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A29 16Application Date: -��" � � Tax Map: �� Amount Paid: �p� ,OU Parcel #: I G, Receipt#: � i a63� `.��_ ) � �� _ ____-- - � ' � � �� / -�-0 �--�.��a �a�mm.,.��,��:�.0 �¢�,.�.u�� ' ��y� e� Application for Services (Septic Systems and Wells) �a`�'� Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 endl ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit �Few/�2gplacement/Repair) $300.Od[$200.0,�)/$75.00 O 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 eS rvices Requested by: N a m e: S h a r o n W. W h i t i f e l d P h o n e #( h o m e): ( 336 ) 597-4235 Address: 338 Leasburg Road (work/cell): (336)503-5205 (work) Roxboro, NC 27573 (919)408-2288 (cell) 2)Name and address of current owner (if different than applicant): Name: Ersene C. Wrenn Address: 525 Weldon Wrenn Road '� ��u�'uS �re �� Roxboro, NC 27574 ��r�- t"��C`v� 3) Property Description: Lot Size: �• 3 Subdivision: Lot #: Address and/or directions to Property: 525 Weldon Wrenn Road Roxboro, NC 275 4 4) Proposed Use and Type of Structure: Residential x Business/Type: � � Other Number of bedrooms 3 / Number of people served (seats/employees): 4 Basement: Yes X No (with plumbing: Yes No � Garbage disposal: Yes No X r------ 5) Water Supply: Private Well x (Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted annlication must also include: �➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am su6mitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. � Signature (Owner/Legal Representative): ��c� C' -�c%ti,,� Date : 04/12/2011 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) o� � t�v j2C� �� J �� ..,,- �--�- � � TCT�7�� ° .�n�a� am �.n�n ��n.��.�. �� s� �s�..11 tE.�n. W�+ �,L PERMIT (New �Repair� P. cemen-�' Taz Map: � Subdivision: Parcel• q, Lot: Applicant's Name: � Mailing Address: o ?5 Phone Numbers: Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County �egulations governing construction and setbacks apply.� 3) Permits expire S years f�-om the date of issue. �, v Pe�mit issued by; �ate: �! ��--/ / CER'I'�+'iCATE O� C�N�LE'1'IOl�T New Well Inspection: Liner Inspection: EHS/Date EHS/Date Location: �_ 5 � - (2- ( � Installer: Grouting: � _ Z�_ � I Depth: � Well Log: Grout: Well Tag: J Pump Tag: Well Abandonment: . Air Vent: -Z.� l r EHS/Date Hose Bib: Completed: Casing Height: Method/Material(s): Concrete Slab: Well Driller: gCt � n�� License #: Pump Installer: License#: 1 Well Approved b. I)ate: � Z�-(( Date Sample Collected: S- ZS-�� Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: ' � Phone: 336-597-1790 Fa�c: 336-597-7808 S/1/08 . `��J�� V � f /!� T� p�p �.�. 7 ^^ 'V 'V � 1L � 1�,��•�,m,r,..,,��.¢�.11 ]HI��.11�l�. Name �(Sene. W�ehn Sub n -- Authorized Sta.te Agent SI'I'E S�TC�-I Ta,g Ma.p #�1 Pa:tcel #�._ Section/Lot# �f —l�'—l� Date System components re�resent approxirnate�contours only. The contractor »aust, flag the system prior to beginning the installation to ansure that pm�ergnade a:r maintained , � /��1��►� a�I S�e{�zc�s _ :� -�� .`��. �� - � ,.. -,��., , � � �` � � � ��. �� n�, °�. � � ' �_ � �,� �-� ``�=� —� -'� __��;, `� i��, � _ �T � � � � �. � � �.. . . � ��. � �r � � �� :. . n � �j v � - i7Y A 1 g", . t�,y I . G� , ` . !4" e_ �� (V U ��. , " �'.� e . � � �� ,�� ,1r,� ;;�F� �� . �� :� � � . �. �� ; - �r , : ,. �-, - � ��: � `��. � �� ,. P.� ;�� ,,�,, I �i.«.A�.." _ �. Y V$y: � ':.�.. �,.,.. ��+�..m+},�... �:$f4;.'. n... North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH ERSENE WRENN P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://sloh.