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A29 226f s • ` � Q � � �Q �� % An lication Date: � j� �� ' O� Tax ilian �: ��Q P�� Amount Paid: �00 • d b � �-� � Rec�ipt �: ,� �i D d 6 ,- � D�rc�� : (�'-� , � � p o � 3 q � �--,�� 1�� l� �� e J, �, � = ' — � � �v-� � �- ,o c� ��.s�� .-.. ��.��.� ��,�.a¢�. �� APPLICATIOiV FOR SEi�VIC�S . IF THE IfVFORMATIOfd IIV i'iiE APPLlCAT10N F�OR AiV 1MPRLiVEiVtEi�T P��flflIT 1S IPlCDRRE�? ,F�LSiFI�� CNo��G��. �R TF1E S1T� IS ALi'�RED. THEitI T4-lE IMPROVEiUIE�dT P�i�flfll�i' s�,i�D �i1TH06dl�'�ON TO COPlSTRUCT SHALL BE�OME IEVVALlD. � '�) �� Permii rec�uested 8� : Owner/agen�/p Home Phone: - ' S Business Phane: .Sb�— b S��i �ob: l� � �ame and address o� cvrrent owner: �.✓ 3) ProQefij Description: Lot size: �(�a Township: Directions to the property (Including road names and Su C�,.e. � s; �z,� en `, - J . Lot # d) €�roposed Llse and Steuciure Description: answer each of the following questions: . a) Proposed �, Existing _ Type of Structure: �� o�� S-�. �3 .�, �l �JNidth: � Depth: b) Number of Bedrooms: �_ Number of occupants or people to be served: �_ c) Basemen� Yes , No y/ VViii tttere be plumbing in the basement? N p d) �arbage Disposal: Yes � iVo _ 5) Uilater Su�ply Type: Private �/ (new � or existing�, PublicJ Communiiy_, Spring _ Are any welis on adjoining properly? Yes_ No .✓(f yes, please indicate approximate location on the y�''. 'site plan. o) Does youP property cantain previousiy idenie�ied jur�sdic#ional we4lands? Yes_, fda�,� PL�ASE i�OTE THE FaI.LOWIIVG: � A PLAT OF THE PROPE�TY OR SiTE F�.l�Id NiUST BE SUBiU11TTE� Wl�i 'i�-81S ,�►�'QLICA��ON. ? P€tOP�3iTY LINES APID CORNEi�S MUST HE Ci.�►RLY NiARKED. �, 9 TNE PROPOSE� LOC.4TION OF ALL STRUCTURES MUST SE ST�D OR FL�GG�i3. 9 T�iE S1TE iUIUST BE R�DILY ACC�SSIBL� F�R Af� El/ALllA'T10N 8`( iHE HEALT�9 i�EaARTM��IT STAF�. � I hereby make appiication to the Person County Health Department for a site evaluation for the on-siie sewage disposal system for the above-described property. I agres that the contents of this application are true and represent the maximum facilities to be piac�d on the property. I understand ifi ihe siie is altered or the intended use changes, the permii shall became invaiid. Cwner ar Legal � 4�i��a3 Date � PCiiD, ret_ 06127;02 � ::t;;. `�.�� LtiJ �� ' � � �� IE��.s-�� .If. I��,�.�11� APpucaz�i Locatinn: i�rnru` �r�st �- - - � T��rh f'.�f-� �� :t r r_ : .f :' . S�u.i� cl i v i:s�:i:a�a F la��:�s.e<S e�� i o r�i!-La c� � ��v�e� Pe� ; Pe�it Valid for ✓�'+ive'Yea�. Rt� �gira�n "� + � 'I`ype of Fac�ifi�: ' .�- , - `� . . New �/�ddition �� mpp1Y�� # of Occupants lQ n�+a. # of Bedroam� 3 �� Pxojected Da�y FlowZ,coc� , g.p.d. - • Proposed Wastewater S�t�m: ��r►� bn�`��a.�i � __ . Type: PraposedRepair. �� C�/. �.u.ac�.�•�. ' � 1'ype: � a, . Pe�it Conditions: �wner or Legal Rep'rese A.uthorized State Ageut: � � 33C�- 5 9 �- 1'�9 a. Date: /- / - a � Date: S-a -o� , .., _ . . . 7he isauauco of ifiis permit by the Health Dopar�ent ia es not gumantee li�e issnenca of oth�r peunita It is the respoasib�iiy of ihe applicantfproperty awner to in snro that aII Peason Cowiey T'lar�ning and• ZoninS and Bw7dnug InsPectians reqnirements are met '�is 3mprov�ent P.er�uit is sue�jec# � revocmtYon ii t!►e �ite P1an, Plat or the inteaded use ehauges. The Improvemaeae# �'ermit is not affected b� a'change � ownerahip oi the �eroPertg- Thi� Permrt was issneai in compliance wltt► the provisinm� of #d►e Noa th Csrolina 2aevs and 7fules,fQr Ser�a�e Tfeutme�at and �isnosal ,Sw�tern�'_(155.