The URL can be used to link to this page

A27 5Application Date: 7'� 6 y13 `�� (� ��q �� Tax Map: ��7 Amount Paid: 0200 , �0 ..... ." �- � � �� Parcel#s � Receipt #: 17� � �� 36 � �% 11 J.3 Z ��'.�ma n.n�aDan.:mrue:2n.4:an.� )j'j��.11a:lr. `f ❑ [mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit re uired) Well Permit ew lacement/Repair) $300.q /$200.00/ 75.00 ilication for Services Services Reauested ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor atio Name: �ti �U Address: t �� ox �rd 7 2) Name and address of current owner (if different than applicant): Name: Address: A� 3) Property Description: Lot Size: �.�.� Subdivision: Address and/or directions to Property: Phone (home): (work/cell): _ Phone: Lot #: 33�-5'`�9-`�71� ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. 7-16- I 3 Date Supporting documentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' 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) �� ?, � 11 �� . � = � � �� IEaawasoa�aa��m]l. lE 3t�0�.Il�7ia. SITE PLAN � IVame �13Si.�. Sa�.t„S Tax Map #�_ Parcel # 5 Su drvisi Secrion/Lo # �,,,,� �. - '1 1 13 iy i3 Authotized State Agent Date �J`�D �C�� Sysrem components represent appmadmate conrorus on/y. The coauactormustllag the systempriot to begianulg the insta/1�dan ro Insure tfiatpmpergrade is maintained. 15�3 P�� K�u` 1Za��__ _ , �� .. �t �`�►�v� ��_ L� � �o�� ` da ��''�b • � Poa� �sa ,�I�� c�- bAs L�� tt.�_ a��►t�� • � a1� Pa.�Qa� �1.�►4��:FA W ►�- w-�.�, Av� wl Q��\L F�eS . %j�� US�L 11P�- �V �'"'''a►�{ ' -tq 1+u�E-Si <.�s�.�. f3 � Q'-tZ. }�,�,nwJ3.Q. • � �,',,.��'`�' � � h 1 : 5fl Feet r � .�s% 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: BILL SUGGS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh. ncaubiichealth. com Phone: 919-733-7308 Fax: 919-715-8611 1523 MILL HILL ROAD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES082013-0047001 Date Collected: 08/19/13 Date Received: 08/20/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 2.4 Sample Description: Comment: Time Collected: 11:40 AM Collected By: Derrick A. Smith Well Permit #: A27-5 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 40 mg/L Chloride 11.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 1.00 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 20 mg/L Manganese 0.37 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 pH 8.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 17.00 mg/L Sulfate 25.00 250 mg/L Total Alkalinity 174 mg/L Total Hardness 190 mg/L Zinc < 0.05 5.00 mg/L P.�CEI'`7�D Report Date: 08/26/2013 SEP 0 3 2013 Reported By: Arno/d Hol/ BY: Page 1 of 1 North Carolina State Laboratory Public Health Environmental Sciences iVlicrobiology 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: ES082013-0076001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: BILL SUGGS 1523 MILL HILL ROAD ROXBORO, NC 27574 Collected: 08/19/2013 11:40 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://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Derrick A. Smith Angela Heybroek Well Permit Number: A27-5 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst 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�� 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. �,�� Sf ��.�� .:. . ��°�� 7�;.�.�a� � �..��.¢�.Il 1L�I � �..Il�Ih�. WELL PERMIT (New�Repair� Tax Map: A�`l Parcel: � Subdivision: Applicant's Name: �31�.`. �h� Mailing Address: 15 �3 N►+�. N��. Rowo Phone Numbers: 33b- S q 9- 9`l l g Location of Property: 15�3 i��-`. N��.L. R,oEtU Lot: 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 5 years from the date of issue. Other Conditions/Comments: La�E. 6�1s u�%. Qti�cR. '�ro �t�c.