A28 140�,f' y_' . ,'\ �d.rl'�es `�is� ..
j�tiQ,��.�r . r� -�� � �5 w��e�) _
'�C Y.� � � .`�'�C�. �- _ � � (.�.�'f �
��ie =°���riC����ea t r. e�ar�riient� ��_;
,; s��'',,:�.; �. �: *� . • . . ,
Orange Perso Caswell, Ch�tham. � Lee Counlies ,
^.' . r'
'` � �� , � � ,
�� s , .
Water Si�Pp� Y nd . ev��je �,!sposai
� ? '�' �a.rn e.� V" � a.,,i► .S -1 D`= z� `.. �
� `. ; :,��'� t�� � . •, D�te �', - ' ,
t w
�
� ���'��r`
. � O . . : �:y � . ,t; �
Locat�on>
.� a� ',� . _
s - '
1 � I'
, 7 �_
�. � Contractor. �—, 1�.��'
� „ . ---•-Q � WaYer Supply: Private ;./ Public
_ . � _._ - _ .
- ___.�, - �
,:.d_;.L.,i ., .. .
Sew.�ge' Disposal Faciliiies: No.':bedrooms Dishwaskier, Disposal,
, . ;,..-.�,. . -_
washi�g,machine, other automatic appliances '`
,:
Size of �ank: � Nitrification line: `
�
Other disposal facility:
Water upply and sewage disposal facilities location, installation and
protecti�,?must meet state and local regulations.
Above �ecommendations based on information received and observed
soil conc�ition. 5eptic tank and nitrification line MLTST EE INSPECTED
AND ApPFtOVED BY ,A MEMBEA OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put i�to.use.
Date approved
Well:
Sewage o:
By:
Countersigned
--�----�=� 1--
� Signe + �^
nrt an
(OVER)
Location of well and sewage disposal facilities sketched on back.
v
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
a� later date.
�
. �,o,�--o � ��„ +- �las �
Application Date: L 2�� p0 ���,5� �����
Amount Paid: �200 ,U �,�0, , �,,,"; � � ��,��
Receipt #: 713 y�{ 6 �(, 7 µ5 is'
l�" uaw$a�,�TM* �TM* �aad,m.Il 7��I�o,si,]Ld�.
C� � �3 � Z �� 1 z;
Application for Services
Services Reuuested
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Weil Permit (1�1ew/Replacement/Repair)
$300.00/$200.00/$75.00
❑ Construction Authorization
(Fea is dependent on the type
0 Permit Revision
$75.00
• � �
Tax Map: A� � ��'i� Z�.�
Parcel#c ; Z57�F 3`13U
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: ��
Name: MIKE �-�Dl)frr►�e-) Vl►JCDLI
Address: Il� �►LX�F 17
��nct�Zc�, Nc_ 2�513
2) Name and address of current owner (if different than appl'cant):
rr�me: 3C� Mt1�►�Q �- �T�rN M� �'
Address: C
DUP_+-�A I�i . N L '11�5
�
3) Property Description: Lot Size: O,UZ �`Sfibdivision:
Address and/or d'uections to Property: � IZ(htpyC
Phone (home): �J�-�J3gZ
(work/cell): �3310 5 3-8
Phone: �� - �J�
#:
❑ yes � no Does the site coatain any jurisdictional wetlands? —' '
L� yes ❑ no Does the site contain any existing wastewater systems7
❑ yes B 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?
0 yes �no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporrtiing documentation)
4) Proposed Use and Type of Structure:
�Residential
L� 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 p(umbing fixtures? � yes ❑ no
ONon-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5� Water Supply: � New well ❑ Existing Well ❑ Community Well O Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this pro eriy? I� yes ❑ no
� 1� L�1S�(�P1b Wk�.t. 1S �(ic�� I� W1Ll. "��U�
6) If applying for `Authorization to Coastruct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Altemative 0 Other O Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inacc�ate, or if the site is fubsequently altered, or che intended use changes, all permits and approvals shall be invalid.
