The URL can be used to link to this page

A30 57Application Date: 3"�4 "� � � Tax Map: A 3 � Amount Paid: a00 . 0O Parcel #: � 7 Receipt#: 'l-9 0 4 3 ( �� `--.`--�`'�.S �� $� �� a g°I � = �-.�-= � � 1� l� � � /�� I r�- �E-.:�za-viiu—<cn�a�r-r�a<t�-�raTf.:.�n.n.71 1C �Lue:�.ea.litil�a l�K �O�e. �avid � App�i��tYon fo�' Se�-viees (Septic Systems and Wells� �-�- o µ�" 5ervices Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 g d) (Fee is de endent on the e of system ern i7 Mobile Home Replacement or Building Addition C! Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit ( e lacement/Repair) Htepair of Existing Septic System $300.0 $200.00/ 75.00 No Charge rv _ ,�- 7- / 1) Servic�s Requested by: �'co.��w-�' : 1��!-�, � QaSe✓S N - �� -09 Y Name: 14� �. � ✓S Address: ,� / .<J � V C. �,�� Phone # (home): �19'0%D� (work/cell): 3G'f — '�'1 / S a�'�_ 8l/O 2)Name and addr�ss of current ow�ner (if dif%reni than applicant): Name: Address: 3) Propea-ty I2escript�on: Lot Size: , 9G A�� Subdivision: Address and/or directions to P o e�y• (o �3S"' �u��, ;,�s.�, ��1 � , .� - � o� o� K%�cb�7F r � i a. � , i 4) Proposed Use and �'ype of Structure: Residential � Business/Type: Other Number of bedrooms 2 / Number of people served (seats/employees): 3 Basement: Yes No ✓(with plumbing: Yes No �� Garbage disposal: Yes No _� 5) Water Suppiy: Private Well ►/(Proposed Existing � Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Lot #: Yes �(please show location on site plan) Note: A completed application must also include: ➢�4 plat/site plan of tlze property ihat �hows property dimensions and the size and locatio�t of all proposed structures. 9 A signerl copy of tlae `Lot Preparation' form verifying t{aat ihe property is ready to be evtaluated. I am submitting this apg�lication to �equest services irom the Person County �ealth Department. I understand that af the information provided 'ns incorrect or i�f the site is subsequently altered, ar if the intended use changes, all � permits and approvals shall become invalid. I i�lrl- lv cl� F�•., � J r✓s� ��: Sggn�ture (Owner/Legal Representative): �p�, � %�t o a.e��, pz� �ag� � .�' /D -(� 9' 10/08 Person County Environmental Health, 325 S. MorDan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� j �. 1Li �� `� \J � • L 1� `�� -��i�T �--- ' a 3�'�-n.�Z-<m�'t�,,,r,;-',<e�..vE.m�. �"'��.�'�� Applicant: Location: T�x , ap � .i ' �.r �el s U, �� v� s,� a�n ' �.�s.:- : ect+ion: � t �eapra�effi�� exnait � ��at ��ad for ✓� e '�e�� Pdo ��pnra�ion Type of Facility: New Addition �Ia�� u�g�Iy �i # of Occupants # of Bedrooms 'Z � Proje�tezi Dai�y Flow _�7� g.p.d. Proposed Wastewater Sys em: � Type: Proposed Repair: � Type: Permit�Conditions: "��-��is-T��1.�--to� l'��9 .��.L' �.y ��n � 2,�A �� /'7gL5 Owner or Legal Representative Authorized State �Agen�t: < The issuance of this pe�.it by the Health De�iaztment in does not guarantes the issuance of other permits. It is the responsibility of the' applicantfproperty owner to in snre that all Person County Plavning and Zoming and Bu�7ding Inspections requirements are meL Thi� �nqsrove�nt ��r�sat i� subject to re��cmtrion if tPte siie plan, plat ox tEie i��d�� u$e chamg�.s. 