The URL can be used to link to this page

A27 4Application Date: J—�3 � �� S (� �� Amount Paid: �Dd . � �27 � •—.-•'' �J Receipt #: �3 4 79 f � � �� nn�nn-aDaa.mrae�m.9:.�.� )�ao�m..��:�a. tion for Services Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600�pd) ❑ 111obile Home Replacement or Bnilding Addition $ISO.U� (if site visit re uired} V Well Pcrmit (New�Re acement/Repair) $300.00/�200.00/$�5.00 Tax Map: � � � Parcel#: —� .� y ��¢1� � �� ❑ Construction Authorization (Fee is depenaent on the type of system permitted) ❑ Perniit Revisidn �75.00 ❑ Repair of �xisting Septic System flpplication: No Charge/ CA $150.00 or $300.00 1� Applicant Info mation: Name: Phone (home): �jc%'7 — J �i� Address: ', (work/cell): -r'�'x3 — ��_ 2) Name and addr�ss of current owner (if different than applicant): Name: Address: Phone: 3) Property Descriptiou: Lot Size: Subdivision: Lot #: flddress andior directions to Pro erty: � 5 � � �� .— p I� . G�--Q ❑ yes � no Does the sitz contai any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ y�s ❑ no Is any wastewate: going to be generate� on'_h,: site �ther than dom;,siic. s:,wage? ❑ yes ❑ nu Is the site suhject to approval by any other public agency? L7 yes ❑ no Are there any easements or rigrt of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Propased Use and Type of Structure: C]Residentia! ,r� ❑ New Singie Family Residence Maximum number of bedrooms: "�'' ❑ Ea:par�s;�m of Existing System If expansion: Current number uf bedroems: ❑;tepair to Malfunctioning System Wil] there be a basement? ❑ yes Q�o With plumbing fi�ctures? ❑ yes 0 no ❑Non-Residential I'ype of business: Maximurri number of employees: Total Square footage of Building: Maacimum number of seats: �) Water Supply: I�'New well CI Existing Well ❑ Community wjell ❑ Public V4'ater ❑ Spring Are there any esisting wells, springs, er existing v✓aterlines on this prope:ty`? �yes Cl no 6) If applying for `Authoriaation to Construct', please indicate preferred system type(s): ❑ C:onventional ❑ �A�cepted ❑ Innovative ❑ l.lternative ❑ Other ❑ Any I certify th�t the information pravided above is cofnplete and correct. 1 also understand that � the. ir�fof�mation providecl is inaccurcrte, or if the site is sz�bsequesztly altered, or the intended use changes, all permits artd a�provals shall be invali�l �� /� Signature (Owner/ Leg Representative�) D te * Supparting documentation required. Peruiits are valid for either 60 months or are non-Qxgiring when accompanied by an approved plat. A completed `Lot Preparatinn' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . ��, s � 1�'I�I�.� ��T �� lEna.vfisca�an.s�m.��.�.m.71� lE-��e.m11�7En, . SITE PLAN Name ��IDI 'OAKI.�V Tax Map #-�2 Parcd #�_ Subdiirisij�n Section/Lot . ,��a_1C. 'S iy � Authorized State Agent Dste Sysrem componenu repruent app�axrmate contorus on/y. The eoneracmrmust}lag t6e sysrem pda� to begfnnir.g rhe iasrallaaon m Instue tJrzepmpergt�deismaaotaiaed �S�Prlc.'t-A�eS,k �: �an+ai� ��K�� ,. , _ . ..: _. waAS �l�A��o�.11D w a . :��` : .. _ __ . _ .. .. _ , � W��.E �v�bs . �' ._ :�� ',�} . _ : . �,. - � . �. . �� _ v�- „ . .. . ��; _ � � Goci�. � ;/ 1 . v �a � � r(•• � �A� � � � . ,. I � . ,� � y.. : _ ��I ; '� _ ; . �: ; :� ��,jiy � i �; � _ .