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A29 262Aoatic:;,�lc�n Daf�: �- OS �mount: ?aid: D: DO%35fi�� C(1�5� �' "�020 Recai �c 4�_ 2�?z.7� 0 � 360 0 � � 00 3°�it� ' ��6rI $ �� 3 � 3D�� .1 � �`'�-,� .��" ��1�..4.a� �� ,►�� ' =�-= �� 3 �� TF� sx,�.-c a.mc-a��a9:ac�a..�ex�.�.�Il. ��ias�.Il.�]Ira �6 �o ��.q�'� �iPPL.1CATt�Ri FOR SEj2VIC�S i ax iUdaq� �• Aarc�i �: 'I) Peprrt,i� reqcae�ted by: {Own$�tagentlpraspective owner): l�� _„�%� � Hoir,er l�hone; �r � - ) Address: 3�'0 !i Busin�ss Phon�: -� o s :!} Rtaur��aa� anr� aoidress �a� currera@ awrner �2n� ,$) PresF;�erty D�s+�ri�tti�on: Lot size: i/�re� Township: ` 8 �� Dir�:;r;tions ta the property (!ncluding road names and numbers): i ,— .,_ - ► ., � . , . _ � I:- „ � , r_ . _ _ _ rs'- �,�}rrr� 5�v� /)� Lot �� ) Pr�n�as�d 17�e an Struciure Descriptian: answer�ach cYf the fotlowing questions: aj i=�rc►posed. L:�xisting � Type of Structure: �s i,�Pi�i�i �4-) Width: Depth: b} t��wnber nf Betlrooms: _� Number af occupants or people to be served: c) E��sement� Yes�; P�o Will there be plumbing in the basemeni? d) r;arbage flisposa(: Yes _, No � ;i) 1N��raar Supply.'�ypd: Private ,� (new � or existincs }, Public___, Communifyi, Spring ` Are any weils on adjoining property? Yes� No _ if yes, please indicate approximaie location on �he �site pian. E�) Dc�..; ;�our prn��rty cantain pre�lousty_ i�9er�#3fiec� jur�sdic$iana! wettands? Yes„ �to t/� f°L�,A::��: PJ�1'� THE ��LL.O{Al1NG: 9��, PL�IT C9� TH� �RC1P�iZ'N OR SITE F'U#W MUS'� sE SUBMFT'�ED WITH iF3IS �►PPLHC,4'�'l�PV. ➢��FtQP��1'�' LlPiES,�iPim �t7RNERS iVIUST BI� CLEe4R6.Y MARKED. �, �"�E PROPa8��3 L�1CATi�N. OF �4L�. S7RUCTURES MUST 8E STAKED OR FL4GG��. ➢"`3�lE SITE ➢IA4JST 8E TtEADILY .+4CCESSIBL� �OR AN EV�II,UATIOM B�l TD�I� l�EA�7H DEP�,RTiVi�iVT :al'AFfi. I hereb�, �riake applieatiari to the Person County Health Department for a site svaluation for the on-site sewage dis�osai system �`a�r the above-descri�ed property. I agree that the contents of this application are true and r2present the ma:cimum %aciliiie:� tc, 6e placeri �n .ihie �roperty: ( understand if ihe site is aitered or Ehe intended use changes, the perrnii shall c�ecam� :�v�iid. J ��,'' �rn�r er �.egal 9,j�05" Date Pcr+a, ��. ��rzlto2 ' �� j �J'1G71S�� V � , � } �., � � �-�� .�a-��.� ��.�71 I�L��.11.� Applicant Location: / �x Ma�p ' �.rc�el7 `s , Su;bd!ivis�ian ,i ;i !y h�:s�e:'S�ct+io�n Lot � Iniprove�nent �'ez^mit _ . �e�it Valid �or �� '� _ t�% ��piration Type of Facility: t,Y ; # of Oc�upants # of Bedrooms � Proje Proposed Wastewater System: , Proposed Repair: , �f'�yQ,=�� l.�� New �/Addition i�ater Snppiy _�j� ed Daiiy Flow . �(�b g.p.d. Type: Type: Owner or Legal Represeatative Authorized State�Agen� � ?� The issnance of this peffiit by the Health Department i�oes not guaza�ea the issuancs of other permits. It is the responsibiliiy of the � aPPli��P�Y awner bo in sure that all Person Coimty Plauning and Zonmg and Building Inspections requizcments are meL B'his Improvesnent Permit is subject to revocation if the site pIan, plat or the intenderl use c�anges. Tiie Improvemeut Psrmit is not affecte� by a change in ownership of the property. This permit was issue� in cumpliance with the provisions of the North Carolina `Z�ws and Rules for Sewatje Treulment and �isnosal Svstems' (15A NCAC 18A .1900). Neither Person �Connty nor the Environmental Health Specialist�warru►ts tl�atthe septic tank system will cantinue ta fnnc�oa satisiactonlp in the future or'that the water supply will remain: potabie. - —.. � ' . Authorization to Conssttrnct Wastewater Sysiem (Reqnirerl for Bwlding Permit) * See site plan and additional attachmen�s� (��• q�T"/1� Propased wastewater syst�m: �orf✓f�i%o,�i�.,L ``'/PuN,o �ryPe�� wastewatcr Flow�g:p.a. New � Repair �ansion �T � Soil LTAIt: • � g.p.dJ $ 2 � Type of Fac�ry: ,_, ,_ � �._ Basement _ Yes � No - � �astewatea Sysiean Requirements Tank Size: Se�tic Taak: I ooD ga� Pnmp Tank: (� doQ gal �rease Trap: — gai �rain�eld: 'Tatal Area: /� /�sq it Total Length _�� ft � Mazimnm TrencI► Depth �p `• in Tremc� �v�idt� �_ ft y 1V�'inim�n�a Soii Cover. _� in lYtinimum Trench Separaflon: 9 ft �istribution: �3istribu#ion Bog Serial Distriibntion � Pressure Manifold Speci�ications: �i s >.fs,� �'. ��' � Anthori�zesl State A.g�nt: � Permit Fxpiratioa Date: Date: ia �1--i — 7— The type of system permitted is !C Conventionai - A�ted Alternative. I ac: �pt the spe�ifications of the P��- i�wner/�Egal �BEpa�esentative: Date: ' PCHD rev. l l/10/OS :�� ► ��\�� ' " ' � �� -��V 1 V � 1� ��m�a-�,r„ �,,.,, «��.m.IL I��eml�� . .. - �. . . . • • • iI .. ... 