'i7ne I�e}�so�ver��s�t 3��ii is not aifee�e� hy a c�n�ge in ownership of the properiy. This �Sernei# was i�saned in c�ffipliance vaitii the pro�vnsfo� of th� Nortfa Carolina `Z�ws asad .Rules far SesvaQe Trer�trs�er�t aa�d Disnasad Svsterns' (15A Pt�CA�C 13A .19�0). 1V'eathes� Pea�o� �oa�nty morr the Envir��axaaent.�l �e:ilt� Speeialis��wBrr�ax�s iiaa�. t9�e septi� ta� systesn v� c�n�ue ta f�c#ion sata��#m�y isi tix� ftc�re oe�that th� watea- su�ply wii! r��ain�potai�le. - -.. � � � Aaa#horiza�da�n �o Co�st�ct ��#e�a$� Sg�s��a (It�nnreqi fog ��i�ag �'ex-�nat) -� * See site pdan and ad.aTitional attachments (�• Proposed Was�te�water Syst�m:�C� New Repair ✓Expansion _ Type of Facility: � , ��:�!_ '�anir Siz�: Se�tic'�ank: 60o g� �r�a�ei�d: '�o�i ��a: � se� � Ty�e� �UVaste�vatex• Flo�r Z�:p.d. �� i,T g.p.d..! ft 2 Basement _ Yes _�A% � � �aste�va�� 3�st�ffi I��°effi��a�s � Y�}� 'lC�: T'otal Leng� � D � g�l �Gr�e Trap: g�l � IyI�an� TY�ncig I)e�tia L�_ � Trenc3a'vi�aait�a _� ff� 14�I'in'affia� So� Coeer. _�L in I�l�'i�a'ana� 'Pr�n�a Se��tio�n: "' �� isiri�au�son. �Di��rib�ion �oz 5eriai �istril�nta��a g'ress�re M�ifmid . spe�ca�aons: � ��i1��.� G' L�3 ' -�ut�ora�es� S�t� ��xt Date: Permit Expiration Date: d � The type of system pernutted is permit. � �w��el��i Canventional �/ Acce�teri Alterna#ive. I accept t.�e spe�ificatians of the Date: � ��' �� PC�D rev. 11/10/OS f�t�A��2_ ��,�� ►�.��J�T �-= - � �,o�� -�a-�,r„ ,r„-, ,��.ffi.11 IE-�i��Il¢� SI"�. S�'�'C�. Name -- . Ta.� lYla.p # �'3o Parcel #�_ Subdivision fo � �� _ Section/Lot# �'t�09 T Authonz State Agent � Date . � System com�onen�r re�iresent ajiproximate�con#ours only. The contractor must, flag the system prior to beginning the instaAatrvn to insure thatproj�ergrnde is maintasned Z "g :�-b� c�MS r� v �?d � Gi�/�3 G �o , - z�o �.c/ �r.- �� y`� r� /y�j�(/.t1U.�i %��i✓G� ��s �/oT�. � 3r�✓t'�� ;;o � , �d�/ �(v$'�9 K�,'vi✓s /#�vgs �•✓� y�►� d�- �'��s. ��£ ;,�� '�90% � ��i� G'oM�i'�� '� �/►/ �G/1?i� . G SC�C: l �� - ✓r'U � .�u�/ l��.�i-ca�.lS Co�r�' �G�c��- '�c� ; . -�`5�37- t7R� �� ' j��1(z l-i rlGl To rl �T> • ��w �� ioao�, '��. P�I�, �ev. 09/12/01 �.� 1� ��- � �' �� `�' � �....� 9�'L � � �/ � ��7�]� 1L'7�� a �lla'�ITIl]L"KDIICL]Lh`L_��aL.Y�.ffi.�� .1L.11,�dflJll�C.117� I , I`�1�r�xe __ �-� �� l r,, , r_ � �ubdt' �e�i�� _ / ,� �_ u�o�ized 5tat� 14��t �Y�'� ��'I'C� Ta� 1VIap � �'1 ��Pas��-el rt '� i Section/X,�t# n --- -� —��_�,,� - nate 3',�rs�`�� c�n�rr�+Y�a�+�n�r ney�+ resent a�i�a��irnra�ta�ce�sa�0�az5 a+s�y�. 7'�� co��w�c�or s��es� f%g� t�re sy.��tas�ela��or �� b��sl�va� �h� �rxst�slln�iosa to snsure tlaatpa��i�rgs� is �uasr�t�cas�� I � � �l i� i � � 1'1� � �� Y, , .,r�� h o�ts�., l � � � �J� )' ' fe P✓operT�l ' " ,� �� ,, �� • �� 1 f �,�y . QN� 1 %DOj �. � F , � � � II �� \ ll �S � ,,�,�� :: � �'�,�°. � ^n /� � .r' _�. �D 1 � I`� �� r � �' . vr ;, � � � �/,� 1( � ' 'l � � 5 r�' 1�i i tt �� a�� `,(� � � P '� �� , •�t' 3 �t f., � ,- � �, �;"� • .,� � 5IJ 5�1� ` .