A29 174Application Date: g' ��-� �
Amoant Paid: 0200 . OQ
— Receipt #: l -�02 1 c� .S
� e.�S-�-} - �..
0 Improvement Permit (Sits Evaluation)
$Z00.00/$30Q.00 (if> 600 end)
0 Mobile Home Replacement or Bvilding Addition
$ I50,00 if site visit re uire
Wetl Permit (lY�vr�(iteplacement/Repair)
��,;,�,� ll ����1. V Tax Map: /402 �
- � � ��,�.� . Parce!#c r� � `7'�
_lL�me*aa•anTM*•�*�*�zAdan7l 1(�Ie,�,$d,�n � _ _ _-
�lication for Services � ee � � �
Services Re uested
❑ Construction Authorixation
ee is de endent on the e of s stem ermitted
❑ Permit Revision
$�s.ao
0 Repair of Ex�ting SepEic System .
Application: No Charge/ CA $150.00 or $300.00
1} Applicant Info at' n:
Name: b� � - �itirP-rYY�
Address: � r ,
, r
2) Name and address of current o ner (if different than applicant):
Name: �
Address:
3) Property Description: Lot Size: r'' Subdivision:
Address ar,}�jor directiqns to Property: .�
Phone (home): ��►o �b� - 8"��3
(worWcel l): � �n .� �d � ' ) a�
Phone•
#:
� yes � no Does the site cont�n any jurisdictional wedands?
❑ yes �'no Does the site contain any existing wastewater systams?
C] yes C�Yno Is any wastewater going to be generated on the site other than domestic sewage7
❑ yes GYno Is the site subject to approval by any other public agency?
�7'yes Cl no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation}
4) roposed Use and Type of Structure:
esidentia)
❑ New Single Famiiy Residence Maximum number of bedrooms: �
C7 Expansion of Existing System If expansion: Current number of bedrooms:
0 Repair to Malfunctioning System Will there be a basement? ❑ yes D no With plumbing fixtures? � yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well LJ Existing Well ❑ Community Well O Public Water ❑ Spring
Are there any existing welts, springs, or existing waterlines on t�is property7 ❑ yes �o
J
6) If applying for `Aathorization to Constract', please indicate preferred sysiem type(s):
❑ Conventional ❑ Accepted ❑ Innovative O Alternative ❑ Other ❑ Any
1 cert� that the information provided above is complete and correct. I also understand that if the information provided is
inac�te, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signatur Ow er/ LegaTRepresentative*}
�` Supporting documentation required.
_�— 1/— >y
Date
• Permits are valid for either 60 months or are non-expiring when accampanied by an approved plat.
• A compleied `Lot Preparation' form must accompauy any appiication requiring a site evaluation.
i•n.•.♦ Tl . _ /1_ . . . i'� _. . . f rT le/ nnr Pt 11.f. ff. Ll. .�._ /1 � . .'�. �.��—� "_ " _'-.
Tax Map: �
Subdivision:
���. sf ���.� ��
�- � � � ���r�
��cnn>n�ramsn�rna��rn�<w.� g�a��.��:�n
Parcel: i�`�_
WELL PERMIT
(New � Repair _ )
Lot:
Applicant's Name: '(L�p�c��t U- ��a
Mailing Address: 195 �,a¢.4.� �*\.a 'P�
Rox�a�.o � 1�c, �.'15`1`�
Phone Numbers: �3to� 503- 85�3 j3b �y- ►a�i8
Location of Property: y� Sa� ���"c*1•'� M�.�,� RA ����� W�r�+, � 7
c� � -s..�sc ��� � t95
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.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: ��CiL �- 5��
�New Well:
EHS/Date
Location: �S - �(�j
Grouting: �
Well Log:
Well Tag: �as i�`6-l�k
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Date: 8 13 1
Certificate of Completion
�iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
� � License #: -'--
�� License #:
Date:
Additional Comments:
Date Sample Collected: 10 - 8-1�} a;1� �cti
EHS: d�0.