'i �� - — �! . _ _ .�. ... -. .�- •.-. 5��. ��. Tag lYlap #��Pascel # ?-� Z Section/Lot# 3 � � ate . � Syslem components re�iresent appr+�xi»sate �contours on�. The contractor must flag �he rystem prior to begi�nrasg td:e issstallation #o insure thatpro�ies^grade zs mctt'ntained . _ 9�� 4��no�/s ��/�� y�� Z " �✓v p p.G�i �i�✓� ��9�-/>�D a �� /�/�/y7'i/��i1� y �� `�� . 0 � �cr�a�.� 4� � ��D�� ., .........-.._....,.K_..,.. ....�,. .a......�...�.LG . fi �iY..i'�.'�r`l'lzatn:�J�7F � �. J :.� �:�:.✓ `�u�T.Y L, n1E ��n�,�r��- ' : _ � -- - � t��---� _ t tZe-r t �,., € � . "� 'S�ST.� � � �� LTqF;L� �\ : •� � � � . -� '�—.��. _' �� SQ f. �'_. �a�__�__ �^�'� �� - = � . � ' . '� ��di1.^� �. . �_ . -,..�` _-._�p� _� ! - � = S- t�"Ac��- � _ i I s ` ` ` `� �----�_ _ - � i ,�, � , ..� �� i�� 5��-� d � _ i �^t'D ,r�' O�"� A/ �� gr� � is �/vr ,Pg9v,�e�r� �r �� /YO� : /� �� 2ocJ i5 ��B�E . /niiT�/YL �g�f �/� 7��S��n/�`�j �u� r� , fi9,� � fo« ��r.� . J Scale: � /'�= Sa ' 2.� �� ✓G,� 8orra•t�s -�,�r� [ C�/� � `�csah r ?',�,o �'� w �1r •� L � L.cr'-,�.-i-�t� t � 3 8��00� = 3roo � ��l 1 � �Ti �L. �ST'�M � 3) �f� �� Co�J✓�n/no�/� rR��-�a. �5✓s� �ys� �DD !-�I�16'T' �Ct1�� P��, �ev. 49/12/Ol ,�vr �� `'�'�'`1. � �� S f� I�I�I�.� ��T �- � � � �� E-j.an�vna-�snsxa�aa��.11 lE-3T�.en.11�E.4a Owner: � "�/ Tax Map: Parcel #: _� Z Date: -- Line Tap Tap (Sch) Tap Flow Line Length Flow / foot f # Diameter(in) ( m) : (ft) 1 %v �4 y � ✓�' .4s�3 2 3 4 5 6 7 S 9 s'�/. .� 10 Ps�� . G� %� ft of line x,65 gal. per 100 ft = = 100 =�� gal % x�� gal =/8�S gal per dose Z/. 3 gal per minute (gpm) _�`low Rate .7 Friction Head Loss: ? ft per 100 ft o supply line x f�_ ft of supply line = 100 =�_ft 3•� ft x 1.2 =�-3 ft of friction head Manifold Size: v? " Force Main Size: y" PVC Total Dynamic Head =1�ft of Elevation head +�Lft of Pressure head +�ft of Friction Head = Z/ TDH Pump Requirement: �� GPM @ Z/ ft of Head� Drawdown: 1�a1 per dose = 21 gal per inch =_� inch drawdown per dose ��• ;r.� �� ,��:�� - �� - — ��i��t� � • . � . . . . • . , , I _ � � . �[(�)1�0000 111 II 111 111 ..:�.:::.::::::.....:�..:::::::; , � � i .........•.....: ................. — — — � � y. Nianifold Size / # Ta s Manifold Max No. Taps off one Size (Reduce by 1/s for tapping t � 2� � , �� ta s -r.-- n 5chedule 40 .,.,.w,.�. •1.Y1•Ytiwu 1N.1+� ; 2�+ 4 2 p� VC ti�1.4�V�•4K�'1•Y'1.tiH 1.1.Nti•ti ' 3�� 3.�,r•r ..i-�.�,s.r-r-. } r.r.r- : 4f> 15 9 � ^ 9m�aca � S � 6� 40i� 21 �� . . . . .. ' � FiO�Y er Ta Size Material Floti�� GP.�i /z " Sched 80 5.5 �; " Sched ?0 7.1 / " Sched 80 I (1,.1 9/�'• Sched 40 1 �.� NEMA 4X Simplex Contml Panel � I� 4" X 4" Pie�nue Treated Po�t j Sloped To Shed Water �2" Separation � EleZtridal Conduit , .: . ' ' " .; • b" Co+rar • ' , Accets Cover • , ' . ; 1 � � . � r ! •�' �� ' � j' ; '�• '' . : �.. Openins Filled With Anti Siphon Hok �\ P land C t Graut Inlet From Septic TanJc ort emen �� H� � 4" SCH 40 PVC Pipe � �� _ � za - � z !.-br � i T'�- ��4� @ +�os�.✓� l ( � ]hut Ssal Both Ends OfTha Coz�duit Concrete Riser -- 24" Minim�un ' � � � � S° Sepuation Threa,ded Gate Valve ; Union • � • '• • . •�..J•y� . �.,r�Portland Coxicrete Gxvut _ , f: Mutic - - : . Zip Cozd • � Oponing Filled With T�� Supply �� portland CQment Grrout . � �. Outlet To Dvtnbution .�uYt�n 2" SCH40PSIC Pipe , Valve � �P� F1oat Wiref ' � High Water Alarm Level : � ' (6" Sepazation� , �. High Level- Pump On i �VaporLock � � F1aat� : : . �, [� j� Hole • ' : . . � Drawdawn �Up H�1) � r�..Removable `•�. � ,� Float Tree � Law Level -Puznp Ofi ' � . ` . puznp . ' „ .. 4" Concrete : �. ' Precast Concxete Tank . �;.; Material Stren�th y3500 PSI B1ock � i " ' .`..� ' . , •. , _ -` . . •,,' � . . '� . • � •' L ,' •,. t D60 GALLDIY FUNII' TA1�K ��. � � ��.� �� -= � � � � -��-�� .�,...,�-�.�.��.�,.�. ��.�..�. �:., : ►° � � ,; , t: ;�•�� :�� t ' �`� t' �� B�] #: _1��_ ��F� t'� �i�v � '�O'W�t� S�ab�eisio�a: 5�a�.: I.�� av t � .,4�,.-� .�� i `\'I . - : : i�� i��. : -� • � � �� . • ta •a u � * � • ��7.iY�l�L'm$S: site Appiov�ed by �s a-a-a -\ s Croui�in� Approve� bp �a�s a-�--�� e�l: Log c�as �-ao -►5 =We�. T .