�t � � `� % �' � `� .,� * , ; J � � � = � ,�� ...t�'a� . � .. t. � ��: .. f . . :i 3 `�' � ��; ��+�p �*�'. y_ 3{ { . . . . �t . ��-: �� t . . . -t e� . . �' �� . .. � 1 ' � � i �� ) C��uC� ', � ��' f J ��' u�S�G,�s � � �� !_ ' � ' � J � .� p�C `� , � 1 =�x �r�v� �Qa _ �� ,,�� , . � y�� F � � -, �� 17 q� �� .�+� ; � � � �, I i � . � � ;(�� l_%� . � =__,� i,F+,. ,+ F, � f ��# �`` "� . ; . �y�,� -,s@ � ��. k � ��y@ �� '!," y �� f ' . i �` ��' �'� � �,� �� _. , �" ; � �*� r�� i � "*'� =�:�� -� _ ,� =i �, ...�. �� ;a�, ttx��47 a �� .� s � � � �� rn�a�-��ssraa��..��.� ��.�.��n. Applicant: _ Locatiort: � ' ax M�p � � �rc I Subdivision Ph�se Section; ot # # of Bedrooms . � !� `�1 � � r (� ckaw►�se,� � . , � System Type (In Accordance Wi�h Tabie Va): THIS SYSTEIVI FdAS �EEi�! iNST�4LLED 1P! COMPLIANCE Wli'H ,a►PPLlCABLE . i�ORTH Ci4ROLlftlA GEfVE#ZAL STATUTES, RCJ�ES FOR SEWAGE TREATME�VT_AND DISPOSAL, AND - ALL CONDIT10iUS OF � THE lI�iPROVEIViE9�T PERMIT AND CONSTRUCTION AllTHOi�f T iV. - � � � � � � � �-:�s o - Au orized State Agent Date instaJled. By: � f7 Date: � S D � � fi5 �� s� � 3Z'� � 3� g-� 1 ��5 C �a,Mb�e� 0 �Afe.<< � � � t . . �� K � �� ; �p in� ✓ 7 I ,L ,r,_ (J� � _ ��as�: � p-!�l'� PCHD, rev. 07/29/04 � � � ��P31� �'��K �NS��`�3�h� �u'�E+Cit�.1S? {�ype �@ a I� Tax IV1ap # .. � Rarca! #.S% System Type (Tabie Va) Owner/App icant ( Subdivision Address/Location SeclPhase Lot # � Se��ac. Tarak State �lD/date �Qx 1%�� Capacity /��0-�.gal. Tee and Filter - • Baff1e Sealant � � Riser (ifi applicable) Tank Outlet Seal Permanent Marker P�am1P T�e�k , � - Vci "dl:lt a�. � � Wate roof /Sealant Riser Water Ti ht � Pu�rap Check Valve/Gate Valve � � Ant�-si on o e Floats/Switches �41arm visable and audible , Electrical Com onents � I � Rate m � A roved Pum Model ' Bloc� Under Pum � Pum Removal Ro e/Chain . �•Disia-ibu�ion: Sys�ern � Serial Distribution � Pressure �ian ol Low Pressure Pi e � A r. Pi e l�liaterial and Grad� � Va(ves � n.Ld� 3 Z` Trencf� Gtade � Trench S acin � Rock De th and Quali Dams/Ste down� etc. Pressure Laierals � Hole S�acin4 � �. in. ft. Pipe. Sieeve Tum-upslProtectors Required� Set�acks - From Welis ' From Property lines Surfaee Waters Public 1Nater Suppiies Vertical Cuts (>2 ft.) Water Lines Vehicle�Traffic � Adjacent SYstems - =Easements/Riqhf of W Other Easements Recorded e e perator on Tri-Partate Aqreement Commen� ./' pcf�d rev. 3/13/0�1 WELL ABANDONMENT RECORD North Carolina Department of Environment and Naturai Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # � 3 � WELL CONTRACTOR: D/UGy�f L � �t�<T1�` ell Contractor (Individual) Name ' rS�.�2��f/� w�,)l L�Zt/��q� Well Contractor Company Name �' STREETADDRESS �� !