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A29 227Application Date: r P P� r� Amount Paid: g00 . �� '��d O O .,�.�.,``��- �� Pa cel#• � _s�� .. ' Receipt #: q 3 4 s�� f g�.230� �� i�'�'nnwua-tn�auaaz:�ra�m� IH�c:en�Q.�a �,}2 � .z61 __._......_ __.._...__...... _. ................._....._..._.__._......._..._........_..... ..... . Application for Services Services Requested Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $ I50.00 (if site visit required) Wett Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: �J Name: �[(CND�AS SGo �fI C��l � UE2 Address: I45< NassEr� uoaTo,��,n ��eDc� M��1- �sc�( 2) Name and address of current owner (if different than applicant): Name: �s� Address: 3) Property Description: Lot Size: 8. y 7 Subdivision: Address and/or directions to Property: �(9 s� ❑ yes �-no ❑ yes � no ❑ yes �.no ❑ yes ;� no �l yes ❑ no � Phone (home): 33( SD�/-3,2?,� (work/cell): Sq�� Phone: r.ot #: 5A Does the site contain any jurisdictional wetlands? Does the site contain any existing wastewater systems? Is any wastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? Are there any easements or right of ways on this property? � (if `yes' is checked, please provide supporting documentation) `� d�s �`� � 4) Proposed Use and Type of Structure: __ s►dential 3 ew Single Family Residence Maximum number of bedrooms: N ❑ Expansion of Existing System If expansion: Current number of bedrooms: � � Repair to Malfunctioning System Will there be a basement? ❑ yes �.no With ptumbing fixtures? � yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: L�New well ❑ Existing Well � Community Well ❑ Public Water ❑ Spri Are there any existing wells, springs, or existing waterlines on this property? es ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any �1o�ice. �• I certify that the information provided above is complete and correct. I also understand that rf the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. � 5 ls Signature (Owner/ Legal Representative*) Date * Supporting documentation required. 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) ��, ; , �� lC�s�.�a�-��.,.-„-„ ��.Il 7I��.Il�11� Applicant: ��'C�td�4� 5�-�- ��/'2�/ . �r Permit Valid for: Five Years � Type of Facility: ��5. Number of Bedrooms � / Occupants Proposed Wastewater System: Gt i Proposed Repair:,Q(,�,-y�,p �Lc�t� ' Improvement Permit Non-expiring New ,�' Addition �Employees / Seats: ��p+ ucil°�1. ryi'a �-�R. � ----- Permit Conditions: _ �� 'jt'� ��!�!�� Tax Map: 2 P rcel• 22 Subdivisiori "e �„�S Phase/Section/Lot # S,Q Water Supply: �� Projected Daily Flow: 3� d gallons/day Type: „1� Type: �� Authorized State Agent: �-+ l=c u�"�� Date: (X) Owner or Legal Re esentative: k 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 applicanbproperty 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. T6e 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 n�rd Rules for SewaFe Treatment and Disnosa[ Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Aut6orization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: P�Im,Q ��Vi°2�'o+zQ� (*)Type�b Design Flow 3� � gal./day New � Repair _ Expansion _ Soil LTAR: • 02 s gal./day/ft2 Type of Facility: `�j� P Basement: _ Yes ' No (*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank D�o gal. Drainfield: Total Area ��{ �� sq. ft. Trench Width � ft. Distribution: Distribution Box Specifications: Pump Tank `�� gal. Total Length � � ft. Min.Soil Cover �P in. Grease Trap � gal. Max. Trench Depth �y �in. Min.Trench Separation � ft. / Serial Distribution / Pressure Manifold � � �QH: �Ta' �s�l' (�Sie��, �S�.P�,� Authorized State Agent: /C��tM �-%c �v✓�P� [ssue Date: 7� �� "� ( S Permit Expiration Date: �� C$' Z� Tl�e system permitted is: Conventional �/ cepted / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: ��) �� l� Person Countv Environmental Health, 325 S. Morr;an St, Suite C, Roxboro, NC 27573/ ph.• 336-597-1790 (rev 5/ 121 ��`�. � 1PI��.� �� 1��.-�� ]E� .��.11 � Owner: .�,J�e�,alGs .SCo�-�— �' vstr Tax Map: Parcel #: ZZ7 Date: `�— ��—� 5 I�ine �'ap Tap (Sc�a) 7CaQ �lo� Line I,engtl� &'�odv / f�ot # iiaame�er vn) ( m) �:. (ft) 1 � z o ?.l 2�� .vS B �. 3 4 5 6 7 2 ✓r o 1� S 9 ].0 � �� ft of line x 65 gal. per 100 ft= ��--''� ; 100 = 3� Z- gal 75% x 3� Z ga1= 'Z3 ga1 per dose �_ gal per minute (gpm) = I+'low Itate �'riction �ead I.oss: �' �ft per 100 ft of supply line x�` �5 " ft of supply. line =100 = g ft �_ ft x 1.2 =�s'L ft of friction head Manifold Size: 3— Y "�'orce Main Size: 2" PVC �otal Dynamic I$ead = N�$ ft of Elevation head + 2 ft of Pressure head +� v ft of Fricrion Head = � c7 TDH Pump Requirement: 3� GPM @ 3 0• ft of Head Drawdowaa: Z3 al per dose : 21 gal per inch =�_ inch drawdown per dose , ;r �, a:� : � � , � . � � , - � �� _ ��i��t0 , , ,. j � � . � : '� ,: ,. ,.. �I(�)1�0�00 I iiiii�i`,iiiiiii�ii�i�iiiiii+ii�� .... ;... . ... III IIl II II/ ��+�.�.��.��N��.��.��« = = � � ,.:� .._ : :� : :: �: ym� � '� s � � 5„ ufoifl 5iz / � Tap3 Max Nu. Taps off one side lace b'/s %r ta i hoth sii t8 S 3/�" t3Ps 1" t81 4 = y g 3 16 � � ,�ia- 2? 12 � I'low er T�p Siye iYltrlerial Flo:v G�yI !, " Scf:ed 30 �•� 1, " Sched 10 7.1 s, �• �cl:ed 80 1 � 1 ;5 ' Sciieri 40 1-. ; ��4s..� �.l�.�J �.� �� '" � � �� 11 �aa<a�-a�c-amaa.�.-,.�,. ¢�aa�.�.�. �"�mam.��. NEMA 4X Simplex Coatml Panel � � 4" X 4" Pressnre Treated Post �; Sloped To Shed Water ' \ 12" Sepaxation Electxical Cox�uit —`_ �� C.OVBZ • i., It�1et Fmm Septic Taak A" SC$ �0 PVC Pipe ' r � .! • � fM v _ •• • � ACCC55 COV!!• • • ' ' • � '� • , • , i � � r • � J I �� ` j�:,-_ _ . ..`• . .y , . i,. Opening Filled With �`• Anti Sipkox Ho1e• - Portlaxd Cement Gxout �� Cl,eck • Valve � . Hig�t Watex Alarsn Level . (6" Separatien� .. High Letrel- Pump Ox -�,�� . � � , � +�Vapos Lock Hole r, '� ��Drawdrnm �p H�� •Law Level -Purnp Ofi .----�—' �. � � ; � P:ecast Conexete Tank .•; (Mater9zlStRngtk>3500 ,� . ., . • ,�,: •' . , • . . T�x M�� P�i�cEl # Suhcllivisioin • • � � Ph:��s•e Sect�ioi�'Lot # Duct Seal Botk Ends Of The Conauit f24" Minirsaun —; Thneaded G fte Valv�e Zip Co Ties 4" Co�zete .: . :• : - ,'` . Coxicr�ete Riser 6" Separatinx � ' • •� i�v�� " 4,,,'..