� v�.t � Hose B� ' Concsete Slab � V u�, � ,� � . �� ru� �'`� We11I)r.c�ter. �l��s�� - W� �. v�. � . t^-� � �`�I��: l ��r� � � � �Se��xtac�aes� Si�e S�cet�*� 1"� - l •n • 1 � • �� • � � , ��a ... 1'I-1- .0 - .• il - ■•.. --•• �•.:..• �'�-I •a .- .� :� �:� ■•.. ..� . .�.• • ••.... Oth�r coaditioas: - PCi�, zev. 09/07/Ol W1SLL I:VPIJ1KUl:11VI�1 KP.I:VKU This facm caa be used far single or multipk wells L Well Con r Informa ' n• ,� �� Well e 3l `� NC Well C�trad� CatiScation Number ��sah c�e�/ ��. 1 �y . �,� 2 Wdl ConsUrnction Permit #: List aU a�pliaable well permiu (r.e Cmmry, Star� Ymiarc� eJc.) 3. R'dl Use (checl� well ase): pAgripiltvral OMunicipaVPablic OGeothe�al (HeatinS/C�1ing SuPP�Y) �ideatial Wate.r SnPP�J' �S�) �ndosfia!/Commercia( �Residential Water SnPP�Y �� Noo-Water Sapply Well: ❑Aquifer Recharge OGroundwater Remediation �Aquifer Storage and Recovery ❑Sal'mity Bazria OAquifer Test OStormwater Drainage ❑F.xp�imental Technology oSubsi�nce Control ❑Geothe�al (Closed Loop) OTracer OGeotheamal (Heating/Cooling Retum) OOther (explain under #21 Rema�ics) 4. Date Well(s) Completed: � �� We11 ID# Sa. W I.ocation: � � 9 Fac�7ity Name Facility (ifa�licable) Physical Add�ess. CitY, and 7�P � �,. �-a��. ,mcy r�a ta�� xo. �r�y Sb. Lafitnde and Loogitude in degrees/minntes/seconds or decimal degrees: (if wc115e1d, one !at/long is snfficient) N 1i1 6. Is (are) the well(s): ermanent or ❑Temporary 7. Is this a repair to an eristing well: OYes or Bflo Ijthls fs a�epalr, fill rnrt Amown we11 conuruction mforma[ion m�d exptain the narun of the repair �mder �27 remm�a sectian or on the back of this form. 8. Number of wells constracted: ' For mulhple injedian osnon-water supply wells NLY with the sm»e cnnclrttction, }rou cm+ submit o�ne jorm. 9. Total well depth belaw Isnd snrface: „� �� (ft) For muUip[e welLs list aU depUu ifdifferent (�ample- 3Q200' mrd 2QlD0� I0. Static water tevel below top of casing: �� (f�) If water leve! is above casin� use "+" � 11. Borehole diameter. � (ia) IZ�ftell construction method� �t �. �� ('ie. aage , mtarY> cable. diuect Pusb. etc•) FOR WATER SUPPLY WELLS ONLY: 13a. rdd (gpm) ��% _ Method of tes� � 13b. Dis�nfection ty�e: AmonnN For Intanal Use ONLY_ �. Certifi ' . ' 6 � Si f Cestifi ell hador Date Bv s uig this form, I hereby certify th� the weU(s) wat (were) constructed ui acoord�ce wrth ISA NCAC 02C.OIDO or ISA NCAC 01C.0200 �elf Conrtnrdion Stmidards aid thnY a copy of this rernrd has been provided to the we!! owner ' Z3. Site diagram or additional well details: You may use the badc of this page to provide additi�al well site de�ails or well conshudion details. You may also attach additional pages if necessary. SUBhIITPAL INSTUCI'IONS 24a For Atl Wells: Submit Wis fotm within 30 days of completion of well conswcxion to the following . Division of Water Resonrces, Information Processing Unit, 1617 M'il Service Center, Raleigh, NC 27699-1617 246. For Iniection Wells ONLY: 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 construdion to the following Division of Water Recoarces, Undergound Injection Control Prognm, 1636 Ma�7 Service Center, Italeigh, NC 27699-1636 24e. For Water Sapply & Injution Wdls: . Also submit one copy of ihis foim withm 30 days of completion of well consWcti� to the county health departme.nt of the coumy where constcucted. ��. sf ��..� �� I��n.�aa-��nsxn�n��.Il � 33La��.11�I�n Applicant: Location: 6 System Type (From Table Va): Type V& VI Expiration Date: Operation Pern�it Tax Map � Parcel # 2�0 �- Subdivision ►'y �; f %� PhaselSection/Lot # # of Bedrooms 3 � Product (IIIg): �z �� 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 Conshuction Authorization. _ _ _ _ ��22 --��' (Date) �--22—(�' (Date)� � �P��, ,�IS �.�-a f�L '"(�o � � � �►s'�P1� .3� r � �P �„ K �5 � Z�� Ou�►o ��1�2 -� N �'fio P�t. � `O ;�n ,�<< r Scale � �lR- PCFiD, rev. 12/14/12 Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: �^�Z Notes• Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes: .�� i vi' �, �P�r � �-O r- North Carolina State Laboratory Public Health Environmental Sciences Microbiology 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: ES082515-0098001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: TONY WESLEY P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htt�://sl�h.