�Q/�-��'1�P �j/�d��.n�� — Q�,T �c��_,/U C. 2_ 7 5 7� C�ty orTown State Zip Code c33E-�- S�7- oD/S' Area code - Phone number 2. WELL INFORMATION: SITE FVELL ID 1t (if applicable� +�� S7'ATE WELL PERMIT # (if applicable) � COIJNTY FVELL PERMIT #(if applicable) �/' v� DWQ or OTHER PERMIT �(if applicable) WELL USE (Circte apglicable use): Monitoring esidenti Municipal/Pubiic IndustriaUCommercial Ag cu tura! Recovery Injection Irrigation Other (list use) 3. WELL LOCATION: COUNTY P�`D.,� QUADRANGLE NAME NEAREST TOWN: c� 1� .G7o.2 c� �C � ��L� ��iSz3S� �� L�e E's'7�c�J DP� , (SueeURoad Name, Number, Communiry, Subdivision, Lot No., Pacret, Zip Code) TOPOGRAPHIC/ �SEITING: Slope Valley Fla Ridge Other (Circle app nate setting) LATITUDE 'May be in aegees, -- minutes, secondx, or in a LoxcrlvnE . a"'�' f°`�` I,atitudeJlongitude souree: GPS Topograptuc map (Location of wel! must be shown on a USGS lapo map and atlached ro this jorm rf not using GPS) 4a. FACII.I7'Y-'[he name of ttie busaus.s where the well is located. Compkte 4a azd4b. (If a residential well, akip 4a; complete 4b, weli ownec info�mation ody_) FACILITY ID #(if applicable) NAME OF FACILT!'1' /i%G� STREEI'ADDRESS J] 70 �l�l4�sg'c /l .S/��./IJ.0 �i�e.2.Q /,e sh,`fls ,� - 2-?.�5� L City or Towu State ' Zip Code 46. CONTACP PERSON/WELL OWNER: Nnt� T/%�,2 �-� � ,�oa ��-5 STREbT ADDRESS City or Towa State Zip Code c�36 �- 5 d 4� �/Z 30 Area cade - Phone number 5. WELL DETAT[S: a. Total Depth:,�Q_ ft. Diametcr.�in. b. Water L.evel (Below Mcasuring Point): �� ft. Mcasuring point is � ti. abovc land surface. 6. CASINC: L.ength Diameter a. Casing Depth (ifknown): �l/D/L�ft. b. Casing 12emoved: R. 7. DISINFECTION: � C L� (Amount of 65"/0-75°/a calcium hy ch(orite used) 8. SEAL[lYG MATERIAL: Neat Cement Cement lb. Water gal. Bentonite Bentonite Ib. Type: Slurry_ Pellets_ Water gal. Sand Cement in. in. Cement Ib. Water gal. Other /J 7� Type material _ �/[ Q C� �/ Amouut 9. EXPLAIIV ME�OD OF EMPLACEMENT OF MATERIAL: 6'D ��e 10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this form showing total depth, depth and diameter of scteens (if any) remaining in the well, gavel interval, intervals of casing perforations, and depths and types of Sll matecials used. 11. DATE WELL ASANDONED_ T� Z� �' � . I DO HEREBY CERTII'Y TfIAT THLS WEIL WAS ABANDONID IN ACCORDANCE W117i l5A tdCAC 2C, WEI.L CONSTRUCITON STANDARDS, AND THAT A COPY OF 7i�S RECORD HAS BEEN PROVIDED'f0 TF� WE[.L OWNER. r--- �-� � ,��.��r� `Z 7 , �`� ATURE OF CER1'IFIED WELL CONTRACTOR DA?E SIGNATURE OF PRNATE WELL OWNER ABANDONING THE WELL DATE (fhe private well owner must be an i�ividual w6o pe�nallv abandons his/het res'�dential well m accocdance with ISA NCAC 2C .0113.) �o,�c�i e 1�/1 u.; �-1— PRINTED NAME OF PERSON ABANDOMNG TiiE WELL , Submft a copy te the owner and the original to ffie Division ot Water Quality within 30 days. Form G W-30 Atta: Iaformatioo Management,1617 Mail Service Center—Raleig6, NC 27699-1617, Phone i�la (919) 733-7015 e:t 56& Rev. 5/06 � �'�-�/f ��.�i� � � � � GL� i oUr✓�`aZ�ja,r �,�x -�,1� d.;�fi � � r- (�G�lG�/S6/G ��i Corc.