�wner/ Legal Representative*)
documentation required.
2Z .
te
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 reqniring a site evaluation.
11N111 Parcnn ('nnntv Fnvirnnmentai Nealth '��5 C Mnruan St__ �uiteC'. Rnxhnrn Nf �757'2 l�Z�_SQ7_t7om
_���sf ���.���
� ���.���
?Ls �-Yn x-�������.Il I�3� � �.11�ll�
Tax Map: �� Parcel: 1�10
Subdivision
Phase/Section/Lot #
Applicant; 1"1�Y.� V�a�o`1
Address/Location: Hw� i5s' wesr -� �.oe�.-w�t Qa L a���C � MEw'� �'R°�. �
Improvement Permit
Permit Valid for: Five Years X_ Non-expiring
Type of Facility: 3-bil. �USE New X Addition _
Number of Bedrooms �/ Occupants �d'�S` Employees / Seats:
Proposed Wastewater System: Go�n�-'�f>�
Proposed Repair: CA:�vE�.ir�� f Aukt�.4
Permit Conditions: t�'►�+��r'nr� 5� � 5���-
Ex�s�rn� tn�.v.. 1�74►7 ln�►�s�sr 't3�e.
Authcrized State Agent: p��R.tGI
(X) Owner or Legal Representative:
VVater Supply: �-�� W �=v..
Projected Daily Flow:�� gallons/day
Type: �
Type: �6
�. ,,� �.,�i. • M�,�a �.
a5 �t s�u�- w �„� Oil�t-o � ��
�v C���' C,c� ,
Date: 1 lb 1
Date: 3�,Z 3
The issuance of this permit by the Healt:► Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandpr�perty owner to insure 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 Improvemeni is noi affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the P1orth Carolina `Luws
n�rd Rules for Setiva�E Treatment and Dunnsal Svstems'(15A 1�TCAC i8A .l9(i()). Neither Person County nor the Environmeatat
Fiealth Specialist tiv�rrants that :he segtic system will continue to f�nciion satisfactorily in the future, or ihat t�e water supply wil!
remair �ota5]e. — - _ —
Authorization to Coostruct Wast�water System
See site plan and additional attaehn:ents ().
�
Proposed Wastewater System: C���L. (*)TypeZi,Ad Design Flow ��o'O _ galJday
Nev� � Repair _ Expansion _ Soil LTfiR: 4.3� gal./day/ft2
Type of Facilir,�: 3 L��� ��1S�C Bssement: � Yes _ No
('•`) System Types Illb, Illbg, IV, and v, re�uire periodic system inspections by the Fetson County Health Department.
Wastewater Sy stem Requirements
Tank Size: Septic Tank 1'00� gal. Pump Tank "' gal. Grease Trap � gal.
Drainfield: Totat Area lolio'p sq. ft. Total Length 4a`O _ ft. Max. Trench Depth Zy-3bin.
Trench Width �� ft. iVliti.Soil Cuver �D in. Min:Trench Separation � ft.
Distribution: Distribution Box x/ Serial Distribution� / Pressurz Manifold
Specifications• _.� L�S `��. �O �'i' E c� 1'F �Stiato ,A 'D-'4dx • 5�r�. ��s����. 'o�'� ';a0 �
��� aL�, � 6�-r� w� a�„a�c _�C�. s�t s�r. a �n� ��ts ��F�, ►'�.�.r c�r.� 't� R�.�,»�
�luthoriz�d State t�►gent: ��.tCX` i�- St'►c� Issue Date: 1� Ib �`t
Permit Expiration Date: o� Ib 1
7'he system permitted is: Conventional ccepted / Alternative / Innovative . I accept the co�iditions
and specifications of this permit. g,,�
{7�) Owner or Legal Representative: �`" � G��� Date: � oZ 3
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
��' i a� ���� ��
� `1J `u �:.J ���
IE��aaosasamaa�a��m�mIl' IHt��mll�I�a
SITE PLAN
Name M��hF V��,CAL.1 Tax Map #� Parcd #� y � �"
Subdivision Sectioa/Lot# �
�E�t1L . 5►'`�Tl�— �� ��
Authorized State Ageat Date
System companeats tepresent Qppmximate contours only. The contractormustllag t6e sysrempdat to begianing thefnsrallation ro
iasvre rhatpnopergrJde is maintained. 1ry�0y� �9�g�'D`
� 5 �S-i�M . ti°6
- 3e.� 6i�o C3-�.��� a�'`y� -� .
