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A29 13� ��1 Application Date: 3�1 �-I 3 C�a �� AmountPaid: ��,—�� a�� ,. ,�•a Receipt #: S J � �o� � 53yt�o � �r � � �� IE:"�.rrn-vnn-cn-anaxs�zndan.lL IC�Cc3.�..11�::Ln CJf� L�. %o� �1 �_l0''�1 �provement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) � iViobile Home Replacement or Building Addition $150.00 (if site visit required) � Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 tion for Services Services Req uested ❑ Construction Authorization (Fee is de enlent on the e of ❑ Permit Revision $75.00 Tax Map: �`, °'� � Parcel#: t 3 _ ❑ Repair of Existiag Septic System Application: No Charge/ CA $150.00 or $300.00 :` '1) Applicant Info mation: Name: ( n �- ��--- Address: 2 (,. s .� o-�, � ,U 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 33C� 5 �1% — 3�'!% (work/cell): b — � � o D Phone: 3) Property Description: Lot Size: Subdivision: Lot #: ,1� Address and/ r direction to Property: D n � �. ....�� .✓-� 4� I �t�� lG �a � n s -^ S�� o t'�c v��-e �r�S a-� �� uf ❑ yes �no Does the site contain any jurisdictional wetlands? V � v S�� ❑ yes no Does the site contain any existing wastewater systems? S� �� ❑ yes �no Is any wastewater going to be generatzd on the site other than domestic sewage? ❑ yes � no Is the site subject to approval by any othe: public agency? ❑ yes no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Propased Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Exgznsion of Existing System If expansion: Current numUer of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential f 6 V � � r �M Type of business: 'I'otal Square footage of Building: '� Maximum number of empioyees: . Maximum number of seats: �[ d�y �� V �a.� 5) Water Supply: �New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring rOo,�,� � Are there any existing wells, springs, or existin� waterlines on this property? O yes ❑ no - 6) If agplying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 c2rtify t{tat the information provided above is complete and correct. I also understand that if the inf'ormation provide� is inaccurate, Qr,if tlze site is subsequ�ntly altered, vr the intended use changes, all permits and approvals shall be invc�lid. Signature (Owner/ Legal Represei * Supporting documentation required. _ 2�- 3 Date • 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) ��, sf ��.� �� ) � �s zrn�n �^ � �rn. �*-,.-,. � �n � � � �� .,�. � ��n Tax Map: Aa� Parcel: I�_ Subdivision Phase/Section/Lot # Applicant: GHAK��t,� iJ. Fic�o1�, Address/Location: '3'ut�� Au� Qp 7 Is�. n¢,�v��V pns� Syr�y„ g��S Improvement Permit Permit Valid for: Five Years }( Non-expiring Type of Facility: ��' x I b' S1�op New � Addition _ Number of: Bedrooms / Occupants / Employees / Seats: Proposed Wastewater System: C„av��cn�a�, Proposed Repair: �avF r�-r�ap�, Permit Conditions: n Water Supply: iwv�E 1„►gt,L Projected Daily Flow: lo� gallons/day Type: IL ct TYPe� Iia Authorized State Agent: (�j , Date: (X) Owner or Legal Representative: Date• The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty 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 Improvement 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 mtd Rules for Sewape Treatment and Disnosa! Svstems'(15A PTCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system wilt continue to function satisfactorily ia the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: _�avEt�-no►�(�1L (*)Type IIq Design Flow l dt1 gal./day New � Repair _ Expansion _ Soil LTAR: �� a,5' gal./day/ftZ Type of Facility: ___ � L' x t �' Sf�4ap w� i��R,�S Basement: _ Yes � No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank,'75 p gal. Pump Tank � gal. Grease Trap � gal. Drainfield: Total Area �i�� sq. ft. Total Length 13S ft. Max. Trench Depth ld �`lin. Trench Width 3 ft. Min.Soil Cover � in. Min.Trench Separation 9 ft. Distribution: Distribution Box X/ Serial Distribution / Pressure Manifold Specifications: a 1-�c�s �, `lo �r Er�c� ' o� 1 ��t�1� � 13� �� S�ti Sr�c Sll�t�C,}1 Authorized State Agent: Issue Date: Permit Exp The system permitted is: Conventional � Accepted / Alte e / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: , Date: � 5 �� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �-��, � Jl Jl..e�� — �.