�� MAt�i-�4�tS A�.� S�%t'f3Ac,i�S Permit issued by: c�k,.,.�, Q�-� Date: 1� 13 CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: � h �1. + Grouting: Well Log: Well Tag: caAs �/ �b ►3 Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: ' Grout: Well A6andonment: EHSlDate Completed: Method/Material(s): _ Well Driller: �AQa�.'n'�. License #: Pump Installer: License#: Well Approved by: Q ,�' , Date: 'j alo 13 Date Sample Collected: $ i�1 � 3 Date Results Mailed: � �`1 i3 Person County Environmental Health 325 S. Morgan St., Suite C� Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 8/1/08 : '�aSTATE;,. : �'C� j� � 'Z\�2 . �:�:; ;� � r., ��. A. ,. = o �,,,,,�,�� ,.. ��: �.I.:=. ''� « ` RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Departmen: of Environment and Natural Resources- Division of Water Qualiry WELL CONTRACTOR CERTIFICATION # 3 3%tl'> ��' 1. W L CONTRACTOR: ` �d n9/ti! : 2 � ��. � /! Well ConVactor (Individual) Name Bamette Well Driiltna inc Well Contractor Company Name 611 Barnette Tinaen Rd Street Address Roxboro NC 27574 Ciry or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2 WELL INFORMATION: WELL CONSTRUCTION PERMIT# �� • �� OTHER ASSOCIATED PERMIT#(rf applicabie)�� `� SITE WELL ID #("rf applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply C�Y^— DATE DRILLED % � Z �" � -? TIME COMPLETED l�J�' � AM p PM f� 4. WELL LOCA710N: cmr: ��. ts ,b„� P.�,_ couNrY Sc� .� v / 3'2 ,3 �. �i �/:�� ,�SL. a �,��,� (Straet Nama, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (check aPProPriate box) ❑Slope ❑Valley pFlat ❑Ridge ❑Other LATITUDE 36 ^� di « DMS OR 3X.XXXXXXXXX DD LONGITUDE '� 7l'`Q��a • DMS OR 7X.XXXXXXXXX DD Latitude/longitude source: �GPS �T'opographic map (location of.well must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELI OWNER �,`/l Sc.�. ��S Ovmer Name i /s'Z3 noill /aiJt �dA�� _ Street Address G.eesb�,�2y O�c• � �5�� Ciry or Tovm State Zip Code �� 5"99 — 9 � �g Area code Phone number 6. WELL DETAILS: / a TOTAL DEPTH: I� D b. DOES VYELL REPLACE EXISIING WELL� YES ❑ NO [� c. WATER IEVEL Below Top of Casing: ZJ �T - (Use `+` if Above Top of Casing) d. TOP OF CASING IS �_ �• �ove Land Surface' `Top of casing terminated aUor below land surface may require a variance in accwdance with 15A NCAC 2C .0118. e. YIELD (gpm): 36 . METHOD OF TEST BIOWfI ZOfI'1 f. OISINFECTION: Type HTH ano�nt 1 2 Cu g. WATER ZONES (depth): Top1� Bottom 120�� P Bottom Top %� � Bottom 3�_ ToP Bottom Top Bottom • �Top Bottom ThicknessJ T. CASING: Depth 1 Diameter Weight Mate�fal Top�_ Bottom C1 Z Ft. �� ,�Z —��— Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Method Top�_ Bottom_� � Ft. Sand/Cement Poured Tap Bottom Ft. Tap Bottom Ft. 9. SCREEN: Depth Diameter Slot Size Material Top Bottom Ft. in. in. Top Bottom Ft. in. in. Top Bottom Ft. in. in. • 10. SAND/GRAVEL PACK: Depth Slze Material : Top Bottom Ft. = Top Bottom Ft. � Top Bottom Ft. 11. DRIILING LOG Top Bottom �_� iv �_/ 4�S �S l / 4�� / / / / � / / I / / / 12. REMARKS: FormaUon Des�cn�ption 171.3�� utiCQ.=u.� S�itle 1'� SR�� rD�14V 0�.�— I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS RECORO HAS BEEN PROVIDED TO THE WELL OWNER. � L � + � _7 - z i�-- i3 �� S�A�URE OF CERTIFIED LL CONTRACTOR DATE R e ��,�� e �. ,2.�i tJ-- PRINTED NAME OF PERSON CONSThZUC ING'i11E WELL Submit within 30 days of completion to: Division of Water Quality - tnformation Processing, Fortn GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09 i�/3j� � C�,l` ...�, n�.Q. -�:;� �ys. (��c - q�i�S� . �-�- �� .��r � �.��{� �.t ,r4 ca;�,�Pa.-,.1.,� �, �� i'�-r-�. -�-e.��r-tit� �-- ��7�-'�iC� '� , -� � � L� %�%`,�i L {%� �^c- � � � �" � �y�-�. �