A30 82a
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The District Heaith Department
•'.^„ASWELL - CHATHAM - LEE - PERSON COUNTIES
W_,ater Supply and Se_,_„wa�e Disposal
IMPROVEMENTS PERMIT No.
Date �0" �'���
Owner: 8. So f a n,o n
Location: .� � 3� �l3 nu, 5C '� C(
Contractor:
Water Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
appliances
itriflcation tine�
�0 3 '
Other disposal facility: --- �-�' �-�-�""�' ��• `��j��'
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: � �a
Well: �
Sewage Disposal: —
By: �
Signe � ����
Sanitarian
Counter-
signed
(Owner or his representative)
Certificate of Com ion
Date Approved: �� By:
Sanitarian
(OVEB)
Location oi well and sewage disposal facilities sketched on baclt.
w
- ..
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�supplies, etc. Note special problems existing on lot. Wr.ite in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
]u�- i� �o
�
� . Person County Health Department
� 4fe11 Per�it
a
DATE ISSUED:
OWNER:
ADDRESS:
DRILLING CONTRACTOR:
AUllKG55
WELL CONSTRUCTION
Distance from Nearest Property Line_ Distance from Source of
Pollution
Total Depth: Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: De Ft. Ft Ft.
Casing: Depths From�to Ft. Diama i inches
TYPE: Steel Galvanized Steel
If Steal, does. owner ay�e: Yes No
Weight: Thickness�.� � Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If 'yes' give reason: _�
Grout: Type: Neat SapdytCement � Concrete
Annular Space Width l` Inches
Water in Annular Space: Yes No
Method: Pumped Pres Poured
Depth: From to Ft.
Materials Used: No. eags Portland Cement Weight of
1 bag lbs.
If mixture (sand, gr�el, cuttings) - Ratio: to
ID Plates: Yes V No
4 x 4 slab Yes No •
DRILL2NG LOG
De th
From To Foz ation Descri tion
� �
�
I HEREBY CERTIFY THAT THE ABOVE INFOftMATION IS CORRECT AND THAT THIS
WELL WAS'CONSTRUCTED IN ACCORDANCE�IT'A �EG�LAT�O;S SET �RTH BY THE
PERSON COUNTY BOARD OF HEALTH. P V�i�D AFT R��THREE ARS.
/��/� � &ignature of Contractor Date
�'�''�J�� ��' �� � I
<
��,� �'/������� a karian's Signature Date Issued
C-' 9� ` �
�,�(� �.��aDS%1�,� • �
Sanitarian's Signature Data Completed
Sketch well lo a on on reverse side.
Applicatiou Date: -2 / � �J
Amaunt Paid: 7.Y. 00
Receipt #: 76 3� 7 3
�
'�.�313
Improvement Permit (Site
�2�0.00/$300.00 (if> 600 gp�
Q Mobiie Home Replacement or BuiIding Addi�on
$150.Q0 ifsite visitre uired
Weil Permit (l�1ewlRe�lacom�n epair)
��..��y?.1� J�" ����.� V Tag IYIag:_���
_ �: � ���-� Parcel#:
I��-�-z�M,.�..,@.m�fl 7H[,c�.:A�
�lication for Services
Services Requested
�L� Construction Anthorization
(Fee is denendent on the t�ae of
�75.00
� Repair of Existiag Septic System
Application: No Cbarge! CA $150.00 or $300.00
1} Applican� Infor1,ma�ion:
Name: �oLin t�}Cn iLvL.�' Lc� ; 2�..��� �
Address: Ei �: � : �; �. ,?
,('���.�, � ��S 7�;
2) Ptame and address of curren# owner (if different tban applir�nt):
Name• ` �
Address:
' 2`1
Phone (hame): �3��� �22 " �3�LL
(work/ce1l): �'�3 c�.� ��, 3 -' (:•,�13G
Phone:� 5ci4 - 5I(c I
3) Proper#y I?escripiion: Lot Size: Subdivision: Lot #:
Address and/or directions to Pmperty:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contasn any existing wastewater systems?
❑ yes ❑ na Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes � no Is the site subject m approval by any other public agency? /�r�',�
❑ yes .❑ no Are there any easements or right of tivays on this properiy? �� �"
(if `yes' is checked, please provide supporting documentation) � / l j��
04 w
�} Proposed iTse and Tyge of gtructnre:
Ol2esidenriat
QG
❑ New Single Family Residence Maximum number of hedrooms:
t� Expansion of Existing System If expansion: Current number of bedraoms:
C] Repair to Malfunctioning System WiII there be a basement`I � yes 0 no With plumbing fixtures? CI yes ❑ no
�Non-Residential
Type of business: Total Squarc footage of Buildin�
Maximum number of employees: Maximum number of seats:
5} vVater Supply. ❑ New �ve11 t� Exisring Well D Community Well ❑ Public Water � Sprina
Are there any existing welLs, springs, or existing waterlines on this property? D yes � no
6) If applying for `Anthorization to Constract', please indicate preferred system type(s):
❑ Gonventional 0 Accepted t7 Innovarive � Altemarive D Other � Any
I eertzfy that tl:e inforrnation provided above is complete and correct. I also undet'stand that f tlte It2foPmation ptOvfded 1s
inaccta�ate, or if tl�e site is subs�qr�ntly aliereat, or the interided z{se changes, all perntfts �rd approvals shall be irrvalid.