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 FARM @ ROSEVILLE LOT 31 ROXBORO, NC 27574 Collected: 08/24/2015 11:25 Received: 08/25/2015 08:41 Sample Source: New Well Sampling Point: Well head A Sarver Angela Heybroek Well Permit Number: A29-262 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 08/26/2015 E. coli, Colilert Absent Susan Beasley 08/26/2015 Report Date: 08/27/2015 Explanations of Coliform Analysis: Reported By: Susan Beaslev f I� 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 Report To: ADAM C. SARVER Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: TONY WESLEY P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sl�h.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 FARM @ ROSEVILLE LOT 31 ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES082515-0063001 Date Collected: 08/24/15 Date Received: 08/25/15 Sample Type: Raw Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.0 Sample Description: Comment: Time Collected Collected By: Well Permit #: GPS #: 11:25 AM A Sarver A29-262 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 10 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 4.00 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 7.g N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 7.20 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 50 mg/L Total Hardness 44 mg/L Zinc 1.70 5.00 mg/L Report Date: 08/28/2015 Page 1 of 1 Reported By: Debbie Moncol —� ��.� ,� � �/e � � . ��Y-e� Q b��+ �Ga� %� � ��-Z � s� � r � � Y��.c� • � � �h�v� 3� 1�d' ��1,� acc��d� - a � �,� � � 5�� e ( S�M,�?� � c�,��.�Pr ,� ��-�� ; , �� - - ., � � �� rE�s �-� x-� �:�.m��.11 IE—ZC � �.11 �lh� Applicant: Permit Valid for: Five Years Type of Facility: i3 �P� Number of: Bedrooms � / � Proposed Wastewater System• Proposed Repair: �r�� Impr�vpme�� P�rrnit �_ Non-expiring New � Addition xupants�/ Emplo�es _ / Seats: Permit Conditions: �P,2 S�� i1� Sc��4� � Tag Map: 2 Q Parcel: `L �0 � Z 6?r Subdivision r�r ; !(-e Phase/Section/Lot # 3c� V4'ater Supply: �'e� � Projected Daily Flow. • 36 o gallons/day Type: Type: q Authcrized State Agent: rt� � �"'ri� Date: �� (X) Owner or Legal Rep sentative: � Date: � The issuan�e of this permit by the Heatth Department does not guarantee the i uance of other required permits. It is the responsibiliry of the applic�nt/property owner to insure that all Person County Planning and oning and Building Inspections requirements aze met. This Improvement Permit is subject to revocation if the site plan, plat or t e intended use changes. The Improvemenc is not affected by a change in ownership of the property. This permit was issued in comptiance with the provisions of the North Carolina `Luws and Rules for .�ewaQ� Treatment and Disnnsal Svstems'(15A NCAC J 8A .19U(1). Keither Person County nor the Environmental Health Specialist warrants that �he septic system wiU cantinue to fanciioQ satisfa+etorily iu the future, os #hat the water supply wiil remair potable. Authorization to Construct Wast�water �ystem See site plun and additiorial uttuchments �' 1/ x Proposed Wastewater System: / Un'1� ��o� — oZs �(• �(*)Typ� c� Design Flow 3 6 � gal./day New � Repair _ Expansion _ Soil LTf1R. �� 3 O gal./day/ft Type ui racilit��: '3i3� ,pS. Bssement: _ Yes ��To (*) System Types Illb, Illbg, IY, and V, require periodic system inspections by the Ferson County Health Department. Wastewater 5y�te!u �Lequ�rem�nts Tank Size: Szptic Tank � v` O gal. Pump Tank �d m� gal. Grease Trap '� gal. Urainfield: Total Area !�� sq. ft. Total Length 3 O c� ft. Max. Trench Depth � in. Trench Width 3 ft. Miii.Soil Cover � in. Min.Trench Separation � ft. Dis#ribu�ion: Distributio�i Box / Serial Distribution / P!'�ss�Lre Man�fold x Snecifcations: �,Pllrrj0 -� /�t�„�f�e i� � S'�4i __�' �� f�__ � � h� S l D C4c�� Authoriz.,d State t�►gent: �M � C�� tssua Da�e: ��(o��(o Permit Expiratior. Date: �'Yfc�2(� l'he system permitted is: Conventional /Acezpted �/ Alter ative / Innovative . I accept the conditions and specifacations of this permit. {X} O�vner or Legai Representat;vg� Date: � 221�_ Person Counry Environmental Health, 325 S: Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12) �..�� ? )� �� l� �L � lEaa.�sss�aa.aaa.��.�.m.II.' lE-3C�v.