� NC4iC.18A .1900). N��r Persan C��t.y nor the Y�nvironm�mtai �eal#�a Speciatist w�'raut� that t�ae aeptdc tmn�c s�stem w�l aontfi►ue to fanc.tion satisiactora�X in t�e futare or that the vvater �u�ply w�l remain potai�le. � " ' . . �An�o�#amn #� ��#�act�'��ev�ater� S�stegia ��eqn�ed �oa� ��a1� �er�it) . * See site plan and addittonal attachrnents l��. � • Proposed Wastea�ater SYstem:S .�n� �onti �ro.�L �1Pe J�_ Wastewater Flow'��. g.p.d New �C air P.�.�ion � 3oi1 I.�TA�t: . 30 g.p.d.l $ 2 Type of Faailiiy:- � l� �� •�Basement �Yes x No � ��vater Syste� I�equire�t�emts � � Size: Septic T�k:100[7 gai ,. �p �aaeic '- � g�l' Ga�ase Trap: "-, ,, S�al fie1d: 'Total Area: / U„�L sq $'im#� I,en� �_ ft . • ']��eac3a Dep�a �'_ an r3a �� y�_ f� Soil �mver: ��_ in Minimum'1'rencii �epazation: q$ �wiaon: �C Disin'bution Boz Sezi�1 I3istn�uti.on �Pressure Manifold 1 P10��`� �u�a��a� st:a�e �e�t• � � Date• � �c7 - 1- ��-Cl� Pennit F.xpiratinn Date: "' -I - 1 -1 tfl-a8-1� � The type af system pennittad is � Conventional . Inn.ovati e Al#ernative. I accspt th� specifications cf the peimit ' � 1 � . . +��e�rlL�g� �}�a�e��: % �-�-'�.�. �. � � . . Date: � - ! �r — [`� � � � , P�7/3�/200� .�.�,;;�� 1. V �""' "'� . � �� -�,�,� � ��.n. ��.m.a�. . � � Si'I'E. S�.']CC�I: � , Name � f�P;., �n�e x � Tax Map # � Z ; Pa.=cel #Z2 (� . Su clivision N I a � 3ection/Lot# N I A ° Q� '� � �1-- l� - o[� Authorized tate .Agent � Date ,,�,�� C� -�a $-�afl �� sy�,f, �„�o� ,��s�t �pm��contours only. The conmtctar mr�sttTag tha system prior to �P�-•�. lregitt�ing the is:stallation to insure �that propergmde r.r maintained `: �_ (� � . � f�-t�cJC ^ ^(� .-�,,��` �� 3 �z � � , �� L-t�2 _ . �.{S'(� �� v��,�,� ��-�� ( �t 1! .1�t2�v., �1-a. . 1 � ;s►-, ��,.�-, � � a� -,,,. � _- ) 0 i�l�� c�. \ �(iv, h--��` 1-�. , t' ��%U . �.,�,� �� 9�.�s+�c�-�s, �Jj� - S`'rl?- ��'7C7• '. �� ' �-- �ccr:�,.�-t.Z . �z� � , ! � z.,.G-.� � " lG�� ,�;� ,�, �{Qs;c,�c�-e� G-tz.Q . J � 1 � �^r1 a-o.h �� i�'X-c..� r �� / /`yl � SCa1e: � - c•v �� j w I ll 2' `'`o`° Yi� ,� �' �� . P `�'Q� � v � 3oc1 . �ay,o-3 � �ci:ab � ` PGHD, nw. 09/12 f Ol •�'••�'•?:��•••..•.•�� j• �n• �.,� � �• �• •.t . v••� : • ��. .�.�.L .• ��••�� l�Y'�y: .:. ...... . , . , . }.. . . '.\,�'y.ti�i"••:��'•.i:�' i: . k': •. �.�'�•� . �Nv¢}1v{.•.-,..y. ..:.,..;ti.'�+':�•..��. • . ,.` ,-.. . . �.�a:�'ai�a�r±h.:..��.'qaa�iai:��,i�;,:3��.:' �'�'�-;�,��3�a:: ': Vi�ELL PF�tMI� ' . ��A,SE SEE� A�A�H]CD PLAN FOR WE� �ST� I,A�I�ZJ'� Tax Map A��', Parcel #�� .. T�ownship: ��.,�-��c�a.. APPlicant: �'rrrn��.,v, �,�.x�e*- � Subdivision: Lot # � Location:<--Iq� �� s+ ti'o..�c��4 (��1,� (lc. � c;r�va o.: L, N � �Jn 'Pyp� of"6Vater Supply: �Individual _ Community Pnblic. $tes�uirements: Site Approved By: �Grouting Approved By: Well Log. � Pump Tag: _,� Well Tag: Air Vent: • Hose Bib: Casing Height Concrete Slab: � 07 Liner. �Installed by: ' Depth set: Gmuted: Date: � Water Sam}�le: � WellDriller: �Soy1 � Well Approved by: .� � Date:. �` 23� �7 ****Se� Attached Site Sketch**** Wells must be 10 feet from property lines. �_� `_' ells must be 100 feet from septic systems Wells must be at least 25 feet from any buiiding foundation. Other conditions: �-O � �(�.� ��- ��C9^ PCHD rev O1/27l04 �—.�� `l..d � �_•' A � � � �� n.v�-�.�-��as�.�s��.Jl. ��.�.�� x Nlap � � Farcel # Subcilivision Phase Section,'Lot # # of Bed�roo �,.s � �":. `�1 !; . , • i System Type (ln Accordance With Table Va): � THIS SYSTEM HAS BEEN INSTALLED If11 COMPLIANCE WITH APPLICABLE NORTH CAROLINA GEtdERAL STATUTES, RULES FOR SEWAGE TREATMEAIT AND DISPOSAL, AIdD ALL CORIDITIONS OF �� THE 1MPROVEMENT PERIVIIT AND CONSTRUCTION AUTHORIZ�►TION. � � . Authorize Si e Agent Installed By: -� . �� s -�- �� / �',� - ?i?