A29 118�
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant IJ ��-��CQ vt � ��Jo� 1�
Address��Q �� Z �P�-�y �
Collected By J `
County 6
Date Collected (� '�-� Z Time Collected q�.3 �
Source: �Well ❑ Spring 0 Other
Location: �House Tap ❑ Well Tap 0 Other
❑ No Charge [�Charge
T\�"'1
�
C �r�sf��
........................................................................�
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Total Coliform
FecaVE. Coli
Present
❑
1
Results
A sent
V�-
Reported By � �,,{�v � '; '(.IL.
Date Reported � � � ( � � _
��
,
�'
0
'� � The District Health Qeparfrt�ent
�......--.
CASWELL - CHATHAM - LEE - PERSON COUNTIES
� �,
23g�:. Water�Supply and Sewage Disposal
„ j�,, IMPROYEMENTS PERMIT No.�
�i', . l.�l,V ; � P�-� f Date �..-�'� ..
� � ,�' ��
Owner: • '�
' �`� pq Location: � =�.�" L, f �le,1 ��►�
; j e , , �'
, ::i� , ' .
� :�v� ,ivtsb� ;:i �'.
' - - Contractori' � `
_ � A ., �
��...�; � pi'�-. � Water $applys Private � -� "'� Public
, . ..
� .�; ' ,..� .
; Seasge Dispos�l Fa�il!
t f. f. i
� washIng" inach�ne,: othE
� Size of, i �nk �
� � � �
� . ; ott►er atsposei ta�iifc�:
' � � Wate'r. siipply _ an��!se�
�' protection,.m�t ri�eet i
i . � :Septic tank.s�iould �e
. tained by, owner, iri �uc�
; Septic. �ank�=-�n�: iiitrif
' �PROVEb•BY�A:�2'E�:
. . .. _._:t�R�Ate�L�4nL+L�AriL��'t[1.TV.
l;a
� �i . .�. � .._.
Date approved j . ,�
Well• ' .
Sewage Disposalt:�
. _ ..
. -��
' :.CertiBcale ad Completioa ; , , �
� Y<< �
{: . ' rJ � �� �' i.
�,� � /�� �
, . .. .Date� �APProved: ' � ' g �` By • �c� i
�. t � � � �anitariari::
: , �. ��
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i . I . � ' �OVl�+'R� ; � ' c }
, � LLocation ot v�►ell and sewage dlsposal �acilitle� .�ke
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and
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tchecf on � baek.
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Person County Health Departmeat
we11 Permit
DATE IS ED":- • �- DATE DRILLED: /� � COUNTYip �+�
OWNER: �� �q..,..yi�/�.�,�� ROAD/STREET:
ADDRESS: �� g �J
DRILLING CONTRACTOR: ,u f� L%�
NA� � " ADDRESS
WELL CONSTRUCTION
Distance from earest Property Line Distance from Source of
Pollution C . '
Total Depth: Ft. Yie1d:L�GPH Static Water Level�_Ft.
Water Bearing Zones: Depth � Ft�Ft. Ft. Ft.
Casing: Depth: Fzom�'(_to Ft. Diameter:��Inches
TYPEs Steel Galvanized Steel G�
If Steel does owner appr� Yes No�
Weight:�Thickness: � Heiqh�ve Ground• inches
Drive Shoe: Yes No 1'
Were Problems Encountered in Setting the Casing? Yes No
If 'yes' give reason:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width. 3 � inch�s/
Water in Annular Space: Yes No ��
Mathod: Pumped Pressure Poured ��
Depth: From �to� � Ft..
Naterials Used: No. Bags Portland Cement�_Waight of
1 bag lbs. j
If mixture (sand, gr 1, cuttings) - Ratio:�_td
ZD Plates: Yes No
4 x� slab Yes No�
DRILLING LOG
De th
From To Formation Descri t on
�� VLQ � Q �
�df1 t �
Z HEREBY CERTIFY THAT THE ABOVE INFal2MATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON CO[JNTY BOARD GF HEALTH. P T V ID AFTER THREE Y
. � -��� �� r-��
Si a ure f o ractor Date
��� ��
nitarian's Si ature Date Issued
Saaitarian's Signature Data Completed
Sketch well locatioa oa reverse side.