�. .�'
- o. 3 �-rA2 o�,�a� �4 �' �3a
- L�i - �� ►a. -��a �� ��1 °`9 �' ,,,�� o�
_ �oa t�.1. �-c'
��
�4 69
�60
�,. C., ,�03
��r
V�� 3��331 .
/ �
C�
111382y� ��'Q-
� �
0
3�g1
1AZg3
i�. %`�1►�i'1'1\� '`�'C�, S:i1�.
a�S�R(3A*�c�
L 69�36�
3a/
-�i� A�v�' Au. 6tcr��
wPC't�4.. l�WA`( �ik,h S1SCE,1'� w
�
df R.��A��.. �s- �
.. �,
� w�v., t�o r�� QE �
(�o.�►�r u4 1v Ca`��
�a,wE, t ss�a•�c� a� C.�.
w
1'f+�or� t�Wb • i rJ.S�E.�a�S
ik (it,�...��- '?� 6��.� �
��u� �
��,���6 .
.'' � `]�.
�S\2s
87.620378
❑
�
N
�
O
�
N
N
380.21964q
...i N
N 1 inch = 100 feet o
0 60 120 240 360 480 Feet �'
�
M
I I I I I 1 I I I
���. sf ���.� ��
` � � ����
I-�+ �a�na-��n.n�cn�sa��.Il. �3IIa��.Il�I�n.
Applicant:
Location:
Operation Permit
Taz Map �Z�Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms , �
System Type (From Table Va): Product (IIIg): L� —�i'c��J
Type V& VI Expiration Date: Type V& VI Renewal Date:
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
���
(Au orized Agent)
I'UI. � a��, �� � S
(Licensed Contractor)
�O19 � t=
15�
�l�- l
(Date)
� �
(Date)
���`�o _
r-✓ ` � / � � ��ZN
—
`�Q ��
7'
��,�,�.S�uc�� �'fl '
Scale �S
PCHD, rev. 12/14/12
— �D� =
� �Ae�
Tax Map: '��Parcel #: /�b
Septic Tank System Checklist (Type II-I� System Type: /'
Se tic Tank InitiaUDate
State ID & Date: i � ��
R l
Capacity: �� a
Tee and filter
Baffle
Vent
�Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set) /�
Serial
Pressure Manifold
LPP
Notes•
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back Iug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes•
;�
Tank Com onents InitiaUDate
Pum madel:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A proved and secured riser
St� 1 Line
Size and material: in. sch.
Length: ft.
���, sf �I��.� ��
�-- � � ����
I��ca�n�r�aa�rxam�ra�.m.Il IE3C�mIl �l�
WELL PERMIT �������.— �,� ��
(New� Repair_)
Tax Map:��� Parcel: 1 �o
Subdivision:
Applicant's Nam�: /VJ; �e 1/ivi('�,`
Mailing Address:
Phone Numbers:
LocaHon of Property:
Lot:
�
Permit Conditions: �-'
1.) See attached site plan for proposed well location.