-.+-p01t�:1d C011CYEt8 C7TORt . - Z4T8LtIC • - - : Supply ' • • ' � Opexing Filled With � � : , Poztland Cement Grout Ontlet To Distnbuti,ox 2" SCH40PVC Pipe F7oat Wires � ; • f i F7oats ,�; fRemovable '.:' Float Tree '� �� r� „ . � � t• , -,, , �; � 1 oa� ��.ar��nu� T�vx � �ar_ � � Pnmp Hust ge Rated Yo Deliver � 3� Gallons Per Hinute. Agaiast 3Q Feet QE Tota.l Dynaa�ic Head (IDN) . 1 � . � 0 �In��•� � � � � �1�� • �."� �� , Q� � ��e� I �' �� - �� , . ^� � �.. _ , �" � �3 � d�, pT [� �,�v e �a P�.. �� ; �C1' �� 2" 'Ouwr� �� C?��e- � '�=too' ` PM `� , "r i' �� PRi �' '� �reo� '1 �\ �` � . '�,�Z . .�; ��,�� .. .:. :�:�:�� 7l�va,r'au�m:�s;;��m.0 �3C�mn� . � � ��SITE �5�'!'�H , Nairie �`i� �'� ' ��Yv'�,� Tas Map #�Z � � Patcel # 22 �Su4;' 1i` S .. Y,�,,S . Section/Lot#� 5L4 '^r�'✓ .,_�— / � "l S Autho�ri�ed State.Ageat � Date Syster� conrp'oneMs repreaem ap16roarinra�a�rnntoars am'y.' Tbe conhucnor mrrsl,�lug the sysrem priar ta beg,rruiing the uu7allarlrbn to irtswr�e thde�ro�ergrrrde rs muintaited �� 13 �� 7nvd S. st- 1��- P� 4go' ��.I �,��,� f �S-2�' � �,�c�, o��,�.1� �� i 2� � _r�� 3$�'�� i �..� ��'�� ' ��.sf ��.�� . � � � �� na�n�c-am�au�na¢3�radam,� g�aa�.Il¢�a WELL PERMIT (New� Repair_) Taac Map: `2 ar e: 22 Subdivision: 'Q�S v Applicant'sName:�iC�c�lo�S ,S�',�..� �w-�,r Mailing Address: Phone Numbers: Location of Property: Lot: � 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: �tew Well: EHS/Date Location: S �I Date: C%t �� 5 Certificate of Completion DI.iner: EHS/Date Grouting: �e' � ' / � Well Log: Well Tag: �� Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Depth: Grout: DAbandonment: Date: Method/Materials: Well Driller: _�jGrh�� License #: Pump Installer: r` License #: Approved by: Date: Additional Com`nents: Date Sample Collected: ��Z�`� 6 Date Results Mailed: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 11/26/13 WELL CONSTRUCTION REGORD This form can be aud fa smglc or mnitiple wdls 1_ Wdl Contraeto� informafioa: �i � ��,�` _! ly�3�-G WcU Coouador Nune 3��.-� rrc w� c�a�c�;fi�c�� N� Barnette Well Drilling, Inc. Cou�a�ry Namc Z Wd1 Constraction Pumit il: i'J ��i� Lfsr d! appltoobk well corutrvc[an permiu (l.e. Gmuy. S+ot� I�arianx'�) � wd� uu ��n� �� : QpgriqilCtral aMunicipaUPublic- ac�ou,amal (Etmcin��g �PP�r) �rntialwater s�Pp�r (�5��) QfndustriaUComm«�ial oResidentia! WatuSupply (shazsd) Non-Water Supply Wdt: OAqviEcr Rxi�atgc OGmticsdwattr Rerriediatitrt ❑Aquifer Stoiage and [tecovay� �Saliniiy Bartia ❑AquiftrTesE D3torm.waterDcainage OF�uimeatal`Cechnology �SubsidenceControl OC�eOth�t (Ctosed Lodp) �'[l•aca QGcodurinal(tirating/CoolingRalum} ❑Otha(ei�lainu�at�2IF d, bate Wil[(s) Completcd: 6'��6Wdl iD1P �� j Sa WeII I.oeariva: . ' y !� s .�..,,�1 J /� S �'G/��1 �'i��'-i'c'K FacititylQtvmNartic FacitiCpID� (ifippl'op51c) .��9v�.��e%�s��i�.� /��. S� Physi.at A�eas, CicY. � Z+P '' ,Z � 7 �'� �� ounry Parcel IdcatiS«6oQIJa iplM Sb. Iatiiudc and Loogifadc in degrttslmiupta/satoudso� daimat ilegtaS (�fweA �dd. a�e laNtoag is mfficKat) �-z�..i9� x %�•- 3_ ��R v� G �Ls (xrej tL� �vd!