�� sav�asoaaaaaue�sn�a.�� IE"3r��.��1ia SITE PLAN Name GlIA�L.�1SE 0. N'�tUl'� Authorized State Agent System componenrs repru appmadc Insure thatpmpergra s � tained. A� %P �` �ol / � � �' a„po'� Ib'x��,� >ioa'. Tax Map #�i aq Parcel # � 3 � Secrion/Lot# �ii<�3s 3�a� ►s Date contours only. The conrractormust flag the system priar to beginning rhe installation to J \°a ' "' 19 5 ' �aao4-t� �ap�0 L � � s��<s�<�� iaacr � S c.,at.�. � � (��w'� � aw�a,��. � P�.-��ls�.,� rmo. �-�v� ��r� �c M��t�� 5 »E D�stHW�rtt�C£ �++� CA,t��c��o ORMc�F�E4p /F�'��4 � 4� v�tR' A�.�. Gw�c'itt� wrt�(L. Rwh"i Fiwi� U�tr'ttr� �E�O .,'� MP�tJ-�a. P�. 5�'R��tIS . � �w,,r�w �`� �r W�4� w c_ar�a � �xi t3t� . w oQo�Q I { � 7� f . / �� C�rtass��0 wF�'CEdLw1�.Y ��, s� ��.� �� I��.�a��,.-�-�. m�.��.Il IF-� � �.IL�I� Applicant: Location: ',� O�eration Perrnit Taz Map �1a°I Parcel # 13 Subdivision � Phase/Section/Lot # -- # of Bedrooms '� System Type (From Table Va): J716 Product (IIIg): ��- Type V& VI Expiration Date: _�.1 � 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. D��- ,A _ sr►r�1 (Authorized Agent) C�.��t S4L.�Moa (Licensed Contractor) � � Scale 1� T'S PCHD, rev. 12/14/12 � � �• 9.�L' � ��b, , �•G. � � S1{�P f�w6. 11�'��1b' �,�„ Pc� � � 0 0 � � �'io�c�� -iAX cy- ►�•�.� 9 �`I t ate) y a� r3 ( ate) a � W£1.L �� ss o F t��c� ��au:�� f �Rf�.S � Line Len! 1 70' �Z, `1�� Tntal 1y0' Tax Map: �� Parcel #: 1� Septic Tank System Checklist (Type II-I� System Type: "B� C� Se tic Tank InitiaUDate State ID & Date: �p-a� �pAS 9 �*1 � ��-�a � Capacity: ►�S -1av� Tee and filter Baffle Vent Riser Outlet boot Perm. Marker Distribution D-box (levels set) 9 �� 13 Serial -- Pressure Manifold --- LPP -- Notes: t,.��s.. wAs 'tl�Ei�1,t, D2��a,Ea �'T�t1�. � S�aP�►L 2i�.SPE�a't� . Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes• `�� ` ��.�� : � ��-; ; � � ''''�"`''- • C� (�J �..T�T��.' , �,.,�-?��--� ^ Il�:.a:n��n� ct� n-�. n.�rn ��.eu.�l .�.�.� �.�..�1 � i�n b�J�� P�� (��w��p�u�� r��: qag ��: �3 �flfl�9Q�fl�'flS�O%fl: ��p�a��ant'� ialaaaa�: Ct�..►�E A_ k%tc.-�va I'�IIaIl�IIlfl� �s�Q�Il'�SS: ��&OIIfl�E 1�fl1HYfl�D�Il'�: I�ag: �L��i��a ��£ ��-a�a��y: Nw�t 4 y 54� � Rib�rc oc�m ��c� Av-�r1 W� � OctivEwrt`t �t� 13uu1 Ci�ta.t�S 'ot� ��T :4 ea�rs�i� C'ondi�aons: 1) See attached site pinn for pYoposed well location. 2� All appdicable StatP and County regz�lations governing constructiolz and setbacks crpply. 3) Permits expire .S years fr-om the date of isszre. ��her �'�n��g��a�/�L'��a�e�a�s: Mn��t,� lao FcEP � 5�rt� 5Ys�t�M ��-arma� is�u�s� �Sy: d��. Q. �.�.� g9�$�: 3Tf �3 ��'R�'��+'��A��E O� ��l�I.,�'�`Y�l� l�d��v �I�g� 1i�ns��s:�.`n�a�: EHS/Date Location: Uris �o + ►3 Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: b�/�il D�fl1I��• Pump Installer: '�'�� bw: Date Sample Collected: Person County Environmental Health 335 S. Nlorgan St., 5uite C Roxboro, �iC 3757; ILn��a� �a�s}��c�fl��: EHS/Date Installer: Depth: Grout: �� A�aa�c��mr�a��: EHS/Date Completeri: Method/Material(s): _ �.,��e��e #: License#: Date Results �/lailed: Phone: 336-�97-1790 Fax: 336-�97-7�08 8/1i08 _ � . ._ . . _ _ .. ; � i � . . �.�.-.,� : -�-�.�"' nsunng a healthy envu-onment. ; � :.�./ � �� _ _. _ _ _. . �n��n��na��n.c�n��.� ��.