�.]i�Ila / SITE PLAN. Name �� `�eg Subdivisio v � ' � �v-c,� Authorized State Agent Tax Map# 2 Parcel# 2�� Z 6 Section/Lot# a . �� ( Date System components represent approximate contours only. The contractor must flag the system prior to beginning the installation to insure that propev grade is mair.tained. . • Noie: An Accepted system may be used in place of a conven�iona! system without permit authorization or modiftcation. . ,� .._.,_........--�- -.._ .._....._...._..--- ` ... .._ _.__.._.._.� .---____..._..----....... I m ; , , � r � ' •- PROPOSED WELL / � � Notes � All supply lines must be installed at the same time within the supply line � easement. /� � All supply lines must be pressure tested before lines are covered.� e Prior to installation, supply line and drain field easements must clearly marked. Contact Surveyor if in doubt. � Drain field layout is approximate. ; �+ Pump requirement (TDH) is estimated. o Any questions contact Person County Health Dept. (597-1790). ��t�o� brnbr :on ntrol � mer I � jl909,IB H 9702'09'V �j �j�r�oo M . ?a 4.-f'�.c.'�„ � �� .. ;'. � �, �u � � lwTes�,�haa @ Em 0.�se,zt�n.macl- �`,15' 9UPPLY UN� EASEMENf ARE1� : j a /�� . � �� P /OdO� ��fr'G �' 4`y! .� �,yp T'�B�✓/L : . , ti� 15' 3UPPLY UNE EASEMENi' AI .. � d,o�-' , � �� ti \ `•.. NM/ FA �``�� r� SUQQ�y�NE �/%� %`�f.��'i� �� ! � �� I00 � o ��t c�l�rQ F�= 'I��' �ao �.n,i �i"'� ��. � � �C�G/I�� 9 � �� K �Yee � S 86'22'S2'E �nn 187.59 L� av �' . � . �� f�f �; - �� 1�auJ .. o+ a �'C �� . � rG � o �p•��M P Z �p� 3 �,� �� . 5� � �� o'�� o �� ...�: � �rn 2Uc�.4: I O N 75•42.� � ; � - .� � : : �-- . `� ';..i3 .� . . LLI � e ! : w:n .,� / 3 s e : m : o , h � ^ � �,,. � ( Im . cd %rri ' `� Z' r ; YO]j��.��;Q � W e e . � � 9 � d :v ��N;� w � �. c � � Q�' ��..� r � � �LU !� jN, O , . j � � 1 � d' ' � G '� 7 . � i � OILSm � , . � 1 � ! �— � � . � '; ; ;. 1� � � . :. � :.�. , . ;. ,, . . �'t.. . � � , •�., ''.. ry�, \, • O�C -,,�� .r_ � , �% �L°��' �*' �� L/Ly ��i �1.�1/ Vy}� p��% 1 '�/ � `V � iY 1L IE�-�� ^ ��.�.11 ]HI�,�..►!�� Owner. w� � �t� ` ( �� '3 O Tax Map: Parcel #: 2� � 2� D�.te: '!(��p I,ame Tap 'Tap (Sch) 1'ap �o� Line I.engil� �'iovv 1�o�t # Diameter(in) ( m) �:. (ft) � Z" � � 7�► � � oY 2 �f z" �l n�� ti� 1 ! c�ro . 0^t 1 3 3� , � ro. � t Za � o g 4 5 6 7 Z . V`P �-- .o � 8 � 9 � 14 � �� ft of line x 65 gal. per 100 ft=��S �� ; 100 =� Q�l gal 75% x� gal =/_� gai p�r �ose � gal per ninute (gpn) = I+'!ow �a#� I'riction �ead r Loss: ,��ft per 100 ft of supply line x"� � Sa ft of supply. line =100 = � 3• 5 ft�� .�_ ft x 1.2 =/� ft of friction head -. )� �. ( Manifold Size: �_" Force Main Size: Z" PVC S G�j��Y ��k� T o t a] I 3 o n a� i c � e a�. _, l� ft o f E le v 3 t� c r. h e a 3 + 2 f� c f P r e s s u r e h� a d �- � ft oi I Fricrion Head = �_TDH l"Q`'�,� � 1ep� _ Pump Requi�ement: � GPM @�� ft of Head a�� Dsawdo�n: �gzl per dose : 21 gal per tmch =�_ inch drawdawn per dose ,: �:.��,.� , , ��:,�� -� - � �� — :�i��t0 , , ,. j _ � ,'.. � : I 1 I I �� [t�al�om�o -�-o-a-�-�.-o-�-o-�-o-o-.-�-o-�-c-�-�-�-�-..-.-.-o-�-�-o-a-o-..-. 1�) 1�� 1�) 1�� i+*��_�:��4��.�a�� ..... :... .. ... . _ �►t�a�ii��N��i��:��+.�.*r.�� 1 1 1 I i• : � _ a ::: ti: , , , , �._... _ �» m1II � u�C�lC�O�B 4� � 9mmo�r • . . . ' ' Flo�v er Tap 3iae �Llc�erial Flow GPy! t4" Sclied 80 �.� !. " ScFted ?0 i.i 5� ,• Sched 80 10, I ,!, .. Sciieri s0 i %•' � ��J�� .�� y � � �� I��.��.�.��.�.Il IE-1L � �,.Il�7� NEMA 4$ Simplex CoatsolPanel 4° X 4" Pressnre T�ated Post � i , Sloped To Slied Wates � 12" Separatiox \ Electrical Co�duit � I ti" Covaz . • ` Access Co �ver• � •- • - e ~ ' �� . '•� , : ,' __ , �. , ; ' � � r �. . . , r . �. ' , �' , , � ` • - -� . . •.• �P�g FiIled With � A:tti Siplwx Ho1e' Itilet Fmm Sepfiic Taa]e Portlaud C4me�{ �t �� t +1" SCH +LO PVC Pipe � . ' Cbeck . ' Valve � High Qlatex Alaxm Level ' (6" Separation) •. » . iii�jt i.evel - Pump Ox -�,�1 . ,. � � 1`� '�VaparLock �Duwdcwxi Hole .., .' � �P � ' •Law Lcvel -Pump Off .�•----- ��. . �. � :,: p T�x M�� P�i�cel # ' ' Suhaliivision 4 . � . � Pli:��s�e Sect,ioii"Lot # Duct SealHoth Ends Of The Condnit r. 24° Mixix�n� :; .� ., Tlu�adeb G �te Valvp • Zip Co TiPs , • :ecast Conex�et4 Tank 4" Cozicxete � � .•; MateaalS�ength>3500PSI Block . �� • , . , . �`'; ' ' • � ' _ ,�• : , �'' , -_ . . �. Concrete Rsser b" Separatinn . k.'..-.