(s): ��irmanwt. or OTemporziy , � 7- is t6is a repair to ari ciisatig:well_ OYes or �iiPt� !fl6ii !s o iepufr, fU outb�orcn w�ll aonsfneaiae i�rmaGan mrd cpinirt the iwwaaJfhc rrpairaqtder g�l Irmarla sect7on or on ih4twckof ihls fomc 8.:NamberoPwellsconstcuded: � For arvltiple iigecC+orr or �on-vaur sty3ily iveps ONLYwith llipsaPne ealri'�+r�ios, yart m++ Skb7nit orKf6n+L . �(� 9: Tot�1 wd! de�t5 bttow laud sncfau: �/� E��i ,Forandr;�rd wr.!l�tiitort depths ifdiffcre+it (a�ty�t-3C°3T00'a�Z�lO� For tutnnal Use OM.Y: Id: WATERZ+DNFS< FROM TO OESt]t(P17a't - G � 2 %�J � f / 3 Zo �t 32�-« � � l ;15.�ifCER:CASR`iG far.malausediidls ORi3[4ER �i'' ica6le PROM t'O DC�ME[Elt 7HfCIQiESS MAIERUL ... O &' /% "- b �,= i°' �.t7 � - " c/�. .: <16,,'IPYFIF3ECAS' IN `O�TOBINC; • dosed�l` � ,, FROM � i0 DC�IHC[ER 7FICIQiES4 MAiFRIAL . Cc. 2_ 10L . k � � �. : . _ ,.: �'�iT.cf!ni7TiN�. .. . . . -.:.'. _ � . . ' .: '- -. -..' �2 2 [OT17' `<' :':, .;: ;;:::: �:: �n rc ZQ rc ft � R 2 �c tc. tt R f;i:il1.�`i;0(�'. i" • e6i iD . � Z:� � (t -. � (c . R: f�� }� �l�fG YV � Et R. K fk R ?Z. Gecdf'uation: /`�LY%' r. �. • �-�l,L� �-r '' 7"�!� �o � � °�: �y �grpr�g�s jor,n, f hexby ccn�y d,m ,hc,�eu(� wu �«�CJ �+u;ao�at b� a�d� , rir/r ISd�NGIC 02G.0[OO.or !ii NCAC QIC.Q20D iPe!( Ca+saticdoaSYo+idar'dr mr� dud a a?PY�f!!� CecnrdLarbeo+gm.rtded tq dr arrlf ovrter. 7.3. �tE' �4l OC adciil60Ha1 Wtll dltail5: You m�y usls die liack of this b W pQuvide::tdditiocr� wcll sitc d�1s sjr well eoiistrt�on ddaz�ls. 7lon may eLto.attachedditional pages if neassaiy- 5UB1tiIi'CAL IlVS('UCI70i�IS 24a. For Ait Wdtx Submit this �fartn within 30 days of oompletibti of vsdl t�cistiudioa cothe"followiitg: p'iviaon of Watcr Qoatity Warma6oa Procasiug Uui4 IQ SIa6� itater kvel 6dow top of easiog: � ��) � 16171Vfail Secv.ice Ceuter, Raleig4,1�'C �/69�-1617 /fxtl�ei kv`l.is cbov2 cios&r& uxt '+' ' 11. Borehole diameter. � �g.) ?i46� For ldiect►oe_ Wdls: In additiEm to sa►ding thb fam to the addirss in 24a � /� ./ above, also subrait g copp of this foad within.30 days of oomplbtion of a�e]t 13. Wdlconstruction mdhad: Lr'y."/ �t /1 �?�%�"�� c��itotti�fdllowi[i� (�c auax, mwq'. eabk, d'uxt push, em.) DiRisiouef Watq Qualit9: Uader�OIIad.[njectiau Conhol pmgram. FOR WATER SUPPLI' R'ELiS ONLY- 1636 Mail.Svriae Ctnta+ Rale�ti. N� z��99-16#� Blown20 minute 24c ForZY�cci' SanWv & Inucti+�u �'Vdls. in additioato sa►dir►Stbe fo�m to )h 13a. Y+dd (gpm). Mcthod aftak �� ad��a� aliove, e[so iubmiC one oopq of. Qiis foiin iVithln 30 days of ca�piaion a€ wd1 cot�tlrudion to the cu�mty hcaftfi dcpaninait of the cvuntY I36.Di5lRCK1.lOII%/� HTH �mo�t 1�1� Cup ,�� Fum GW-1 Nord� Cm�ufuu Dcpatdueoc atf Favimwo�at aod Na4nl Aesoatces-Dir'siaa of WucQiialiry RevistdJaa. 2013 ��. sf ��..� ��T �� I��na- � ��.��.11 IF-3L � �.Il�I� Applicant: /C��A�� ,��-''l,� ��t/L Location: Operation Pern�it Taz Map � Parcel # � Subdivision ��iT�S��,�! Phase/Section/Lot # # of Bedrooms �_ System Type (From Table Va): Product (IIIg): y� �� Type V& VI Expiration Date: 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. (Authorized Agen 1'�i��,�'�.