��n. Date: January 25, 2006 Greg Blalock 481 Robert Whitfield Rd. Hurdle Mills, N.C. 27541 Re: Application for improvement permit for lot on John Allen Rd. Person County Environmental Health - Tax map: A29 Parcel #: 013 Dear NIr. Blalock, � � . •� The Person County Health Department, Environmental Health Division, on Januarv 25, 2006 evaluated the above-referenced property at the site designated on the plat/site plan that accompanied your improvement permit application. According to your application, the site is to serve a 3 bedroom facilitv with a design wastewater flow of 360 Qallons per day. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940-.1948, and the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DEI�iIED. A copy of the site evaluation is attached. The site is unsuitable based on the following: Unsuitable soil topography and/or landscape position. (Rule.1940) _ X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941) X iJnsuitable soil wetness condition (Rule .1942) � Unsuitable soil depth (Rule.1943) Presence of restrictive horizon (Rule .1943) X Insufficient space for septic system and repair area (Rule .1945) Unsuitable for meeting required setbacks (Rule.1950) Other rule: _ These severe soil and site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified innovative or alternative;systems. However, the Health Department has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified iJNSUTTABLE and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). phone 336.597.1790 fax 336.597.7808 20-B Court Street, Roxboro, NC 27573 However, a site classified as UNSUTTABLE may be reclassifed as PROVISIQNALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is attached. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUTTABLE. You have a right to an informal review of this decision. You may request an informal review by the soil scientist or environmental health supervisor at the local health department. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil scientist. A request for informal review must be made in writing to the local health department. � You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. To get a copy of the petition form, you may write the Office of Administrative Hearings or call the office�-at .�919) — 733 — 0926. The petition for a contested case hearing must be filed in accordance v�nth the� provisions of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335(g) provides that your hearing would be held in the county where your property is located. PLEASE NOTE: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WIT'HIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is Januarv 25, 2006. Meeting the 30-day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeaL � If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of Environment and Nahual Resources. You must send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of your petition to your local health departrnent. Sending a copy to the local health department will NOT satisfy the local requirement in N.C. Gen: Stat. 150B-23 that you send a copy to the Office of General Counsel, NCDENR. You may call or write the local health department if you need any additional information or assistance. Sincerely, . N� Justin B. Smith Environmental Heal�h Specialist Person County Health Departrnent Attachments (copy of site evaluation and copy of Rule.1948 (d)). • Appli2:ation Date: �"3'�� • Tax Maa #: �t z I Amount Paid: .0 • Receipt #: Parcel #: I� i��- � a�� ss I�'I�I�S O�T - - ' z ��- ��.�-��,.-,-,. ��.n ��.a�.� , � � � Y s` N APPLICATION FOR SERVICES � �O� IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. . 1) Permit requested bx:(Owner/agent/prospective owner : 6 r � lal oz,i� Home Phone: 5q' I- ZDZ� Address: 1� �, i Q,�� Business Phone: d- 5 , i S 2) Name and address of current owner: w � � �� Q,t-y� "j� �-}p�� ' �C 3) Property Description: Lot size: l, D Township: �� Subdivision: /� Lot # Directions to the property (Includin� road names and numbers): , 4) Proposed Use and Structure Description: answer each of the fo1l,owing questions: a) Proposed �/ , Existing � Type of Structure:�G � �� #c',m Width: IZ Depth: � b) Number of Bedrooms: _� Number of occupants or people to be served: 3 c) Basement: Yes_, No � Will there be plumbing in the basement? d) Garbage Disposal: Yes , No ✓ 5) Water Supply Type: Private (new �or existing�, Public___, Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the 'site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. � L Legal Representative 3� Date PCHD, rav, 06/27/02 : � . .. S�,,� ?:��:`:�:� ��'. � �� `� ".' • -< � ,. . r` ''<•' Y N�� . �:�� `� :�;.