� �I � , l,�Q'r` o� -�_ �is-ct�� _ �'� �: ��- �,,�� . �,�''�s'A�` . � ' ° �� ,,� `��j " �,�`c.� :,. � ' R. L►`� �►�s . .. �.- >zs `'� �;�� ; _.... , � -..:. . cSd. �.-�--:-, _ . .. - j s'�c1a' . i�--� �a� :: � . . . -~'�4-� � �:1 . : �, : .: Ft�k4� �"! � ' : . .. : , .. .... ..'�1��.. :.� ...�.:'� � . � : � . . '. . '' '� � , . . „ . „ �' �� p � . .� � ,�. : � ��c��-'� ��"� , � w��`- `�-� : � � �� I�t. � �� , ��. R� ^ �� ,. �.: �� 1 : �U .F�f , �� ` �� . �� ; �___. � � 1- �� ; � (� �.T�� --�?�'� �: 'i�;��a��.a-�.�:��.)1 ].1F3i��.]I.�',_� ��J �+ ��, P�� (i�� X ��p�ur� C,P�P�c�t,�.�1^�i T'�� I"�ap: � �l`� ��c��: � �anb�lgvnsao�: ��p��ant�� I,1affi�: NE►o� oa�v�Y I��anli�g �s€�d��s: L�{55 M�� N��.�. (�oeto (�oxr3�st� , ts c, a`15`la &'�oaa� �u�ab¢¢-�: �'9'1- 5 81 �o L�satioaa a�f ��g��a-�y: t�l � S M��-t.. w��L. Roa�o :4 8b'i➢1l� CO➢�fll�d068�: 1) See attached site plan for proposed well location. 2) All applicable State and County �egulations �overning constructioaz and setbacks crFply. 3,� Permits expire � years fron� the date of issue. OPhe,r �'onr�i�'io�a�/Cotrat�ee�tP�: MA�a�A�IS A� S�TBAcvS �E�'flII➢H� fl3,1d�i� �8�: �.w.Q. a. �, ��$�: � �r t3 ��'I�'��+'��r�� 1�L��'��1� l��wv �J�fl� 1�ans��.`n�u�: EHS/Date Location: � � � ;t$' Grouting: Well Log: � 7 �f� Well Tag: dpa� h ig Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: �.n��a� ��p�c�fl��: EHS/Date Installer: 17epth: Grout: �� aaac�o�at�a�uai: EHS/Date Complete�i: Tdethod/Material(s): _ o�l �-1► G �1�i1 D�nl��: �b�,�. � . �ac��a�e #: 3371v-ff Pump Installer: 7- License#: '�'��fl ��a-�� b�: oQ,.�.� Q_ �. �9�$�: � 18 13 Date Sample Collected: � 1� 1� Person County Environmental Health 335 S. IVlorgan St., Suite C Roxboro, �iC 3757.a Date Results Nlailed: _ K a ►3 Phoue: 33b-�97-1790 Fa�: 336-�97-7�08 8/Ii08 •�.,,, STAT£.,' P� '��.�_.. ��/r =� f�2 RESIDEN�'IAL wELi, coNSTRucTTON x�coxn :�� ?� 's'' ,�, �� e' ' p North Carolina Department of Environment and Natural Resources- Division of Water Quality �;,,,� , � _ , <��c�'. /� � � ' WELL CONTRACTOR CERTIFICATION # �� r , _ ��4 p`a.:r9`� 1. W L CONTRAC'(.OR: �.. %�n � � � oV.r � �- v rc Well Con actor (Individual) Name Same e Well Driliina Inc Weil ConVector Company Name 611 Bamette Tinaen Rd — Street Address Roxboro NC 27574 City or Town State Z�p Code 3c 36 i 599-0015 Area code Phone number 2. YYELL INFORMATION: „ WELL CONSTRUCTION PERMIT# ,1.� �► � � OTHER ASSOCIATED PERMIT#(rf applicaae) P �i�, SITE WEI.L ID #{"rf applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply C�}� DATE DRILLED / '�I� ^" � 3 TIME COMPIETED Z�'S'�.S AM ❑ PM C�� 4. VYELL LOCATION: CI7Y: �f�,i � � �a COUNIY '�. cil /1' /`f� �- n� �.i N� c� R�4 z 7sz� (Street Nart1e, Numbers. Commurnty, Subdiwsion, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (check appropriate box) ❑Slope OValtey at ❑Ridge ❑Other tATITUDE 36 ° i�� DMS OR 3X.XXXXXX)CXX DD LONGITUDE �°��._.�Q.— DM5 OR 7X.X� DD Latitude/iongitude source: �PS Qfopographic map (location of.weil musf be shown on a USGS topo map andatfached fo fhis form if not using GPS) 5. WELL OWNER lfed.; D �4�/ e �J � Owner Name /.� 53 f�?