� (Licensed Contractor) z/�/�� j- � OOb -� 5-r3 3z�- ��,��,s / Scale / `�=�d0 PCFiD, rev. 12/14/12 µ�c't.1� . � // T'R �Q�q�,�,�;�-y 1��► ►�-}� 5y� �n rt- / ��k �\ \ 9/ (Date) ( ate) 1 r=�.� ��ii�%%O��I� �d/G �✓rLlutii�i�t/ /�J/o�v �/� �lJ ��y�lR% �lff�� e ,� �� Ni4h1� �o `o � ��' r �idit/�LG{�'� ��L•��'�' �r�� °fd1� Tax Map: �� Parcel #: __Z Z� Septic Tank System Checklist (Type II-I� Notes: System Type: _;� Pump System Checklist Pum Tank InitiaUDate State ID & Date: , / �/ Ca acity: ODO Riser (6" min.) NEMA 4X Box Model: Piggy �ack plug Hard wired ,/ Alazm functioning Mounted on ost �/ Above grade (12") Conduit sealed t//' Pressure Manifold Number of taps: Size and sch: � � Contracted Certified Operator (Type IV Systems): �/u� � +'�-/r� �+ � �ti`.�$: f�fr .�'� � J� +�' `�/ ��r� f �.rr��/�/�fiN� �'� �it/�� • � i �� l � �., � �� L./ � �.J �. V � � lE�a�nmon�n�a��a��.Il �[��.Il�l�a Date: �/ /� / i(v Name: �-li _.,�� {� G�1s�L✓�� Address: c �� /1/G Z9l'7� Re: Bacteriological Test Results Dear Well Owner: Tax Map:��y�Parcel: Z� Your well water was sampled on 1�/�/��, and tested �or both total and fecal coliform bacteria. Your water 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 bacteriological results only. X Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 'lotal coliform bacteria are nzh�rally found in tl:� soil. Fecal �olifor .m bac+eria are asseLiated :�:±h animnal and/or human wasi�. The presence of e:ther total or fecal coliform'�acteria 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 childrer., the elderly, and the individuals x�ith compromised immune systems are especially vulnerable and their physicians sfzould be notij'ied of the test results. A well that tests positive for !otad or ecal colifor.m bacteria should be proper: disin;ected and retested �rior to resuminQ norma! 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, �lease contact the Health Department io 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, �� Environmental Health Specialist Persor. County Health Department (rev. 4/20/16) Person Counry Er.vironmentai Heal:h, 325 S. Morgan St., Suite C, P.oxboro, N� 2'S73, Phone: 33b-579-1740, Fax 336-597-7808 OEC-15-2016 11:34 FRO�-HEALTH DEPT 3363226099 T-538 P.0�1/002 F-402 p�RSON COUNTY HEAi.TH i,iEPARTM�N� 355A SOUTH MADIS�N BLVI� R�XBORO, NOR7H CAROLINA 27573 �ACTEFt{GLICG[CAL WATER SAMPLE ANALYSiS Name of Owner or Tenant l� a��'� Address '�� O��ty , CDlie�ted B�y , u'� Da#e Cotleated �l Z-j2" 1 7ime ��Ilected � 4� Saurce: e�Well r� Spring a Other Lo�ation; ❑ Hduse T�p ❑ Well Tap ❑ Qfher �, Q No Charge �harge a��ra�a�a��a�s�Ya�f�s��.etsra�.aafit�a�r�fa��a��sat��rAf��M��a��fa��M� �vwwwx*�+*,vws#f,r�r*��.��ewWi�**#�,r�*�F*�r**�vrtrx#t,k+ew�kvrwww.:*f,r,rww*x*#�rwx*#*�re�ic�t Te�tal Ga[ifarm Feca1/E. Goli Resufts Pre$ent O Rep�rt�d B D�te Reparted �` � �� ~ � Report Called �1f�S ❑ NO Call�d To � / •/1 - /� Absent �� ne department of health and humen sBrviees , � , . .