�'ii;: � . •„ •., . � �.�.':V '.�r^` �r. r';., ..,:.�, �• ::. . i �.. . ._ .. . ' •.'•.• ••' :::>a.:::::��.; :..,.=`�M!; , �:�f�:^��•�.;.>i: � M'�ti^v+S:;�,-K•y��[4';?ti��-{^;;�'tt'�n+ Jh� . r.y.1•�r�♦yw.��y� . j . ��s�iw,��NtvA��~��ver+Ai•'��1�+� . .... �l�.v.•ti. • f • � �JliiliY.iLCJL . • Y�� ri SiYVYJ�/ ��•�Y\ �� •I�Y�W ��YJfS3�� T� � ,,Q2�_ P�� # �.� � ro�: � �li��: G� IQ �� r�=, � - sui�division: Lut # � I.00�OII: yQ S�� d _�e � Il L� l�O n"'-'� -v �Z ,►'M �'!G o n. �_ . �� • -�cJ • �� • `�� Ot'�A�H',►�16�D�D�: V l�1V1d11A1 �.'OIriIIlUII1�J �111C ��'M . 7 , � ��1'CffiB9E�: �� ' • � � Sl� �pI'OVed B�/: � � � '� -O la fronting� p�roved. By: CS � - �3 �� Well Log-. C5 a�- �r-ota Pump Tag: / ' . Well Tag: � ' �w�: � � � a -�-o� �� s�: � � casing xei : ✓ � . C:oncreta Slab: v� . . . ��iri� . 7nstauad by; - s Depth set• ' . Gmuted: � Date: ' � • w� s�ie: � l,�oS2.� �Z �s c �x j - • . . � cnz �.1y 1(0" 4�,^ S'�, -to . �ITe;ll Driller: �- ��.Q.-� eas` ��\. i �� ,a.Q-• Well Approved by: ' � I�ate:, 2 , �� . .� � �� w�� *��*3ee �t�cli� Sit� S�etc�t�'*** Wells must be 10 feet from pmperty lines. �(Jells must be 100 feet from s�ptic systems. � �lells must tie at least 2� fest from any buiiding foundation. Z<< ". Other conditions: . � . s PG'� rev O11'�71Q4 m � .. t::• . -`�1;;�/ �1l..�I��J�.1� `_' �—.c�;Q.��1"JC� ��-�,m,.,,,,��¢.m.n �,��.Il,�� ,..- •+ . , , .. ••-� ►, . � �� ■ -• �.-�i S�'I'�. S��'I'��: Tag Map # 2q Pa�cel #L3 _ Section/Lot# � 3/� Date � System com�ionents represent approximate�contours only, The cont�ractor qtarast, flag the systesri�irior to beginning the installatzon to insure fhat propergnade is maintained � --7 aarn5 � � 1-_ __ i � � _-_. Scale 1 �o�' -� sca ��i �,� � 5��, , -- s rev. 09/L/01 1. We(1 C tract� Information: ,,� f / V,�/; ) , ^ �, Well tractor Name �l�( NC W ll Contractor Certification Number � � 4(J J� [ �� .�� -� Company Name 2. Well Construction Permit #: List all applicable we!! construction permits (i.e. County, State, t�arim�ce, etc.J 3. Well Use (check well use): Water Supply Well: ❑Agicultural ❑MunicipaUPublic ❑Geothermal (Heating/Cooling Supply) esidential Water Supply (single) ❑IndustriaUCommercial OResidential Water Supply (shared) Non-Water Supply Well: ❑Monitoring ❑Recovery DAquifer Recharge ❑Groundwater Remediation �Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control ❑Geothermal (Ciosed I.00p) �Tracer ❑Geothermal (Heatina/CoolinQ Retum) ❑Other (explain under #21 I 4. Date Well(s) Completed: f�' �� s. wev I.ocahon: ��,L%.r � _r, �? � ��, ��'��,n FacilitylOwner Name Facility ID# (if applicable) Physical Address, City, and Zip � � '�� .`% %�,r:.�� %.� County Pazcel Idenrification No. (PII� Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one IaUlong is sufficient) N W 6. Is (are) the well(s): �fPermanent or ❑Temporary 7. Is tttis a repair to an existing well: ❑Yes or CdNo Ijthis is a repair, fil( out known well construction information and explain the narure of rhe repair tmder d 21 remarks section or on the back of this form. 8. Number of wells constructed: � For multiple injection or non-water supply wel/s ONLY with the same canstruction, you can submit one form. 9. Total weli depth below land surface: �"� (ft) For multiple wells list all depths if d'�erent (esample- 3(�00' and 2@I00') 10. Stafic water level below top of casing: � 3 (ft.) Ijwater level rs above casing, use "+" { 1 11. Borehole diameter: l: t (in.) 12. Well construcNon met6od: � �� (i.e. auger, rotary, cable, direct push, etc.) 13. FOR WATER SUPPLY WELIS ONLY: 13a. Yield (gpm) � Method of test: �� /(� 136. Disinfection type: �� / ' Amount: ' 14. WATER ZONES FROM TO DESCRIPTION � � fr� :� � � !