�- o G `7j��fl C% � " Date � Date: . � / 6 7 `3" � �/ `�j'/z," � � . r. . � ��f/?� �� ` : ',3,�y � _� . . / I�' ._ . . lv�6„ ` v�� . ST� � Joo O ST' � `�'Z— �f- Gi��s � !� � --�1 -A�- �'ct'i V � `L� . w/caN��- PCHD, rev. 07/29/Q� �EP�1C TAN&C 9R��P��'�ON ��E��f�..9Si (%e I9 - IV) Tax Map # �ig Parce! # �o Sys�em Type (Tabie Va) �_ Owner/Applicant cs,,��.�t Subdivision AddresslLocatiori Se�fPhase Lot # State �lD/date Capacity Tee and Filter Baffie Sealant Riser (if appiicable) Tank Outfet Seal Permanent Marker Puma Tank Waterproof /Sealant Riser Checic Valve/Gate Valve Alarm (visable and audibie Electrical Components Rate (gpm) - Approved Pump Model Block Under Pump Pump Removal RopelChai . � Distributivn. Systen Serial Distribution Low P.ressure Pipe Appr. Pipe �(ateriai " �'i � Trench Width � ; ✓z ft. � Trench De th ti in. � Trenct� Len th ft. Trench Grade � Trench S acin � � Rock De th and Qual' Dams/Stendowns etc. Hole S acing � � o e �ze Pi e. Sieeve Tum- s/Protectors Require� Setbac4cs From Wells � � From Propertv lines Grade � Surface Waters Public Water Su lies � Vertical Cuts >2 ft. Water Lines " � � V � � � Ve�icle �Traffic - � Other Easements Recc . Tri-I . Corremen#� pct�d rev. 3/13/0�1 ---..—._.� � :��`�, s� 1� �.� �� ' '"� � ' �� '.1az�-a��„-,.,+-'*-+.a�aa ��eaIl��a �� i��.� ►,D :: � I � Cc�►ttE�,�r�,, N�.,rtt� � � / � - ID;tt�� Di�:ilc_�cI � � , • � Well Log - Oumer: �c,n. c�nde�.�ek- T� ��9 P�a ��a� Location: �' Subdivi�ioL,� � Lot # � � Wdl Constrnction �i'�. ta�ace From neare.st Property Liue (Mir:imum 10 fcet) ! Distance from Segtic System (Minimum 60 feet) TotaI Depth: _�� t Yield: � GPM Sta c Watcr I,eveI: ft Water Bea�ring Zones: Depth � ft fi ft ft c.��mg: f o5 ` � Depth: Frorn �� to lU'�[ ft. Diameter: C.Q �� in Type: Galvanized S�el �_ 'Weigh� ,�Q��_ Thiclmess: _,�g�' " Height above Cmaund: l o`Z in Drive Shoe: ��es No Any problems cac;ountercd while setting c:asing? Yes �No If "yes" give reason: Gront: N�at: Sand/Cement Concrete GraveUCemeat Annular Space Width inc�es Water in Annular Space Yes _ No Method of Grout: Pumped Pr�ssure Poured Depth to F� '_1-iuterix�s Used: No. Hags Porttand cement Weight of 1 Bag ____� Paunc3s If auxttu�e (s�nd, gcavel, cuttings} — Ratio to ID plates: Ycs ____ I�o 4 x 4 slab ____ Yes � No Drilling Log Lacs�tioa Drswiag From To Formation G ; ' ! 5 � �_____—_ � I hereby certify that the above information is correci and that this vvell was constructed in accordance writh reSulations set forth by +hz P�rson County Health Department Si �ture of CuntrAct ID # aa - /� Date �—/" � ! � � D� � .... PCHD rev O1/16,'0�, �� . � � �...�►. � 1 �_.` �V � �.l � � � ��C1L'�'`nli°�CD7nl.7L'�C]1.uLIC11.'I�atA.� ��d.�.Jl1��71. Building Additions/ Mobile Home Replacements Tax Map #:�_ Parcel#: 2„2. (,2 Approval Requested for: �� obile Home Replacement ✓ Building Addition Applicant Name: �a✓t �'�� n ro��.�Q ��e � �r. Address: " Phone #'s: ��q�-qS/�l �oz1-- Ogg9 Permit Located: Yes No Installation Date: �-1( OC� Design flow: 3C�0 (gpd) Current Contract with Certified Operator on file (if required): Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: /D �/D -D(o (date) (Applicant's signature if site visit is not required) Comments: Addition/Replacement Approved 1 -- �a � ja —0(Q Envir nmental Health Specialist Date 11/15/OS Application Date• � / 8�i � Amount Paid: 7 � Receipt #: l 7� 9U� �-� � � 3a . _. �� ) f �11d��1 � Tag Map: A 29 ~.► • *�.,,r.. �. � ��,�� Parcel#: Z 2 % �aavaa-oaaaaacra�v►� �0�.