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A29 43AA�►plication Date: �� Z^� `� =�� S� ��T Tax Map: 2� AmountPaid: __ /��a `,. .►�- � v Parcel#c Receipt #: T� � � �� ".�rav-an-�ca�cn.urraac�.2n4":,m.� �l'��m,si..�d.!}a. for Services Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the ty e of system ermitted �1YIobile Home Replacement or Building Addition ❑ Permit Revision $150.00 if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Itepair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: ��n ��. �;� c� r� Phone (home): �� "�� 1 �� 3 Address: 1� Ic Ne�}�c s� R� (work/cell): _ �� -� 5b y�.l�� 2) Name and address of current owner (if different than applicant): Name: Phone: Address: 3) Property Description: Lot Size: � ac�, Subdivision: Lot #: Address and/or directions to Property: 141� ue�� rL C� �Z�b , r�- Z�s.�y ❑ yes Ef'no Does the site contain any jurisdictional wetlands? C�'yes ❑ no Does the site contain any existing wastewater systems? ❑ yes C�no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes 0 no Is the site subject to approval by any other public agency? ❑ yes C�no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ 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 on-Residential � ype of business: Total Square footage of Building: 3� � 3Z 9a"�� Maximum number of employees: Maximum number of seats: �� 5) Water Supply: ❑ New well Q�Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes O no J 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. I�-�c�' �.� a.� 8 2z � 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) ., N � ; � �� ico� ` f It` �I �U \` t t�• ' � � � . . �\ , � � � v � . I ... 4 � c� o� � � ' � � ,. � , � . . � . ,. , � . � � � . , _ . .� , ` �` � �. � , � _ � � � . . , �`` NF \ .� � . �\ � �\ . � �� \ � �. S s � � . � � � � s z•a�, � � 73� �4 oF � � `. � \ i IF � S� � . 6 . . i , 2 , . � 6p � � . � ; , �. . . . � �, �� , . . , , � � . . . . � ' 56�. � . �` • 28� �A �� I � l4� �¢�� , �e . . � 49 F � rC � T . � � . Q SR � � \ \ '��4 . .. � . . NF \ • � , � � 0 . • \ � N • . • � \ n ` M' � « � � ~ � • : IF � ACRES • . P.C. l6. P. 71 KENQRICK F.� PRITCHARO 0.8. 622, P. 452 P.B. 23,� P. 104 • � w -� _ � :- �- � o _ �- � o � N �. O � 2 ,a, 5t,8� Q � � = O ►� f- O � � �O N � �o � o. N � RICKY W. WILIIA D.B. 255. P. 1.. ' 123.27 . IF � 103.50 S85'18'S9"W i CONTROL �• � IF ' S85' 18' 59"Y� IF � CORNER � ' . , j � �� I � � - . f . KENDf2IGK F. PRITCHARD � D.B. 622, P. 452 • � � � P.B. 23, P.�iO4 ! � •� . � � � � , , �. � . . . J � � � � r � 1 l � 1 � ` , �.r�.,� / , . . _' . . {{ , � �/ � � � \1./ �1L��Il7i'�Il��]LCfiIL'Il.¢.�.�L Jl. J.L�'.�.11�'.� Building Additions/ Mobile Home Replacements Tax Map #:� Parcel#: �3 �f Address: Approval Requested for: Mobile Home Replacement t/�uildingAddition �a�� 3��roC�n-� jc�r ,� zd G�e-e� Applicant Name: �/ i GGt�J D Address: �1�/ ' � � Phone #'s: Permit Located: '/ Yes No Installation Date: ?�i/ 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: . I (date) (Applicant's signature if site visit is not required)' Addition/Replacement Approved Environmen 1 ea pecialist � Dat Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net :i� N � O �„� 2 ,a, 51.8' UNE STQRY OIIELL INC N 64.3' l �` � / / i3,. a�, .�, �'� SQ uro�o,�.t 103.50 � S85' 18'�59°W Person County Erniron 325 S. Morgan Suite G � Roxboro� NC ; //,�I j%Z . �� . � � 1�23.27 S85°18'S9"W IF KEAlDRIGK �. PRITCHARD D.B. 622, P. 452 P.B. 23, P. 104 '_..'�"_T I F ''CONTROL , CORNER i i � .r . � � � \ � � r- �. i � . ► RICKY W. WILLI� D.B. 255, P. 1. Application Date: 7 -3 � - � � Amount Paid: Receipt #: �`,;.��Jr, �J1G��1 � Tax Map: �� I � � ��,�,� Parcel#: �i4 �:�rn�s*nu-�analrn.ar�n4;an.� ��rc3,a.]