� l/ �i �` il Ro �� Street Address ��x� �2� /l/`G � Z 7s'7� City or Tovm State Zip Code c3�6 � 5 `�'7–�S S/1J Area code Phone number 6. WEIL DETAILS: p a TOTAL DEPTH: �o D b. DOES WELL REPLACE EXISTiNG WELL? YESl�NO p c. WATER IEVEL Below Top of Casing: Z S �T. (Use '+' lf Above Top of Casing) g. WATER ZONES (depth): Top r 33._ Bottom�o� c��P Bottom Top i fD Bottom .r�/ToP Bottom Top / bs Bottom.f�o J'`��t�ToP Bottom Thickness! � T. CASING: Depth Diameter Weight Material : Top_(�Bottom_ ,�3 Ft. �� s�zl Pv�. � Top Bottom Ft. Top Bottom Ft. : 8. GROUT: Depth Material Method : Top�_ Bottom� Ft. SandlCemeni Poured � Top Bottom Ft. : Top Bottom Ft. 9. SCREEN: Oepth Diameter Stot Size Material Top Bottom Ft. in. in_ Top Bottom Ft. in. in. Top Bottom Ft. in. in. 10. SAND/GRAYEL PACK: Depth Size Material Top Bottom Ft. 7op Bottom Ft. Top eottom Ft. - 11. DRILLING LOG Top Bottom . �� . /5 I / �O / / / / / � i / � / : 12. REMARKS: d. TOP OF CASING IS � FT. Above Land Surface' `1'op of casing terminated aUor below land surface may require a variance in accordance with 15A NCAC 2C .0118. . e. YIELO (gpm): �� ' METHOD OF TEST BIOWII 2OI11 f. DISINFECTION: Type � �"'� Amount � 2 U Fortna6on Desc�n,ption u u e R. b w R� cstiJ i✓ 1'1- 11t4 R. I�. Q ft t-3 �1 acK i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THiS RECORD HA$ BEEN PROVIDED TO TH�WELL OWNER. �.., y��' �_--/3 �92�i1i,� � SIG�NATURE OF CERTIFIED WELL CONTRACTOR DATE v N �` � � � t�i-Ff PRINTED NAME OF PERSON CONSTRUCTIN THE WELL Fortn GW-1a Submit within 30 days of completion to: Division of Water Quality - Information Processing, Rev.2/09 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Report To: North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: HEIDI OAKLEY 1455 MILL HILL RD P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES082013-0048001 Date Collected: 08/19/13 Date Received: 08/20/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.6 Sample Description: Comment: Time Collected: 11:55 AM Collected By: Derrick A. Smith Well Permit #: A27-4 GPS #: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 65 mg/L Chloride 11.00 250 mg/L Chromium 0.02 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 0.68 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 18 mg/L Manganese 0.32 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L p H 8.3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 14.00 mg/L Sulfate 13.00 250 mg/L Total Alkalinity 197 mg/L Total Hardness 240 mg/L Zinc < 0.05 5.00 mg/L � Report Date: 08/26/2013 � SEP 0 3 2013 I Reported By: Arno/d Hol/ Page 1 of 1 North Carolina State Laboratory Public Health Environmental Sciences i�icrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES082013-0077001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: HEIDI OAKLEY 1455 MILL HILL RD ROXBORO, NC 27574 Collected: 08/19/2013 11:55 Received: 08/20/2013 08:50 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph. ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Derrick A. Smith Angela Heybroek Well Permit Number: A27-4 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Anatyst Date Total Coliform, Colilert Absent HLBRASWELL 08/21/2013 E. coli, Colilert Absent HLBRASWELL 08/21/2013 Report Date: 08/22/2013 Explanations of Coliform Analysis: Reported By: Susan Beasley � P�C��v�� AUG 2 7 2013 BY: If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. 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.