From To �t. N f�rom To FL Fram To Ft t0. OR1LU(VG LOG � m 3 F� tion Oescription ZU � � i 1. REMARKS: � no r+ew�sv c�n�v nwr ��s wEi� wns coNsrauc�o re wc��wce nmM 15A NCJ1C 2C, WELLCAN57RUC110N STNJDAROS. WJA iHAT4 COPY OF i1i1S k�eoan w�s se� �xovnEo ro're� w�u_owr�. .��- � 6-��~�'� SIGNATURE OF CERTlFiED WEEl CONTRACTOit flATE 1 ��4 �.n �. �- P�NAME dF P�RSON CONSTRUCTiNG TNE W�IL S�shcnit the arigihal to the Oivision of Water �uatity witEiin 30 days. Atfn: lnfocmation Mgt... F� �� '16'17 fiAaii Senrice Center — Raleigh� NC 27fi99-16'17 Phaae No. (919) T33-7�15 ext 568. Rev 7ro5