��,�in for Services Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d) Fee is de endent on the ry e of s stem ermitted) D Mobile Home Replacement or Building Addition 0 Permit Revision $iSu.00 �ifsite visitrequiredj $75.Q0 0 Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $ I50.00 or $300.00 1) Applicanfc matiop:°� „� Q . f Name: VU��'J Phone (home): �� l�`- �Q`�C'E1�4 I Address: (worWcell): 2) Name and add �ss� of cur nt owne f different than applicant): � Name: _ �-�`t\ r'{�- nhc,ne: ��j �^ � � � � �9 .) Address I�ii ?) �Property Description: Lot Size: L� Subdivision: Address and/or directions to Property: Lc�t #: ❑ yes no Does the site contain any jurisdictional wetlands? ❑ yes C�-�Does the site contain any existing wastewater systems? ❑ yes Cj.1ie-- Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes q� Is the site subject to approval by any other public agency? ❑ yes ❑�e there any easemenis or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑IZesidentiaf ❑ New Single Family Residence Maximum number ofbedrooms: J/ ,Q �(�� Expansion of Existing System :f ex pansicn: Currer,t r,ia,�►YiE!' O� J0dC001TlS: f�_�J` ❑ Repair t� :�Fzlfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? O yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: To:al Square footage of Building: � 0 X I 3 01 e C.� M�a:imum numb�; o: scats: �) Water Supply: ❑ New well L�t'Existing Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): � 0 Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certi zat the i;zformation provided above is complete and correct. I also understand that if the information provided is ina e, or if the ' e is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. iv31 �I a �gn ture (Owner/ Legal Representative*) Date * Supporting documentation required. Permits are valid for either 60 months or are non-expiring when accompanied 6y 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) I�� T�x M�� F��rcel # � � ��) � � � � Subd'ivision II : ,,, , _ , , , , � , , , , � , I I I . i � I , Phase Sect�ion Lot # Permit Valid for Type of Facility: . # of Occupants b Proposed Wastew Proposed Repair: Permit Conditions: �Owner or Legal ] Authorized State �/ Five Y # of Improvement Permit No Expiration � �, New Addition $ � „ Projected Daily �low ,3G 0 Water Supply 1'�e i� g.p.d. � Type: Type: Date: � Date: S" -/ The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicandproperty owner to in sure 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. The Improvement Permit 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 and Rules for Sewa,ee Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_). Propose Wastewater System: EZ c � � Type� Wastewater Flow �( �g.p.d. �r�,, � , i , � '��t31 el� New � Repair Expansioxi _ Soil LT � g.p.d./ ft 2 Type of Facility: ��Pv�Ce, Basement _ Yes No Wastewater System Requirements � nee�� Tank Size: Septic Tank: DO gal Pump Tank: ce gal Grease Trap: gal Drainfield: Total Area: � Dn sq ft Total Length �ov ft Maximum Trench Depth Z4'' in Trench Width � t Minimum Soil Cover: �_ in Minimum Trench Separation: � � �ft Distribution: �Distribution Box Serial Distribution Pressure Manifold Specifications: �� /�6 � Authorized State A�ent��-�� Date: -�- �-// Permit Expiration Date: �- � - /(� The type of system permitted is nvention � Accepted Alternative. I accept the specific tions of the permit. �- q l Owner/Legal Representative: Date: < PCHD rev. 11/10/OS � . , .� .\ . ; � � �l��xal� S� , ,. , ,� � , , � �-5 a s,� � , , .� �, �� ,, �� . , � �� '� '� ,� ,� ,� , � '� � '� ,� � �� , ; � � ro �� , � i Fa►tu SR , � � ROAD �6J ` � i � �. �. ' � �� \ � �� ;; BARN PLOT PLAN FRANKLIN PRITCHARD SCALE 1 �' = 60' ,a�—,, i ��-��S �� NF � � � �. � `\` N �� `\� ` � w�i ; i __ pau:r�usm� sY aptu�.�qTourj�� acnsus o,� uor�n�su: ar� �un�ui�aq � �O�d �� '�� .�w�u� �y •�uo .r.cno�uoa; a,�nsuzxatqiqUn. �uasa.�r�au s�uauo�ruoa uca�rs�Cs a�.�eQ . —� -� #��'I/II��aS —�# ta��d._��# d� �y H��L�S �:I,IS �ua� aa.�.S paz�ro�n� i v u ierpqnS � . e� � � . �� au�eN • '��'g3t �[��.��..�� .. , �� L O✓ ' T'{4 `r� . • �� ! ��. ��,s. f ��.