2� �Il applic�zb�e State ana� Courry regulati�ns gove-rring construction ard setbr�clw apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
� C�.�.�.ti, P.�„ �� �C , R �
Permit issued by:
I�1ew `JVell:
EHS/Date
Location:
Grouting: ;�l �er ' ��
Well Log: �
Well Tag: r_��
Pump i ag:
Air Vent: �
Hose Bib:
Casing Height: �
Concrete Slab:
Date: � 'o� 5 � ( (o
Certif e�te �nf Compl��ien
� �Liner:
EHS/Date
Depth:
q-�-� 4 Grout:
Wel� Driller:
Pump Installer:
Approved by: a ��i
A��ilional Corr.m�n!s:
Date Sample Collected:
EHS:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: l — 3=_____�p
Date Results rvlailed: ��£o
Person County Environmental Health
325 5. Morgan St.,Suite C Phone: 336-537-1790 Fax: 336-5�7-7808
Roxboro, UC 27573 1i/26/i3
Sep 01 16 01:50p Barnette Well Drillinglnc
WELL �ONSTRUCT[ON RLCORD
77.a focm a� be usd for ciogEc or mytripk a.elfs
I. VVdI Contractor Informauea: �,
� � i: , _�
wai c��a N,� �
—�7 �� �.� �,l�
N� Wdl Contraaoc Cca fication Namba
$ame#te Vyell Drilling, Inc.
��y rrm�
� WrllConsirncrioo Pa�aitll•�� '
Liir alleppltrnb/e �.ell coAw�,+c�ion penn'u �ie. Sror t( '
�R t arieur�uc)
3. Wdt Use (e6ecG wel! user
Qkgic�tJ pt�ai
QGaothetmal {Heatin�(',00ling SuPP�Y)
Qlnd�ia1/�5ummcrcial
�Aquil'cr Kcdiargc
��1qul%r Stvragc an�i RuAvrn
❑Aquefc'Fat -
C]£�iimmtat 7echndogy
�Creothexm8! (Glnstd LooP)
C3MuniapaVPublu.
C�iR�idenfiai WatesSuF��Y i�8��i
ORrsidca�a! WatcSuPPJY��)
L7 GroaindivaltrRetscdiafion
QS'aliniLy Barrert
E]S[ormwatcr,Thainage
❑SubsidenGe Gonuol
OTracec
------ - - -.�..��..y naum� Lt(JtbCfic747Ta14U�CCii2I i�]2iiY
s. �c�wd��s� co�,i«�a: 9/-/6 wa�:ro�e f% Zg
sa. we.a Lorac4nn: ..`�.`
�_ t! P v«v�-��` �
FaiiLtylQwmcrName Faalit}r iD$ �t£applicable�
��✓� � �l.�Q`y 7� /..�e�,7� }C� /71ri�. ,PC/.c��.
p►v��t.aa�. c�y, a.a� --�--_
��r�s��
�"' ,,. e� rd�a�h� rro. tt�ni3
56. Lstiiudc utl I.oagiindcia .dcgreeslmiQ�lalse�olnds'or dceiot�S deg�rrte�
336-598-9275 p.1
Forlucaoaf UseONLY_ •
' J3 rr. � � rc
`f�v !t ��y.- rc
�OiICE1C(':i1$fNG: for
t� ,�
/°1 ft �[ fC
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tON TO
i�L [G,
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ft- ¢
2 �
CGROUT .; .�;.. �.::.';' �::.c.
LOM 7'p
O � zu �
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�� ft
ft iL
�
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js � s�A
Z �5U [a � �J
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tt
z,�rc�L
s:1. ... . . . � .
s ��
(�wip 6d� o�s IatllooS n safficicct} •. ?.�- Cesl�c'1$b�; �• I
3 3�4�8 ��9 - c� r s� o`� ��:s=�� Cf _f
' �` —%�i
6�istueJ�zwL1l(s;: �saent or �Twporar� • S'�°cofCaSsa►WdPcmuamor p,�. •
- 8!''+��+�8'�L*}�n+. / heairlry aerr�y dr�s rhe- *eII j� w+ (�c�'e,i c�airraled ib ccswrrQO+a
7_�stfiisar+epsirtoanczistifig•.wdL E3Yes ar � »irhl3dN�ACO2G_a100.drLi#NCdCD1CA20OTPelIC«uridmoaSYawdardrro�drFor.e�
ljrkts bo rspol , f�l! ort,�noxar w,elr oonri`aaion - �10PY9I �Jys rcaadli¢rbecqFmvfded fa�dr welf orwer.