�--Po,ritlandCoacrete Gxout . �' Mastic � . _ • :•. • ..;; , . • Spply ' '. • � OPeaiag Filled With � � . � Portland Cesnex►t Gmut Outlet To Distnbution 2" SCH4DI�VC Pipc �e Float VJires � ,: • .r i Floats ; �; �R+emovab1e '.:' F1oat �'xee ; � : .. � � � .. ' • 1'. t. .' .'. � Ddo c��.a�v� T� � t�r_ � . Pump Mt�st ge Ra t ed To De L ive c � � �' Cal lons Per llinute . Agaiest 3 Feet Of Tota.l Dpnamic �iead I'DN) _ ��.sf ��.�� - � � �� ra�n�r�aa�nam�ra��.�. ��aaa.�.��a WELL PERNIIT , (New� Repair_) �� Tax Map:�'2 l rcel: 2' � C Zl6 3 Subdivision: vr� v-� lG� Applicant's Name: f�� t,(/P t Mailing Address: Phone Numbers: Location of Property: � Lot: '�7O �n(% �-'r C��a.�-er- �� Permit Conditions: 1 j See attached site plan for proposed well location. 2.) All applic�rb�e State und County regula£ions g�overning construction anc� setbacks apply. 3.) Permits expire S years frotn the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: Certif cate of Cornple#i�n �fv WeIY: � S/Date Location: � -r � � �� Grouting: -1 � � �'7 Well Log: Well Tag: ''� Pump Tag: 2�� Air Vent: �' Hose Bib: Casing Height: Concrete Slab: Well Dxiller: �.�Sov� Pump Installer: Approved by: , Addilicna[ Com.ments: Date: �^1�P� � �p OLiner: EHS/Date Depth: Grout: �Abandonment: Date: Method/Materials: License #: License #: Date: � - Z�—( -1 Date Sample Cullected: ��! �"( � Date Results Mailed: ENS: � 5 Person County Environmental Health 325 S. Nlorgan St.,Suite C Fnone: 330-597-1790 fax: 336-597-7808 Roxboro,NC 27573 i1J26/13 W tLL I�UIUJI tSUI� 1 IUIU tSCI,UtSU Il7YV-1) 1. Well C tractor�m . � �, Well Co Name 3f �� NC We Contractor Certification Numbu uo�� Gc��u l�. T�e . �� Company Name 2. Well Construction Permit �: Lisf a!/ applicab/e we// construclion permits (I.e. U/C, County, State, �ar/ance, etc.J 3. Well Use (check well use): �M cipal/Public (Heating/Cooling Supply) esidential Water Supply (single) �mmercial �Residential Water Supply (shared) Non-Water S�pply Well: Rechazge �Groundwater Remediation Storage and Recovery �Salinity Barrier Test �Stocmwater Drainage iental Technology �Subsidence Control mal (Closed Loop) �Tracer mal (Heatin�/Coolin� Retum) �Other (exDlain under #21 F 4. Date Well(s) Completed: �� Weil ID# 5a. Well Location: � � f C � � Facility/ er Name Facility ID# if appli le) �n� � !'�iyt 5 ��n �_ U, //G Physical Address, City, and Zip ��ersd� c',� �l�� un(;o ty Par�Identification No. (PII� ..� 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field, one laUlong is sufficient) N W 6. is(are) the well(s) Permanent or �Temporary 7. is this a repair to an existing well: QYes or No 11 this is a �epair, fi/l out known wel/co�struction inlormation and exp/ain the nature o/the repair under#21 rema�ks sectian or on the backo/this form. 8. For Geoprobe/DPT or Closed-Loop Geothermal Welishavingtr�esame construction, only 1�jW-1 is needed. Indicate TOTAL NUMBER of wells drilled: / 9. Total well depth below land surface: �� (ft.) for muitip/e wells lista// depths ifdiflerent (examp/e-3@2o0' m,d 2@I00� 10. Static water level below top of casing: 1�1 (ft.) !t water level /S above casing, use "+ " / 11. Borehole diameter: � (in.) 12. Well construction method: �. /'�. l.J � (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: � 13a. Yield (gpm) C� Method of test: �� 13b. Disinfection type: � 6 � �� Amount: � Lr'or internal use Uniy: I 14. WATER ZONES FROM TO DESCRIPTIO �� ft ft. s / �Cj � ft. ft. r �.. 15. OUTER CASING for muiti-cased weils OR LINER if a lica6le FROM TO DIAMETER TH�CKNESS MATERIAL ft. rt. �4 in. � � 16. INNER GASING OR TUBIN6 eothermalclosed-oo FROM TO DIAMETER THICKNESS MATERIAL ft. ft �� ft. ft. �� 17.SCREEN FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 78. 6ROUT FROM TO ERIA! EMPLACEMENT METHOD & AMOUNT � ft b�. tt �Rt� � T4 OUT fL ft. �i�tt� 1' l? �l7 =IJ ft. ft. 19.SAND/GRAVELPACK ifa licable FROM TO MATERIAI EMPLACEMENT METHOD ft. ft ft. ft. 20.DRILLINGLOG attachadditionatsheetsifnecessa FROM TO DESCRIPTION color,hardness.wiVrock e, rainsize,etc. ft ft O C� n 70 fc. �� el '� S�.-.r� 7Cv fc. r�. y.�'u..-� ft. (i�ft. / _' %G .��. LT" ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certif' tton: �� Signature Cectified Well ConUactor Date By signing this form, ! hereby certr/y that the well(sJ was (wereJ constructed in accordance wrth 15A NCAC 02C .0100 or 15A NCAC 02C .0200 We!l Const�uction Standards and that a copyo/this record has been provided to the wal! owner. 