� �� IE��-��.,,-„-„ ��.Il IE33L��.IL�II� Applicant Location: Tax Map �� Parcel # L� Subdivision Phase/Section/Lot # # of Bedrooms System Type (From Table Va): Operation Permit Product (IIIg): c Z �Ez�,.l This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. � .ZL�•� ( uthorized Agent) �. �� s (Licensed Contractor) b�� , � -�'�',�EQ � `�T='a � GO � � ��z q-zS- �o , n � "' K c�° � ^�I/ �v �o Q ��' L'� `� �� . -�v�.A► � Scale: �i� �� -�� J►�� 0 �/'il�. (Date) 5 /I 1/ (Date) 3a :��p�.�s � � � = � �►� . �r. �T?2.oTk-�, '�►�o +�t.5 �� --- _ . .� 1 �� ,. �. Tax Map: � Parcel #: �3 � Septic Tank System Checklist (Type II-I� Notes: System Type: _�� Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: 1) ' �� ' , � \� , < <�� \ � I � � �_„�..�► ,-,�-.:,�, ►, Suilding Additions/ Mobile Home Replacements Tax Ma #: � 2 Parcel#: i 3� Address: ��C �S'�'r �S .��r-r �9'C - p � � ?S? ,r Approval Requested for: Mobile Home Replacement � Building Addition . ApplicantName: �+�Glh� � �fi C� / �-l��cGr�( Address: c?.-� �cS �' �� Phone #'s: � 5 7 3�_�'�-_((� 3 S' �` Z�O Permit Located: V Yes No Installation Date: — Design flow: � �' � (gpd) Current Contract wiih Certified Operator on file (if required): k Water Supply: � Well Public or Cammunity Wastewater system shows no visual evidence of failure on: �� ►� (date) (Applicant's signature if site visit is not required) ��&� L �✓Yil,� SSI Gh '� �(,tr l4f" �Z �� 3 z Addition/Replacement Approv�d ,,, �a �vv�../. � vironmental Health Specialist �� , Date � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www�ersoncounty.net � �1� ?�.�f �� I� �� a- � �.� � �. �.�.Il I�IL � �.Il. �I� Applicant Location: Tax Map �� Parcel # C� Subdivision Phase/Section/Lot # # of Bedrooms System Type (From Table Va): Oueration Permit Product (IIIg): cy;-u,«,L_ 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. ��-�Zr�•1 -�uthorized Agent) �• ��t�.�/ � (Licensed Contractor) �Q� `�i"+a � C50 6 �'� �'�z q� •-z�- �a � y� `—� 6 lo �� ?" � b�� Scale: �G� �� d�� C 1! �� (Date) � �f e� (Date) 3a ��p�.s L u5' = 7.-�-�o ��.1. �T. ��ZETk-�, '�ai{o +�.5 �'�� , ; � �� ..� .�„r `l.� � � � � � 7�,�.-n.�a��m�a-��n��.1i �3I��.11-�.1� WE�,�, PERMY�' (New=�/ epair� Taz Map: � Parcel: � Subdivisian: Applicaxat's Name: {ien irr{'r.hc�ml Niailing Address: Phone Numbers: Lot: �'ermit �onditions: �) 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, f-om the date of issue, Other Conditions/Comments: - � Pe�mit issued by: I�ate• �� CERT'�'�CATE O� COldIPLE'TIOI�T New Well Inspection: EHS/Date Location: � ��.� Groutin �� "�' �` S� �r�:�Q o,.a .. � Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Lnner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: � Y��Q, License #: Pump Installer: i License#: �Vell Approved ]b�: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 I;ate: Date Results Mailed: ' � Phone: 336-597-1790 Fax: 33b-597-7808 sii�os North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH KEN PRITCHARD 325 S MORGAN STREET HESTER STORE RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573 EIN: 566000331 EH StarLiMS ID: ES071211-0036001 Date Collected: 07/11/11 Date Received: 07/12/11 Sample Type: Sampling Point: Welll head Sample Source: New Well Temp. at Receipt: 7.5 Sample Description: Comment: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27617-8047 http://slph.ncoublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 Time Collected: 10:30 AM Collected By: J. Smith Well Permit #: A29-43A GPS #: 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 < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 5 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.8 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.80 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 147 mg/L Total Hardness 110 mg/L Zinc 0.10 5.00 mg/L Report Date: 07/20/2011 Page 1 of 1 I��,. .