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A30 26r Application Date: i t, 3 Amount Paid: o iO" Receipt #: 1'1 � g C.�41��► 3"�`13— ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit re uired) Well Permit e eplacement/Repair) $300.00/$200.00/$75.00 `�� " �� Tax Map: � 3 � �� Parcel#c a� .�.._ �.�` �� Ey�rn�vn.n-¢n a�a_mra�c..rn.4':an..11 7HI�,ai n.ti�a. lication for Services Services Re uested ❑ Construction Authorization (Fee is denendent on the tvpe of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: ! -e- rn � • � � Address: D l u l�F � o�,-v C- 2 7 S 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3�� ' S q�-�� D J (work/cell): 33C ��`� �' �/ �� Phone: .� � ��3'�.�.�. 3) Property Description: Lot Size: Subdivision: Lot #: �"�"�`� � Address and/or directions to Property: Ac er,s s fa�►�.� b+5� '(�i,c��\�.�v,.� KD �'�'�� ❑ yes C�no Does the site contain any jurisdictional wetlands? ❑ yes C-I no Does the site contain any existing wastewater systems? � yes �tio Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes E�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 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 ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: C�New well ❑ 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): ❑ 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, or i site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �� 1�-13 Signature (Owney�/�egal Representative*) * Supporting docu�x%ntation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparalion' 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) �� S f ��.� �� +'Y ► ! V�/ � �� 7� .�.� a � � ��. � �. ¢ �. Il I�3T � �. Il � J�a. WELL PERMIT (New�Repair� Taz Map: _f�30 Parcet: �lc Subdivi5ion: Lot: Applicant's Name: ��-�-Y M . A��t� Mailing Address: 1a� �oH�.1, A,,�,E,a Rfl Box(��.a r�C. �`159y � Phone Numbers: 33b -59 q- a�� s3e -�qg -�1�� Location of Property: A�gaas Faar. '�! b►5� '4*�cc-�abc'ar� �fl : Ac��►c�.�r To '��u� �w,x. A�v.x�� Permit Conditions: 1) See attached site plan for proposed well location. 2i Al! applicable State and County regulations governing construction and setbacks appdy. 3) Permits expire S years, frorn the date of issue. Other Conditions/Commsnts: i�1��t� Ru., S�CB,qc.ai.s ; Q�z P�tJ ��, r�wc.� w��a Permit issued by: c�� Q►. � Date: i`� l3 CERTIFYCATE OF C�1�ZPLETION 1V'ew Well Inspection: EHS/Date Location: 7 1ss 13 Grouting: Vdell Log: 1Ne11 Tag: 4r�.s '1 �► � Pump Tag: ��1s � ti3 Air Vent: Hose Bib: Casing Height: s ai ►3 Concrete Slab: o�s i� 1� Liner InspectiQn: EHS/Date Installer: Depth: Grout: �7Ve11 Abandanment: �HS/Date Completed: 1Vlethod/Material(s): _ Well Driller: L�ta��. Licen�e #: Pump Installer: �► : C3. C�trt,v��, License#: Well Apprc�ved b,y: ��_ .0 i� . h� , __ Date: � 1°1 l 3 Date Sample Collected: 9� �� Date Results Mailed: t`J `l � Person County Environmerital Health 325 S. Morgan St., Suite C� Roxboro, NC 27573 Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 �1� ?,� �� , � — �� IE aav+n s� saasa� �cv.�mll IHL �0 �m1� �IIEa SITE PLAN Name �E1.1-.`! P'1. �41.�1, Tax Map # J�13QPazcel #��O Subdi:nsi Section/Lot t�� . • ��'� t Authocized State Agent Date System compoaents tcpresent approximate contours on/y. The contractormustflag t�e sysrem prior ro begianing the insrall�rion ro insure t6atpmpergrade is m�rained. ,:�s.t �: � s�r� r ,ti �4' E �� ''��„ S��y� g v�\, �p�� ,��.� � �t C�i7R (�1 :5fl Fe�ti � ' � STATf;�-� ,�,P��;i �:..,.,\��- :`K : 5 it' 2 . \Z'. _�� '� �•; -::i> =� '�:;:..u:;��-:. •.,,�� j� _ �e a.,..=*` lIESIDENTIAL WELL CONSTRUC'TION RECORD North Carolina Departmen: of Environtnent and Natura! Resowces- Division of Water Quality WELL CONTRACTOR CERTIFICATION # � S� %�� -- f� 1. W CONTRACTOR: C �oav,�� e i� .. .