+r�anrwliwi ondarplbia li raratpv c of 7be .
�+epalraader CZI romw+� saction ar ar theboaFcfdrlijoroe. Z3. �tC dlsptJlRt 6Psidditiultalwd! dehJi�
8: Kambez of �vdls eoostructcd9 You ue3y ust 8ie back ot dv"s page to pis+�vid"c�additional� vadl. srte dttxils vr wd1
Fw marbiple tnjaY�on or r�orr_warcr to�tuh�ution ddaits. ]'ov aiay eisti�attYcla e�dditibAat pdgcs �oemtssaiy,
.sf�uttfodef6+at �Y�r'e11sONLPwirl+llie.t+cmeto�px�r3atyar+r�t
5U1T1VIiTCAL iN.Sl'ilC�'IONS
4 Totai-we3! dcpt� betnw.lsadsodxee: � 4 C7 (C�) Z4a For Nf Wrd� SubmiC t6is.�attu wihu� 30 days of wmp[dioli of u�ell
Foriavhr/a!e'weGsltuall�pduil�genniCci�e-i81�0'bn3Z8.tU� ouns4udienin'tfiC'foilpwieg
10_ S[alie Nater levd bdae fnp isFcasins: _ �i�j' ��:� Dieisioa oLSY9trrQwdit�, lafaraaa�on pcocasiog U+ait,
Ifru1� tevr7ls abavt ass'vr& rsr "a - 16I7 I17iil Sen!ix Eeatec, xLaleigk,l�C �76tJ9-ib17 '
I� Bor�bota diaiaeter. G f�� z4b. Far �a �ct��n.t��[�: � a�aition to smd� �c � to ihe adaitiss in z�
12 �'irelt eonsirucaoa.method•. ,� ai�uvy aiso subnut x oppy ni tfiis form within.30 days af oaiepletion af wr.li
�! � lL. 7'�Ar�'C� [f amts6ut3ion to Uie follo
�''�-"ot : �Y.cablc, dimctpuih, dc,J ��
�oa d[�'4'.atvQaslih, Uuderg�onnd.Cajectioa GoatrroCPingcam,
FOA'Wrl'CEFi SUPPL3' NELiS OlYLY: 1636 iNa7_Scrvioe Gseater, Ra�k,1VC27699-1636
13a. Yidd fgpm}_ Cb Mcueod aft�sk Btawn20 mettute 7yle �'or ZYater.Sabnh� & Tniafioh �CYd � i� addi�an w�ngshe,form ta
thri ad a a�o'
i36. DisinCctLioQ � HTH Ca� -�on o wcii taot�t submit one evpyr of. Biis faaia i�i8sin 30 days o£
� .emount 1�2 Cup p trltdiort t+o tht «i�mcy� kp1�i a�m«�r ef th� �c;ey
�ere corisLiu�ai
FamGR�-1 NotthCarol�aaDc{�at�ofEnvuaemeata�dNas�alResoQr.es—ikvisionoEWaterQinlity � Reriscd.Jaa_Zlll3
� yl
��' /
� 1 � j �
��. � � � ����
I -C�n.�na-on�anca��a��.Il IHI��.Il�ll�a
Date: IZ / Zo / 1!v
Name: _ Ta_x Man:� Parael: . /��
Address: �
Z _ �
Re: Bacteriological Test Results
Dear Well Owner:
Your wetl water was sampied on f 2/�/�, and tested for botn total and zecal colifarm bacteria.
Your water sample test results are noted below:
x No coliform bacteria were detected in the sample. Your well water is safe to use for drinking,
cooking, washing dishes, bathing and showering, based on the bacteriological results onlv.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are nzturally found in tl:P s�il. Fecal col form. ba�teria are asseciated :v:th
animnal and/or human wast$. The presen�e of either total or fecal coliform bacteria in weil water may.
indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated
groundwater may be entering the we(1. If coliform bacteria are present in your water sample, the water
may not be safe for use. Young childrer., the elderly, and the individuals u�ith compromised immune
sysrems are especially vulnerable and their physicians should be notified of the test results.