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed: �0-�-��'
Phone:336-597-1790 Fax:336-597-7808
11/26/13
1 �1�� J f ���� �b V
�..�� � , ��� � � �� 11 �
���s�����.�.m.n ���n�a�
SITE PLAN
Name �'+*�1 �Q• �74�tilL
Subdivisio
�R4tU� A. Sn
Authorized Shte Agent
Tax Map # �a� Parcel # (��
Section/L #
813 �
Date
i System compaaents tepresent appm�mate contocrrs on/y. The contractormustflsg r6e system pdor to begianing rhe insrallnrion to
insure zhatpmpergrade is maint:vned.
� .
WELL CONSTRUCTION RECORD
This form can bc nud For smglc or multipic wtlls
i. Wdl Contractor Informatioa:
p .
���i/v �r� �/ • �1`��
w�u coo�o� N�,�
33�6-�1
NC'WcU Contractor Catification Numba
Barnette Weil Drilling, Inc.
�o�N� f� 2 �
Z. Wdl Cor+sirnctioo Pcrmit #:
Ltsr a!! appllcableWel( consuvuion pem+lu (Lc Cmmry. SlatG Yariaxe, erc�
3. Wdl Uu (c6eck wdl usc):
Watcr Sapply Wdt:
pp��� aMunicipaUPubtic •
❑Geolhamal(Heating/Coolin8 �PP�Y) �dential Wafa SupP�Y �u�81e)
�Indusc�iaVCommcrcial DItesidenrial Water SnPP�Y i��)
Supply Wdl:
OAquifcc Rxfiarge ❑Groundwater Remediation
DAquifa' Storage and Rxova} ❑Satinity Bartia
❑AquiferTesE OStortowaterDrainage
�ExperimentalTechnology OSubsidenceControl
�GeotheCmal (Glased Loop) O'[tacer
Fa Idcwl Uu ONLY:
❑Geothcmal(Heating/Cool"mgReh�m) �Othu(exQiainunder#2lRimarlcs) 1
a. nac� w�u�s� compi��a: q- 2-/ a�:nw� 2
Sa WeR Loeauon:
.�o�l. N� y !l wR�n�ri1
FacilitylUaner Name FaatiCy [D8 (if appliablc)
,_,,/ Q S Li��le� �11 �f u �����
Physi Address. City, and p
���� d� i ^ i 74�
�„oty w.�a ra�ufi�«,Nfl. trlM
Sb. I.atitudc and Longifidc in degrecslmiuota/saondsor dewnaF ileg�a5:
�ii'w�u sad, ane la�Ons i4 sa��itau� -
36 - zo - 3,C� N`7q - 4 - 3S w
6 Is (arc) thc wsll(sj: OPermancnt. or ❑Temporary
7 Is th` re 'r to an szisting wdG OYea or fitNo
�2 fL - Z A 1
,of� z��r
cc i /�i � f� ���? 18'
[L - ft �°'
(t fL 'u'
ft S1 ft
V
R h
R �
(c I ic.
ie t �
2�0 �to2S�a ���
. ��---,.��..
tr. I S" Ec I n(f e�jud�
� ,�r� 3'�4�s�idrKl�
L
i2. CtstiSe�fion: .
^ � � ��� ����
s;��ofc«ss�aw�u�a� D�.
Br r►enrr�g thit fo,m. f lureby cerrifr � rhe wen(� �wa �kere) const�ctea fn axo,dana .
vith IS�i NCAC 026.O100 w lS�t NCAC OZG .0200 Well CaratN�� �°t'dO7�T 41� � a
1S H(� coPl' ofl/+fs riooridhas bet� p+ovrded w Jre wd! ownQ
,jjrhis !s a mpnf , fdl our lmown wel! owuuucrioR l�ornwGan md.eglain tht nattQe afrhe ��� �m oc addition4l Wtll dbtails:
.eporrw�der �Il n�.�a sear'oa or on rhe 6cck oJrhts jortn Yon enay use die back of t6is 1�°c ta providc: additional wdl. site dt�ails ar wdl
8.:lYumber of wells eonstructed:
' cdnsttuction detai�ls. You may elso_attach additi�al pages if necbssary.