�,1 w� ��::� JUL 25 2011 Report To: North Carolina State Laboratory Public Health Environmental Sciences' _ : Microbiology Certificate of Analysis � �� 20i1 I ._. —_----- �:��__ PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET i�OXBORO, NC 27373 EIN:566000331 EH StarLiMS Sample ID: ES071211-0075001 � �� ES Microbiology ID: 28524 GPS Number: Sample Description: Comment: Name of System: KEN PRITCHARD P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://siph.ncoublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 HESTER STORE RD. RQ�ER4R0, NC 27573 Collected: 07/11 /2011 10:30 Received: 07/12/2011 08:59 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A29-43A Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 07/13/2011 E. Coli, Colilert Absent `�-- --'� Susan Beasley 07/13/2011 Report Date: 07/14/2011 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. Jun 01 11 10:28a Barnette Weli Drilling 336-598-9275 p.1 . srar�: t-`�'? �`'�.:, ,h: r . c ` %I' �; , "''. n > L�• "�:� � �� ..� :.� J:,��. �E,4I�EIV7'IAL wEr,L corrs�rxucriorr x�coRn RE North Carolina Departrnent of Environment and Natural Resources- Division af Water Quatiry WELL CONTRAC'I'OR CERTIFICATION # _ � � �j � -��__ 1. WELL CONTRACTOR: � l� lS �� wen Contractor (IndmCual) Name Bamette Weil DriNi�a Inc WeII Contraetor Comparry fVame '— 6 1B m in en d Sireet Adtfress ox oro NC 7 4 City or Town State Zip Code �6� 599-00'15 Area code Phone number 2. VYELL INFQRMATION: WELL CONSTRUCTfON PERMIT# 2 q-� �.. La( .3/� OTHER ASSoCIATED PERMfT#(ilapp�icable) SITE WELL !D �{rtap�li�ble} 3. VYELL U5E (Check Applica5le Box}: Residential Water Supply� RAiE DRILLEp "r + TIME COMP�ETED Z�D � AM ❑ PM L�� g. WATER ZOHES (depth): iop-17p Bottom ig 0 Top 2 J D Bottom Z? C� Top 8ottom TaA Bottam 7op Bottom rap Bottom Thicknessl 7. CASING; Depth Diameter We(gh; Materiaf Top�Bottom��Ft •2jJ �� _�RV/ ' 7ap Bottom Fi. Top Bottom Ft. : 6. GROUT: Oepth t�Aaterial Method � Top�_ Boriom Z 0 Fc. Sand/Cement Poured --_� Top Battom Ft. i op Bottom Ff. 9. SCREEN: Depth Oiameter 51ntSize Alaterial 7op Bo�om Ft in, i�, —'—�_ Top Bottom Ft. in. ;�. —�� Top Bottom Ft. in. in. 4.1M1fFLL tOCQYION: � 10. SAHDIGRAVEi. PACK: CITY: D a COUN7Y e Q/l� Oeplh Size c��J : Top Bottom F1. � J d e . l� O e /j� Z�,.7 Top Bottom F't. (S�eet Name. Numbers, Commuoity, ouhdivision. Lot No., Pamxl, Zip Code) � TOp BOflO(Tt Ft. TOPpGRAPNfC ! tAND SETTING (theek apprapriate box) �Slope CValiey pgfat GRidge LlOther 1 �. l7RILLING LOG Material lAT1TLIDE 36 '_� " DMS OR 3X.�ocXXXxx�cx pp 7op Bottom Fo tion Description LONGITUDE 7� � � � L� �v ° " DMS OR 7X.70CXXXXX)cX bD �S /�' �6 O"�' ,S LatitudeAong:tude source: �pS Qfopo�raphic map ' .�2.� �_,�P. �!�/9y �Qa � f lJocation olwell must be shown on a USGS topo map arrdattached to I this icrm if nor using GPS} � 5. WELL OWNER ! r! {�r9- Qwner Narne _ � sfe�t sfo e� JP�,. �S eet Address t� x b� �o Dl� C- 2 iS.�"iL C�ty or iovm S,ate Ztp Gode 3�.a S�7 — � S^ � Area code Phone number 6. WEL� DETAiLS: 1' a. TOTALdEPTH:�� 7`b b. DOES YYELL REPLACE EXISTtNG YVELL? YES p NO �'/ c. WA7ER LEVE� Be�ow iop of Casing: �O �, (Use'+" itAbove Top of Casing} d. TOP OF CASlNG IS l FT. At�oye Land Surface- 'Tep of casing terminated aUor below land surFace may require a variance in accordance wiUt 15A IYCAC 2C .0198. e. YIELD (gpm): _�_ M��{OD OF TEST BIOWfI ZOCii r. fl�siHF�cnoN: Type HTH �o�nt 'l/2 Cuo 12. REMARKS: 100 NEREBY CERTIFY THA7 THIS WELL WAS CONSTRUCTED IN ACCORQANCE WITH 95A NCAC 2C, WELL CONSTRUCTION STANDARQS. AND TNAT A COPY OF THIS RECORD HAS BEEN PROViDED TO'fHE WELL OWNER. • %��.�.— '/� l/ �,�-� 5� SI TURE O� CERTI IED WELL CONTRACTOR OAT� l��} cliS GS RNe� PRMTED tVAME OF PERSON CaNS'fRUCTING THE WELL Subrr�it within 30 days of cornpletian to: Divisian of Water Quality - Information Processing, 9617 Mail Service Center, Raleigh, NC 27699-161, phone :{919j 807-63UQ Form GW-ia Rev. 2109