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 325 S MORGAN STREET 525 WELDON WRENN RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES052611-0028001 Date Collected: 05/25/11 Date Received: 05/26/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 7.5 Sample Description: Comment: Time Collected: 1:30 PM Collected By: J. Smith Well Permit #: A29-16 GPS #: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) r -Arsenic < 0.005 0.010 mg/L ;Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 23 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 5 mg/L Manganese < 0.03 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 g,g N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.50 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 96 mg/L 'Total Hardness 76 mg/L Zinc 0.26 5.00 mg/L � - Report Date: 06/09/2011 Page 1 of 1 Reported By: �%�c i�ur� Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH StarLiMS Sample ID: ES052611-0059001 � �� ES Microbiology ID: 27426 GPS Number: Sample Description: Comment: Name of System: ERSENE WRENN P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slqh.ncqublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 525 WELDON WRENN RD. ROX80R0, NC 27574 Collected: 05/25/2011 13:30 Received: 05/26/2011 08:36 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A29-16 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result . Analyst Date Total Coliform, Colilert AbSent � Darneice Lyons 05/27/2011 E. coli, Colilert Report Date: 05/31/2011 Absent J � Explanations of Coliform Analysis: Darneice Lyons 05/27/2011 Reported By: Susan Beasley ..' aI- / .- . 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. _ •' << STATF.; ��r•��,. ��=• M•�- '� �-`Z RESIDENTIAL wELL coNs�ucriorr �coxn W�`f �,I�"]Y'�%. �` �' ?�, �,�: North Carolina Departrnent of Env'uonment and Natural Resources- Division of Water Quality • � ---�-- ��%.� �-�� 3�6�-/-� � - .�""- �VELL CONTRACTOR CERTIFICATION # 1. WELL CON7RACTOR: � � � n Well Contractor (Individual) ame Bamette Well Driilina Inc Weil ConVactor Company Name � 611 Bamette Tinaen Rd Street Address Roxboro NC 27574 Ciry or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2 YVELL INFORMATION: WELL CONSTRUCTION PERMIT#�G�t rl � ` OTHER ASSOCIA7ED PERMIT#(iE appiicabie) • �4/LG_�G SITE WELL ID #(if appiicabie) 3. YVELL USE (Check Applicable Box): Residential Water Supply LB' DATE DRILLED �' ��— �I TIME COfdPLETED ��00 AM LK PM ❑ 4. WELL OCATION: CfTY: 6�� COUNTY f P�'! S�. S wC �lXa� �,(�l�[firl K6� (SVeet Name, Numbers, Communiry, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LANC�,SE7TING: (check appropriate box) pSlope ❑Valley �at ❑Ridge ❑Other LATITUDE 36 '_ " DMS OR 3X.)OCX)WOOCX DD LONGITUDE 75 '_. " DMS OR 7X.XXXXXXXXX DD LatitudeAongitude source: �PS Qfopographic map (loca5on of we/I must be shown on a USGS topo map andattached to this form if not using GPS) 5. VYELL OWNER %�t5 nC L1�rCM Owner Name �/�� S�S l�/G(r,%n Wr�trt� If.rJ' Str t Address o heio _ C, a?S�N Ci or own State Zip Code ` �{d�- a2�c Area code Phone number 6. WELL DETAIIS: j� a TOTAL DEPTH: � � J T f b. DOES WELL REPLACE EXIS7ING WELL? YES P� NO ❑ c. WATER LEVEL Below Top of Casing: ��l FT. (Use '+' 'rf Above Top of Casing) d. TOP OF CASING IS �— FT. Above Land Surface' 'Top of casing terminated aVor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e, yIELD (gpm): 3 ME7HOD OF TEST BIOWiI 2Otll f. DISINFECTION: Type i"'�Tf"i Amount 1/2 Cut� g. WATER ZONES (depth): Top l ro Bottom 1 r 2 Top�,S _ Bottom�Z._ Top Bottom Top Bottom Top Bottom Top Bottom Thicknessl 7. CASING: Depth Diameter Weight Mate�ial Top O Bottom�L Ft. �� • ! �lY � ✓aa �� Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Method Top a Bottom�� Ft. Sand/Cemeni Poured Top Bottom Ft. Top Bottom FL 9. SCREEN: Depth Diameter Slot Size Materlal Top Bottom Ft. in. in. Top Bottom Ft in. in. Top Bottom Ft. in_ in. 10. SAND/GRAVEL PACK: Depth Size Material Top Bottom Ft. Top 8ottom Ft. Top Bottom Ft. 11. DRILLING LOG Top / Boztt.om a Z / ?D ZO / Ze � / / / / / / � � / / / . 12. REMARKS: Fo ation D s/cription �,/ ��lSa�.c�/ � �gn.cLi �— rrY2l!/� .�C Q/art��, � I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ; ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION : STANDARDS, ANO THAT A COPY OF THIS RECORD HAS BEEN PROVIDE TO TH WELL OWNER. �! e�-� : SI CERTIFIED WELL CONTRACTOR DATE lo �•, �yq � �',l� �, �' -� : PRINTED NAME OF PERS CONSTRUC NG THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 � Rev. 2109