23. Site diagram or additional weil details: You may use the back of this page to provide additional well site details or well construction details. You may also attach addiNonal pages if necessary. SUBMITTAL INSTRUCTIONS 242. For All Weils: Submit this form within 30 days of completion of well wnstruction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. Fof I nieCtion Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Divisionof Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NG 27699-1636 24c. For Water SuDolv & Iniectian Welis: In addition to sending the form to the address(es) above, also submit one copy of tl�is form within 30 days of completion of well wnstruction to the county health depariment of the county where constructed. Application Date: � c�i 1 Amouilt Paid: = /�� Receipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 1) Applicant I.gfnr�ation'•" � Name: D (.V.�S Address: � Ss � � � i 2) Name and address of current o�vner (if di Name: � �N�c p � <<1 �� Address: �� Tax Map: �� «. .. . r ,.�'', �.�1.��,��y . Parcel#: �2�t— IEunwa�u-�xa:—TMTM* aea�n4�n.Il )E'ilo,a�.l�¢.�n. Services for Services Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of E�isting Septic System Application: No Charge/ CA $150.00 or $300.00 than applicant): Phone (home): (work/cell): _ 3.3C� S 9 Z- UlP �� Phone: 3) Property Description: Lot Size: Subdivision: . Lot #: � d. Address and/or directions to Property: ❑ yes ❑ no Does the site contain any jurisdicrional wetlands7 ❑ yes ❑ no Does the site contain any existing wastewater systems7 0 yes O no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes � no Is the site subject to approval by any other public agency? O yes ❑ no Are there any easements or right of ways on this properiy? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: 1 c.� ,j��(.�r s-t��,o�Z /�v��5 �Residential ' ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? � yes ❑. no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water D Spring . Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any laiown ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be irrvalid. Legal * Supporting documentatio}i required. �. p Date �• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. ;' / • A �e�gleted `� ot Prep�ration' form must accompany any application requira�g a site e-.valuation. ��unt.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) s . � � .� � � � : `� �► 4 ••:• � ..;r►. • � . � � �1.J �� .�71��71'Il.71.�Cn,.cE'ili�.,��.�, �c��.JL�.lt�. Building Additions/ Mobile Home Replacements Tax Map #: t� �`� Parcel#: � � � Address: L� 3 � T1,e �ar,�,. � �oS�U � 1( � Approval Requested for: Mobile Home Replacement �Building Addition ApplicantName: �O.N �/ l�e.�� Y Address: Phone #'s: 3 36 -,�� Z- 06 7 Permit Located: Installation Date: ✓ Yes No =—, '' -- Design flow: (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: (date) (Applicant's signature if site visit is not required) Comments: � � � v r �-'�o�C �� c l� X l� Addition/Replacement Approved � Environxnental Health Specialist � � Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-17901 Fax: 336-597-7808 www.personcounty.net ��' y 4 � �iiL �� `� �.� � � �� a.�na-oaa�n-n.�n-a��.Il IE33L��.Il�I�. Applicant: ��✓ ��"SG � $� 1 l�a Location: Operation Permit Tax Map i� Parcel # ZG � 2G � Subdivision ��LiK � ,��,� i/i �`� Phase/Section/Lot # # of Bedrooms ,� System Type (From Table Va): �,>�� Product (IIIg): �� Type V& VI Expiration Date: Type V& VI Rene al 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. , ( uthorized Agent) �� L�u�JtS (Licensed Contractor) -� - 20-!'1 (Date) �-�-11 (Date) G' ��vJ�-r�r� Scale 9�rs PCiiD, rev. 12/14/12 -- 7Sa �� L�,� � C�t� b�� - _ Line ya L ` ys � �9 Tntal i G, c�t�v<,�G V b�?� i r5 "t000 �9 t"`�' '� �coa 'I S'CL� � �tZ Z�ZS�e.7 Tax Map: � Par:.�l #: �/ � Septic Tank System Checklist (Type II-I� System Type: _'� Se tic Tank InitiaVDate State ID & Date: 5�' / � ,{� �J �' 2�' i Capacity: <j IDOp Tee and filter Baffle Vent Riser Outlet boot Perm. Marker Distribution D-box (levels set) Seria1 7 / Pressure Manifold LPP Notes• Pump System Checklist Pump Tank � InitiaUDate State ID & Date: �f- �' ,�, � 1/, Riser (6" min. NEMA 4X Box Model: Piggy back plug Hard wired Alarm functionir Mounted on post Above grade (12 Conduit sealed Pressure Manifold Number of taps: Size and sch: / � �I��,�G��O Contracted Certified Operator (Type Systems): Notes• �� l � � � y►� � ,��v � � � �� .u�.vrn�r•�uamrn.a��atL,x�.