Formvltipfei+gectionorno+r-»aterny�lywe(IsONLYwi�h�l+esameeoasA'acBua.Ym+am SUBhSI"ITALIIVSTUCI70PIS
subm�tonejorm. �'�'
3�? . 24a For NI Wellx Submit this.6orm wi`th¢► 30 days of e�npletion of wdl
9. Total wdl deptG below land surfaee: _ �f t) ���� ��e following:
For mul�Jpld we1Gr lista!! depths ifdifjererit (umnple-3�700' nnd ZQI00')
Division o[ Water Quality, Infarmatioa Processing Uni4
ID. Statie water levd below bop of casiug: Z� t�) i�q �� �ryice. Ceater, Ratag4, NC 27644-1617
If unter level is abwe auirr� ase "+"
li. Borehote diameter. �ia:) ?�3� For [niecdon Wdls: In iddiUai to sending the fortn to the addrrss in 24a
above, al5o submit $ cnpy of this fortti wittcin: 30 days of canpletion bf well
1Z Welt rnnstracaon metl►od:. _1. r�� R a f�� � cpnstrut:tion Lo thc follotva�
Si.e auga. mt�y. wble, d'aed posh, ea.l pivision oE Water Qaalitp, Undergroand.Injectioa Con6d Pcagnm,
FOR WATER SUPPLY R'ELIS ONLY- 1636 Mail Servicc Center, Ita[aidh, NC 27699-1636
Method oftesk B1O�ZO minut 24c For 1V�►ter Suublv & Inieetion �Vdls: In addition to sendin8 the form to
13a reld (gpm). the address(es) above; aLso 3ubmiC one eopy of this form within 30 days of
complction of wdt constructioa to the county hcaltti dcpaztmcnt of the crnmty
236. Disiafecfion type_ HTH ,,ma�� 1/2 Cup ���
Fum GW-1 Nadi Caroliaa Depae�wto;FEavieonmcnt aod Nalunl Reso�sees — Divaion ofNa�u Q[mtiry
R�vistd Jan, 2013
North Carolina State Laboratory Public Health
Environmental Sciences
iViicrobiology
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: ES100914-0083001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
RODNEY D WRENN
P.O. Box 28047
4312 District Drive
Raieigh, NC 27611-8047
htta://slah.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
195 LARRY WRENN RD
ROXBORO, NC 27574
Col lected: 10/08/2014 14:15
Received: 10/09/2014 08:10
Sample Source: New Well
Sampling Point: Well head
Derrick A Smith
Angela Heybroek
Well Permit Number:
A29-174
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present Denise Richardson 10/10/2014
E Co/i, Colilert Absent Denise Richardson 10/10/2014
Report Date: 10/10/2014
Explanations of Coliform Analysis:
Reported By: Cindy Price
�nc� �,t,�,ce
U
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.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: DERRICK A SMITH
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
RODNEY D WRENN
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slah.ncaublicheaith.com
Phone: 919-733-7308
Fax: 919-715-8611
195 LARRY WRENN RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES100914-0057001 Date Collected: 10/08/14
Date Received: 10/09/14
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 1.5
Sample Description:
Comment:
Time Collected
Collected By:
Well Permit #:
GPS #:
2:15 PM
Derrick A Smith
A29-174
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 25.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 0.25 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 9 mg/L
Manganese 0.50 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 7.7 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 14.00 mg/L
Sulfate 5.30 250 mg/L
Total Alkalinity 127 mg/L
Total Hardness 130 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 10/20/2014
Page 1 of 1
Reported By: Arnold Holl