��e �� F�� I� � t2-1�� p e,� %� JE� �� G��2 �f�� ._<- ,... - `.. :..,.,v.s_...:; -^-.. v.;,.._..: .:.- •..;..:->-a ::•_a-- �,� � n S^ ...,.. � :.• y :_ I(= - M1 � . f �. --2' ..:, r �e�;'� � U1[IWI�f IILJ � I . } '. - •- +` • ` f f �3 l_ .._ a i � � li � wi �{r + : 1_.4-•� ~A '� ^ �� •�� 'u�.�'L�•'• 'F % t" ♦ �� M+ [�, n ^ ��.��.,. _ _t- ,. ]J Y � o�b��'(/�tG �TI �� I(/�'��''� ••'•_v�'. •_t�•�••-�:J.'-�.a...• ��1��'\F�'�••` �isa.�+o►�-•,`-T'�'�i-�Ca.�:�: - ��x' . LJ�Ci�5l3J iJl(Wll�f _ � � � �...D � . .. Grout Log o�: _.DA� c Ros ��r - T� �, 3, .r� #�s� Location. � 6; 5� 4� 9 5 . Subdivisia�: .---=- - Lot # `_ � WeII Consttnction Dis4nc� From nearest Property Line (Minimum 10 fe�) t o �' Distance fmm Septic Sys�cn (Mmi�mn 60 feet) � � a Total Depth: 'Q.A u ft Y=eld '2-a GPM • St�tic Water I.eveL• Z s $ Wa�r Bcazing Z� ��r� f� ( 3 5" ft ft ft DePth: From - � to � � '� it Diam�er: � �� in � . - - . � C. � Weigh� Thiclrness: SD dZ�/Height above Grotmd: _ L_Z m• i � Driv� Shae: � No Any problems encoun�d wh�e s�mg �iug? Yes `.�To . . If `�res" give reason; - . (�ou� - / . � . _ . ' - . Nea� SancilC,em�ut ✓ Camuanete GraveU�t • '• �� i� ' inchcs Watzr in Affiular Spatx Yes �_ Na " ' Method of Cu� P� Pres�ue - Pouned �_ �- d._ to Z� Ft Materi�s IIsed: - Na. Bags Pordand arneat ' Weight o£ 1�ag � Povnds . . If m�ue (� gravel, �&s) —Ratio ta . - - ID plat� Yes i, No 4 x 4 slab �_No - Liner. " � • • �P� Date InstaIled: Grou� installed by: - D�b � . I�ocsition DrAwing - �m To Rormat�on . . ,o � . �� 4 • . . �� 1% _�� ^ _ / ' ��+�+' ��C &tiOV�" J�BfI� 13 �:L 8nd ��1S WC� Wd14 C�OC� 7II ��VI�1 IEg11�1IS SPt fQif� 131 �1C PE'd'S�1 L'OLIIliy$CS�1 � . - �re oiCa�cbor 7 rw-- ID# 3Z, G�7 �� .Z J-�9 . . �'amP In�[icoeat . . ��n��,,,,,�t� ��r � �,� � �� S��N� 1 � b � �P � � z � �$ � wa� L�wel: Zr � �� etmp .Make & ModeL• 12��'�,�1�� L- Pumq, siz�e and Raxia�. GfR= hp �� gpm �Y �Y ��s pump �vas mstatled an,d ffie well head �cou�le�ed a�+d"mg tfl 8�e Pecsan Camty Well Rules in e$e¢ n i�ris date and that a copy of ffiis recoid has tx.cu p�+nvideci to-the wdl o�rne� _ � �� re �'•�"' �� Date: � �°�"�7 PCfiD n-vOU27/04 North Carolina State Laboratory Public Health P'O. Box28047 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 http://slph.state. nc.us M i c ro b i o I o Phone: 919-733-7834 g y Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEAL�I-� ,., 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES052809-0022001 � �� ES Microbiology ID: 5302 GPS Number: Sample Description: Comment: Mary B Rogers 6835 Burlington Rd Col lected: 05/27/2009 11:30 Received: 05/28/2009 09:18 � � Sample Source: New Well Sampling Point: Well head Jonathan B Wiley Angela Heybroek Well Permit Number: A30 - 57 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Total Coliform, Colilert Absent Analyst Date Darneice Lyons 05/29/2009 E. Coli, Colileft Absent ` �: '� r � Darneice Lyons 05/29/2009 ` � � �� . ,` `w` 0 u�v \• , . Report Date: 06/01/2009 Reported By: Susan Beasley Page 1 of 1 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking watec Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/I No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established lirrucs Iron Lead Magnesium Manganese Nitrate Nitrite pH. Zinc � � • r 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 l0 mg/1(as N) 1.0 mg/1(as N) Not less than 6.