�� 'f-�- Weli ConUactor (Individual) Name Bamette Well Drillina Inc Weti Contractor Company Name 611 Bamette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number Z WELI INFORMATION: WELL CONSTRUCTION PERMIT#_ �%%� �- � 3L� OTHERASSOCIATEDPERMIT#(itapp�icable) � Z� SITE WELL ID #(it applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply ❑ DATE DRtLLED 7 �'l� �� TIME COMPLETED_ % z 30 AM ❑ PM C�.� 4. WELL LOCATION: cinr: _ h'c�:,�E('F I2� �JI r couNnr E(�Sv/t� /4Ci�dSs ��.�'t � � .S'� �ti Saw� h (Street Nartfe, Numbers, Community, Subdivision, Lot No., Parcel, Zip Codej TOPOGRAPHIC / LAND SETTING: (check appropriate box) ❑ Slope ❑ Valley (z��t ❑ Ridge ❑ Other LATITUDE 36 °�'—��" DMS OR 3X.XXXXXXXXX DD LONGITUDE �°��'�• DMS OR 7X.XXXxIUOUCX DD latitude/longitude source: �S piopographic map (/ocation of.wel! must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OWNER - i ��' y �7, /� l�Erv Owner Na / �-'1_ .i [:��lt% /��e � �c� " Street Address' �sr�b� /� � ,t/c - z %s`� s� Ciry or Town State Zip Code �( 3� , - �-�-,'� ._ z .lCi j Area code Phone number 6. YVELL DETAILS: a TOTAL DEPTH: Z �%C� b. DOES WELL REPLACE EXISTiNG WELL? YES O NO g� c. WATER LEVEL Betow Top of Casing: Z,� FT. (Use `+` if Above Top of Casing) d. TOP OF CASING IS j FT. Above Land Surface' 'Top of casing terminated aUor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): Z�'� . METHOD OF TEST BIOWII ZOfYI f. DISINFEC710N: ry� Hl'H Amou�t �/2 CUq • g. WATER ZONES (depth): : Top /� Bottom /.S5' ��Top Bottom • Top / fv 8ottom dO °" �Top Bottom Top % �'� Bottom i�c-��3op Bottom Thickness! 7. CASING: Oepth Diameter Wetght Matar(al . Top � Bottom ��( Ft. G� SQ �e� t (/`C Top Bottom Ft. : Top Bottom Ft. ' 8. GROUT: Depth Material Method � Top d eottom ZC� Ft. Sand/Cement Poured : Top Bottom Ft. : Top Bottom Ft. 9. SCREEN: Depth Dlameter Slot Size Materiat Top Bottom Ft. in. in. Top Bottom Ft. in. in. Top Bottom Ft. in. in. • 10. SAND/GRAVEL PACK: ' Depth Size Material : Top Bottom Ft. Top 8ottom Ft. � Top Bottom Ft. : 11. DRILLING LOG Top Bottom � / 6 �� J =s�� 90 b / ZCio / / / i / / i / : 12. REMARKS: Formation Desaiption � O lP P,2 �f_ �?� K% rN,�� s�,�� S%iNIE rT S%i!�/.Q_l�D�'/� �JTT—j��c(,2 S�- �ti�f� i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITli 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T� WEIL OWNER. .-, ' �n2�i�� - .� � -. 7�-/�" / 3 SI( t�ATURE OF CERTIFIED LL CONTRACTOR DATE U�It1 YV t C" �. Y'"f� C� y'� PRINTED NAME OF PERSON C NSTRUCTING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2I09 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: ES092613-0091001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: TERRY M ALLEN P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 ACROSS FROM 6155 BURLINGTON ROAD Col lected: 09/25/2013 13:28 Received: 09/26/2013 08:40 Sample Source: New Well Sampling Point: Well head Derrick A Smith Angela Heybroek Well Permit Number: A30-26 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colile�t Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Lyons 09/27/2013 E. coli, Colilert Absent Darneice Lyons 09/27/2013 Report Date: 09/30/2013 Explanations of Coliform Analysis: Reported By: Susan Beasley OCT 09 2013 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. Report To: lin State Laborato of Public Health✓ North Caro a ry Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES092613-0067001 Date Collected: 09/25/13 Date Received: 09/26/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.9 Sample Description: Comment: Name of System: TERRY M ALLEN P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncqublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 ACROSS FROM 6155 BURLINGTON RD Time Collected: 1:28 PM Collected By: Derrick A Smith Well Permit #: A30-26 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 9 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 2.30 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 6.90 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 46 mg/L Total Hardness 43 mg/L Zinc < 0.05 5.00 mg/L Report Date: 10/04/2013 Page 1 of 1 Reported By: Arnold Holl