� 1��u�.�a� 1.�n Date: �_/ 3 /�_ Name: L o e � _ Tax Map: �_Z� Parcel: 2(n � Address: Cl r. o fC� Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: V 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. Total coliform bacteria are naturally found in the soil. Fecal coliform bacteria 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 ireay 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 or total or fecal 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 additionat 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, w� Env�ronmental Health Specialist Person County Health Department (rev. 4/20/l6) 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 Microbiology 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: ES091217-0092001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: LYNN & BETTY LONG 167 CLEARWATER DR. ROXBORO, NC 27574 Collected: 09/11 /2017 13:45 Received: 09/12/2017 08:37 Sample Source: New Well Sampling Point: well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htt�://slph.ncaubiichealth.com Phone: 919-733-7308 Fax: 919-715-8611 J. Smith Susan Beasley Well Permit Number: A29-261 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent O9/13/2017 E. coli, Colilert Absent os/13/2017 Report Date: 09/14/2017 Explanations of Coliform Analysis: Reported By: Susan Beaslev / � � 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. � nc dQpartment of health end human serviees County: �.' F ! � � � t-�,t � ,(/-� � �y --n ,--4 4 , M f�, � �, �,....l1 C '� l�`�� I y-� i p� � [ E F .` � �� i Y � ..�.. � t � i � i � i �, eF,';i a 4 ,. ? I % i i ` F I i,` i ( l,' :• E � � ,"-__•.. ` �,.-_� � ..,� r f .-�< • �� 1 t ,-�., �.. �_,� �.,� � ,-. --w •� � � F . �� y F-' �" `,� � s �_.s E�.; � ?� i � r�^' �-� � I �,� � ' � ;•i F �,�; + i:_I.; �? e E." �:...,,r' °....i' ', _ F E E i@ I' � i C. G't�,= ` ti_.+ Sample ID #: �- � For Inorganic Chemical Contaminants Name: L o Reviewer: ,.„ ` � TEST RESULTS AND USE RECOMMENDATIONS 1. � Your well water meets federal drinking water standards for inorganic che�nicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic c hemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. ❑ The following substance(s) exceeded federal 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 circled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inorFanic chemical results onlv. Arsenic Barium Cadmium Chromium � Copper � Fluoride � Lead LIron Man�anese Mercurv Nitrate/Nitrite Selenium Silver � Magnes�urn � Zinc � pH 3. 0 a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/l. 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 taste, odor, staining of porcelain, etc. 4. ❑ Re-sampling is recommended in months. 5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and I S 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 andlor 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 inorQanic 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 � Zmc For more information regarding your we[I water results, please call the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3�2Dst�c�Drve Environmental Sciences Raleigh, NC 27611-8047 htto://slph.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH LYNN � BETTY LONG 325 S MORGAN STREET 167 CLEARWATER DR ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES091217-0024001 Date Collected: 09/11/17 Time Collected: 1:45 PM Date Received: 09/12/17 Collected By: J Smith Sample Type: Raw Sampling Point: Well head Well Permit #: A29-261 Sample Source: New Well Temp. at Receipt: 2.5 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 mg/L Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium 9 < 5.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.005 4 < 0.03 < 0.000: 1.10 < 0.1 7.5 < 0.005 < 0.05 7.90 < 5.00 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m 10.00 m 1.00 m n 0.05 m 0.10 m m 250 m Total Hardness 40 mg/L Zinc 7.50 5.00 mg/L Report Date:09/19/2017 Reported By: Deddie .r't�lonco! 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