� t� f� I5. OUTER CASING for mu1H-cased wells OR LINER if a licable FROM TO DIAMETER THICIINESS MATERIAL ft � ' ft �� m• � � � 16. INNER CASING OR TUBING eothertnal closed-loo FROM TO DIA11fETER THICIINF.SS MATERIAL fG ft. � tt ft � 17. SCREEN FROM TO DL4METER SLOT STZE THICKNESS MATERIAL ft ft � ft. ft in. 18. GROUT FROM TO MA7'ERL1L EMPLACEMENT METHOD & AMOUIVT f� fr. fL fG ft. fw 19. SAND/GRAVEL PACK if a 6cable FROM TO MATERIAL EMPLACEMENf METHOD ft. fL ft ft. 20. DRILLINC LOG attach additional sheets if necessa FROM TO DF.SCRIPTTON tobq hardness, soiVrock e, in s"ae, etc. '1 ft / ft � /� ft - fL i � tt. � fw n ' .. . �' (.� ft ��+ ft .♦ : fG � fG C'��,� • ft f� ft, tG 21. REMARICS 22. Certification• /� �, ✓:J • �G" /G ^i l � l�13 Signature of Certified ell Conlractor Date By signing this jorm, I hereby cenify [hat the wel!(s) was (were) constructed in accordance with I SA NCAC 02C .0100 or I SA NCAC 02C .0200 Well Construction Standards and that a copy of this record has been provided fo the well owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. 24. Submittal Instructions: 24a. For All Welts: Submit this form within 30 days of completion of well construction to the following: Division of Water Quality, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 246. For Iniection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Quality, Underground Injecrion Control Program, 1636 Mail Service Center, Raleig6, NC 27699-1636 24c. For Water Suoalv & Geothermal Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of completion of well construction to the county health department of the county where constructed. Barnette Well Drilling Inc 336 598 9275 02/09/06 05:25P P.001 .�.��;��s�� . . �� : .�,�: .YyY . � :��T°��Y ' � � r.�c� Gv ��vn:�-��.��,�.�::�� .��a�:� D�o D�l � • � -dC� /� Grout Log p �wner: U- ICe • c� �� . Tax ' ap �l Parcel #�.3 ioCatiOn: �`v � � �M $111X31`Vi5i0n: I.bt # ,-.�� ' WeII Constr[�ctiun Distancc From nearest Property Line (Minimum 10 feet) Q Distance f,cotu Scptic Systcm (Minimwm b0 feet) �,_ Totul Depth: � ft Yie1d: � GP� • Static Water Level: � j-- � Water Braring Zanes: Dcpth ��!� tt #i ft f� a�- ° N� ��5�.� Casiag; ' ' riepth: From -�— to �,�` ft. Diamctcr. / � in '�pe: Galvanized Steel _�_ Weighr: Thiclmess: �_ Height above C'xcound: 1.� in � Drive Shoe: �Ycs No l,ny problcros encounccred while sctting casing? Ycs a If "yes" give reason• . ._.._ Graut: • � Nesit: Sand/Cement Concrete Gt��+eUCemtnt , '. Amlular Space Wadth � inches Vlrater in Annular Space Ycs No Method. of Crrou� Pumped Pressure Poured I?opth to Ft Materisls Used: No. $ags Portland cement � Weight o� 1$ag Pounds if uwct�e (ssad, gravel, cuttings) — Ratio to ID Fja�� _ Y�s � No 4 x 4 slab Yts No Y.inAr� � —• • n� Ucpth: Datc Instailed: From / To Driiiling Log Cixour. Tn,etalled by: Lncation Drawing - ]Formatioa �� { a �� S_ t � --. o•-�.c�_ S s�` n� 1(•�.�. (!.l �'1 �� I hcreby certify that the above informa#ion is comect and that this wcll was constructed in accordance witl� regulations set forth by the Peison County T3ealth Dcpamnent: •• —�..��,�` . Si�atarc of � ��Cy ID# Date . o? o_ I %� v �'nmp �ttst�llmcut - . /� � �'ump Installativn Cantractoc ��--R-�� State Regis�tion Number: �CG �s. � Pump Depth: �o�C� ft Static Wat Levcl• � ft �'— pump Make & Model: C� Pump Size altd R,ating: �hp ,_ f d gp� I hercby certify that this p�anp was installcd and thc wcll head completed accordin� to the Person County Well Rules in effcct on this date and that a copy of this r�ca 1�cen pro 'ded to the well owner. . �,� Pnmp bnsfaller S' �_. r� --• -�-- .. Date: ,r� '.f�". o q P�i�D rex Q1 C"�7!l1.4