� units 5.0 mg/1 North Carolina State La�oratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM . Name of System: Rogers, Mary B Address: 6835 Burlington Rd Zip: County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street Ste C (336) 597-2371 Roxboro, NC 27573 Courier: 02-33-15 Collected By: J WILEY Date: 5/27/2009 Location of sampling point: Well head Remarks: Permit # A30 - 57 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 1:30:00 PM Parameters Results Units Date Analyzed: Silver <0.05 mg/I 5/28/2009 Alkalinity as CaCO3 45 mg/I 5/28/2009 Arsenic <0.005 mg/I 5/28/2009 Barium <0.1 mg/I 5/28/2009 Calcium 8.7 mg/I 5/28/2009 � Cadmium <0.001 mg/I 5/28/2009 � Chloride IC <5.0 mg/I 5/28/2009 ,(� Chromium <0.01 mg/I 5/28/2009 � Copper <0.05 mg/I 5/28/2009 Fluoride <0.20 mg/I 5/28/2009 . ,.. I ron <0.10 mg/I 5/28/2009 Hardness as CaCO3 (Ca,Mg) 34 mg/I 5/28/2009 Mercury <0.0005 mg/I 5/28/2009 Magnesium 2.9 mg/I 5/28/2009 Manganese <0.03 ` mg/I 5/28/2009 Sodium 8 mg/I 5/28/2009 Nitrite as N <0.10 mg/I 5/28/2009 Nitrate as N <1.0 mg/I 5/28/2009 Lead <0.005 mg/I 5/28/2009 pH 6.2 Std. units 5/28/2009 Selenium <0.005 mg/I 5/28/2009 Su Ifate <5.0 m g/I 5/28/2009 Zi nc 0.91 m g/I 5/28/2009 rn 0 N �—► � z � � � Date Received: 5/28/2009 Report Date: 6/9/2009 Reported By: Today's Date: 6/9/2009 Ref: 7319 Login Batch ��z� � Sample Number: AB89936 � Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. . . Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 IVo established limits 250 mg/1 l .3 mg/1 4 mg/I No established lirruts Iron Lead tilagnesium Manganese Nitrate Nitrite pH Zinc 0 0.30 mg/1 0.015 mg/1 No established limi[s 0.05 mg/1 10 mg/1(as N) 1.0 mg/I (as N) Not less than 6.� units 5.0 mg/1 ��.s�- ��.�� `--- -s-.� �� I��.�a�-� ��.��.¢�.11 IHL � �.11 �I� WELL PERMIT (New�Repair� Tag Map: ,Q- 30 Parcel• �7 Subdivision: Lot: Applicant's Name: �.,2. � Mailing Address: 3 � J G 27 Phone Numbers: o - Location of Property: � S��' ,� t_ r �� -�, , a?� . 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. Other Conditions/Comments: �f� �j�;�// �� - Permit issued by: Date: � �010 �' CERTIFICATE OF COMPLETION New Well Inspection: E S/Date � Location: �/ Grouting: CE L `f�D `� Well Log: Well Tag: ` �i z7`o � Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: C�(jsn�/� t�s.� EHS ate Completed: � z7 D 9 Method/Material(s): q..�ly_r/ C �.�� C�f� G�.C! � Well Driller: � ��-� License #: Pump Installer: License#: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date: Z Date Results Mailed: �' Phone: 336-597-1790 Fax: 336-597-7808 8/1/08