� r s � i f- , 5�� '� � 't � '�_S �- ��; � `• i �,� E �-!�. }� `�+"j "� E ; , � F ; �f ��f 5 L. `�; if y\1� I � �� ! :�` ; ! � � �; �. � ��i �..F � w--• . � ��• 4 � �-• � � � ,,, ';,�,., � •' F��I � Y � � 'e, t�� `� i�,. � r� � �� . y 1 i�, 't ,i j ; 1'� � "� ,�� r^ ��,j t t l/' ...,..:' tir `t.� 't �. �.J' �. f ! e ? E i _� �'� '1' I.! E � `,? [ �"V �l . , �'e� , � .��-i�• Ii - .�.I For lr�organic Chemica/ Con�aminants Name: � �1r� � � TEST RESULTS AND USE RECOMMENDATIONS 1. Your wel! water meets feder�l driaking water stardards for i�targaKi� c�e�nmiea�s. Y�ur water can be used for dri lu , cooking, washing, cleaning, bathing, and showering based on the inar�anic chemical resulls oalv. You may have other water sampling resuits that aze not taken into account in this report. 2. 0 The following substance(s) exceeded federa! drinking water standards or the 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 install a water treatment system to remove the ci:cled substance(s). �Iowever, it may be used for washing, cIeaning, bathing and showering based on the inoreanic chemical results onlv. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Manganese_ Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. � a. Sodium levels exceed tha U.S. Environmental Pratection Agency's�(USEFA) Health Advisory level for sodium of 20 mg/i. 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 bas�d or. the inorganic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. 4. � Re-sampting is recommsnded in months. 5. 0 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 frst draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. ❑ 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 inor,eanic chemical results nnlv, hut aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want te install a household water treatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Ma esium Maneanese Selenium Silver pH Zinc For more informatian regarding your we!! water results, please call the North Carolina Divirion of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: SCOTT CARVER P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph. ncnublichealth. com Phone: 919-733-7308 Fax: 919-715-8611 234 FIELDSTONE RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES102716-0064001 Date Collected: 10/26/16 Time Collected: 09:55 AM Date Received: 10/27/16 Collected By: A Sarver Sample Type: Raw Sampling Point: Outside spigot Well Permit #: A29-227 Sample Source: New Well Temp. at Receipt: 4.2 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Barium Cadmium Calcium Chloride Chromium Copper Fluoride Iron Lead Maqnesium < 0.00: < 0.1 < 0.00'� 29 < 5.00 < 0.01 < 0.05 < 0.20 0.15 < 0.00; 4 O.U10 2.00 0.005 250 0.10 1.3 4.00 0.30 0.015 Manganese 0.049 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 1.60 10.00 mg/L Nitrite < 0.1 1.00 mg/L pH 7.9 N/A ium < 0.005 Silver < 0.05 0.10 Sodium 15.00 Sulfate < 5.00 250 Total Alkalinity 105 mg/L Total Hardness 89 mg/L Zinc < 0.05 5.00 mg/L Report Date:11/03/2016 Reported By: Deddie .�lvnco�' Page 1 of 1