�4:�a tion for Services Services � Improvement Permit (Site Evaluarion) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replac� $300.00/$200.00/$75.00 0 Construction Authorization is denendent on the type of ❑ Permit Revision $75.00 � Repair of Ezisting Septic System Annlication: No CharQe/ CA $150.00 or $300.00 1) Applicant Information• Name: Phone (home): ��( " '" �� Address: —'i ' (work/cell): 3 — ' 2) Name and ad ress o current owner (if different than ap licant): Name: Q.�f1 � � � ' Phone: .�%i�o—��i "b4'$ 9 Address: 3) Property Description: Lot Size: .�L Subdivision: Address and/or directions to Pro e C P rtY� Lot #: � �,. �. ��-�'�. . � � ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes � no Does the site contain any existing wastewater systems? 0 yes O no Is any wastewater going to be generated on the site other than domesric sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes � no Are there any easements or right of ways on this property? � (if `yes' is checked, please provide supporting documentarion) �� 4) Proposed Use and Type of Structure: 'h� ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: O Repair to Malfunctioning System Will there be a basement? � yes ❑ 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 ❑ E�cisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no Please note any known ground water restrictions or sources of contamination: 6) If applying for �Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted 0 Innovarive ❑ Alternative 0 Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccura�e, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signatyi�e (Owner/ Legal Representative*) * Supporting documentation required. q� q-r,� 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. �� sf ��.� �� - � � �� ra�n�r.-�aa�m�rn�.m.� ��Il��a WELL PERMI� / , (New _ Repair ) {�-� � � Tax Map: ��( Parcel: �� Subdivision: Lot: Applicant's Name: (i� � '��X�P�r �c7 W',j� �,�' "`S Mailing Address: �,�,t ` 1� � � d v� C ?S�1 Phone Numbers: Location of Property: 7 40 �vkk.q�s C�-tq¢e � CL- � �� 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 S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: � QNew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Date: C � t ? � � (�o Certificate of Completion �iner: EHS/Date Depth: ( `LD � Grout: ,/SS q• i 3 -1(p DAbandonment: Date: Method/Materials: J.�1 ✓(,d ) r n v�� License #: License #: Date: Additional Com`nents: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 �� y.��.. �� ""r� � �'Y � �� il. �</ ICit"Y Ai '.I' �i 1IiL ]LZC"S sL Iiil `�L.;It:1. A�L 1L �L: �".L zl il. J�1 Date: 2 /1�/� Name: _(�,�a��a Po�ho�e�c .-� Address: qq p �(nunns C�a�,� CJ� ur� �. ��s�at'��Z751 �j i Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel: 22l� Your well water was sampled on �/�/ j�, and tested for both total and fecal coliform bacteria. Your w r sample test results are noted below: 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 bacteriologica[ results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 7'otal coliform bacteria are naturally found in the soil. Fecal coliform b�cteria are associated with animnal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total or ecal coliform bacteria should be properlv disinfected and retested prior to resuming normal use. The 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, � �;3= � E ironmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences f�icrobiology 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: ES020117-0094001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http:!/slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: CLAUDIA POINDEXTER 990 YOUNGS CHAPEL CHURCH RD ROXBORO, NC 27574 Collected: 01 /31 /2017 10:45 Received: 02/01/2017 08:25 Sample Source: Well Sampling Point: Well head J Smith Susan Beasley Well Permit Number: A29-226 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent o2/02/2017 E. coli, Colilert Absent 02/02/2017 Report Date: 02/02/2017 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. ��;�� i��'�'/1 ' nc department of health and humen serviees �� , I ;� ; r _..,, � � �;� � `f� � � � E � � I �r�r�� V 'rs�� C�a � � �•� !� � .I> z � E^ ;�' ..ry E ��; `.. ' �—., � --�,. rz `� �" V'^ d � s ;�` �� : �� r'' � ! �,.,�—� ��— "� I�S I� �i J S � � � i ! E e ; j :;� � �-_ —. � y-- � , ti �`. F k •` �...�s' ��' �._.� �u ,�'i �� ._..' �,•.� � � � € � ( �..� o I ,' ;�, � c ,� :' E �._.i County: ,t,�s�h � Sample ID #: For lnorganic Chemical Contaminants t... � � .•',' Reviewer: , TEST RESULTS AND USE RECOMMENDATIONS 1. Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results on[v. You may have other water sampling results that are not taken into account in this report._ 2. 0 The following substance(s) exceeded federal drinking water standards orthe 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 instali 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 J Fluorido � Lead � Iron Man�aneseTMercurv Nitrate/Nitrite Selenium Silver Magnesium Zinc � pH 3. � a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. 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 inor�anic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad ta.ste, odor, staining of porce(ain, etc. 4. � Re-sampling is recommended in months. 5. ❑ Re-sample for lead 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 the source of the lead and/or copper. � 6. 0 The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorPanic chemical results 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. Barium Cadmium Chromium Fluoride Iron Maneanese Selenium Silver pH Zinc For more information regarding your well water resu![s, please call the North Carolina Division ojPublic Health at 919-707-5900. Report To: North Carolina State Laboratory of Public Health 3�2 Distnc�Drve Environmental Sciences Raleigh, NC 27611-8047 htt�://slqh. ncQublichealth.com Inorganic Chemistry Pno�e: s,sassa3os Fax: 919-715-8611 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: CLAUDIA POINDEXTER 990 YOUNGS CHAPEL CHURCH RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES020117-0037001 Date Collected: 01/31/17 Date Received: 02/01/17 Sample Type: Raw Sampling Point: Well head Sample Source: Well Temp. at Receipt: 1.5 Time Collected: 10:45 AM Collected By: J Smith Well Permit #: A29-226 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 mgi Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manaanese 5 < 5.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.00: 2 < 0.03 m 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m Mercury < p.ppU5 U.UUZ mgi� Nitrate < 1.00 10.00 mg/L Nitrite < 0.1 1.00 mg/L � Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.30 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 36 mg/L Total Hardness 23 mg/L Zinc < 0.50 5.00 mg/L Report Date:02/09/2017 Page 1 of 1 Reported By: .xennet`i y'reene _, , .:._: �...�W � _..,.�...---__ � ,�.,� _u_�_�� ..u_�� - � - _ .._.._ _ __.,_w ��._. _..z�m�.. �� ►� `�-o s�y ProQ�r4y � �.. �c� �-zg-o � ,��.�s �� «. � ►� b �� .�,�. s urv •�� ,� �o N e �eek o � � �- � -o� 3 - a � �� '�►�5 -� r�. 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