A well that tests positivefor totcrd or ecal coliform bacteri� shculd b� praperlv disirtf2cted ar,d retested
prior to resuminQ normal use. Tne well may be disinfected using the enclosed disinfection procedure. A
well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly
flushed out of the system, please contact the Health Department to request a re-sample.
For additional information, please feel free to contact Environmental health at 336-597-1790. Our office
hours are 8:30 to 5:00, Monday through Friday. "
Sincerely,
��
�����
Environmental Health Specialist
Person County I�ea.th Department
(rev. 4/2U/l6)
Person Ceun,ry Envirenrnental Hea!th, 325 S. I.4organ St., Suite C, P.oxbcrq :v`C 27573, Phoie: 336-5i9-179Q rax 336-59i-7S08
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
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: ES120616-0091001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
MIKE VINCOLI
4983 LEASBURG RD.
ROXBORO, NC 27574
Collected: 12/05/2016 10:00
Received: 12/06/2016 08:20
Sample Source: New Well
Sampling Point: outside tap
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
H. Kelly
Susan Beasley
Well Permit Number:
A28-140
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Absent 12/07/2016
E. coli, Colilert Absent 12/07/2016
Report Date: 12/07/2016
Explanations of Coliform Analysis:
Reported By: Susan Beasley
/ � /
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.
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For 1no�-ganic Chemical Contaminants
County: - C, �.l Name: � i
Sample ID #: Z� L b Reviewer: •�'ZL,�
TEST RESULTS AND USE RECOMMENDATIONS
1. ❑ Your well water meets federal drinking water standards for inorganic c%e�nica[s. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
have other water sampling resuits that are not taken into account in this report.
2. ❑ The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inor�anic chemical results onlv:
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Manganese Mercury NitrateMitrite Selenium Silver Ma�nesium Zinc pH
3. ❑ a. Sodit�m levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning,,bathing, and showering based on
the ir:nr�nnic chemical results onlv.
❑ b. Levels over 30 mg/I may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5: ❑ Re-sample for (ead 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 th� source of the
lead and/or copper. �
6. dThe fol(owing substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorQanic chemica! resu[ts onlv, but aesthetic problems
such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system
to address aesthetic problems.
Cadmium � Chromium � Fluoride � Iron � � Magnesium
Selenium Silver pH Zinc
For n:ore information regarding your we!/ water resulis, please call tlie Nort/i Carolinn Division ojPublic Hea[th at 919-707-5900.
North Carolina State Laboratory of Public Health 3�12 D� tnct�Drve
Environmental Sciences Raleigh, NC 27611-8047
http://slph.ncpublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH MIKE VINCOLI
325 S MORGAN STREET
4983 LEASBURG RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES120616-0023001 Date Collected: 12/05/16 Time Collected: 10:00 AM
Date Received: 12/06/16 Collected By: H Kelly
Sample Type: Raw Sampting Point: Outside tap Well Permit #: A28-140
Sample Source: New Well Temp. at Receipt: 1.5 GPS #:
Sample Description:
Comment:
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 36 mg/L
Chloride
Chromium
Copper
Fluoride
Iron
Lead
Magnesium
Manganese
Mercury
N itrate
Nitrite
pH
Selenium
7.50
< 0.01
< 0.05
< 0.20
0.19
< 0.005
10
0.140`
< <
< 1.00
< 0.1
7.8
< 0.005
1.3
4.00
0.30
).01;
0.05
).00�
10.0(
1.00
0.05
N/A
m
Silver < 0.05 0.10 m
Sodium 8.20
iotai AiKauniry
Total Hardness
130
250
Zinc 0.06 5.00 mg/L
Report Date:12/14/2016 Reported By: Deddie .r'�lonco!
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