Representative�`)
'� Supporting documentarioa required.
I D �2/ -20/�/
Date
g Permits are valid for either 60 months or are nan-expiring when �ccompanied by an approved plat
a A completed �Lot Preparatior�' form must accumpany any applieation requiring a site evgtu�tioB.
i� ni> > 1 De.ti..... l�..,...f., �..�n.v..,,,,e,++el LT�1+1, 1'7� Q Ad.,...�.. Ct c.,;te r v....l....... T.in -f^re�� i��G s�►� �•fnn�
Tax Map: � 30
Subdivision:
Applicant's Name:
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- ������
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ParceL• �_
WELL PERMIT
(New _ Repair� )
Lot:
Phone Numbers: Sqq -5��01 '
Property:
7
Permit Conditions:
1.) See attached site plan for proposed well location.
Z.) 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: {�2rm�f�ec� -�-,� (-i�e�
Permit issued by
Ql�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date: /o -21-(�
Certificate of Completion
i t
iner: d n �
EHS/Date �vei r l�i �
Depth: �13, �"
Grout: 5 o-z�-iy
QAbandonment:
Date:
Method/Materials:
Well Driller: ���`/1��Z(�,r�5 lJ o�� H License #:
Pump Installer: License #:
Approved by: Date: �a -Z�-�y
Additio�al Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Margan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
Apptitation Date: .3 �_
Amount Paid: 3= ________
Receipt #: �'3 � 6�`�
� 101� A_
❑ Imprnvement Permit (Site Evaluation)
�Z00.00/�300.00 (if> 600 gp�
G Mobile Home Replacement or Buildin�
$ I50.00 (if site visit required)
G3'Well Perinit ( er Replacement/Repai�
�.���, f 1���.��l�T
" ������
�'C�.'aa-�s-aa-�TM+TM.��sad�.g ��'��m��'-a.
tioa for Services
Services
L� Construction Authoriz
(Fee is dependent on the
G Permit Revision
of
Taz Map: �
Parce!#: SZ-
c0.1� ���`�'
D��-� be�orP
�°'�-
v
❑ Repair of Egisting Septic System
Application: No Charge/ CA $150.00 or $300.00
1} Applicant Information:
Name: �ril�n ��n �i,vo-}�c� Lt�; ZG.�d?� �
Address: �i J: r:1 i rr� �.-�
�.�`,,��n'� � �'�S %�l
2) Name and address of current ow�er (if different than applicant):
Name: �
Address:
' �tr /yl'
3) Properiy Descripiion: Lot Size: L/• � Subdivision:
Address and`/or directions m� perty: r�� �
�in..i f.!-si _ .. �
Phone (home): ��� �) �2 - �3�LL
(warklcell): i� •1 S"��-' f�/�,3�
Phone:
�
#:
yes � n Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
� yes t� no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no is the site subject to approvat by any other pubiic agency?
❑ yes L7 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:
OResidentia!
❑ New Single Family Residence Maximum number of bedrooms:
� Expansion of Existing 5ystem If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System WiII there be a basement? ❑ yes � no With plumbing fixtures? ❑ Y� � no
❑Non-ResidentisI
Type of business: Total Square footage of Bailding:
Maxunum number af employees: Maximum number of seats:
5) Water Supply. GZrNew wetl 0 Existing We(1 0 Cammunity Well O Public Water � Spring
Are there any existing �vells, springs, or existing waterlines on this property? � yes ❑ no
6) If applying for `Authorization to Canstruct', please indicate preferred system type(sj:
❑ Convenrional 0 Accepted ❑ Innovative 0 Altemarive 0 Other ��Y
t�
I cert� that the information provided above is complete and co�^ecf. I also urtdel'sta�td that if tlte fnfopmarion provided is
i�taccut ate, o' the site is subse uent altered, or the intended use changes, all permits arzd approvals shall be invalid.
� 3 �23 -/.�
gi atnre (Owne Representative*) Date
� Supporting documentarion required.
o Permits are vaIid for either 60 months or are non-expiring when accompanied by an approved gla�
o A compieted �Lot Preparation' form must accompany any application requiring a site evalnation.
�t n�� » PPTcnn C:rnmtv F.nvironmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573 (336-597-1794)
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7� �.� u- � �� m � ��.Il IE3C � �- Il �l�
WELLyPERNIIT
(New� Repair_ )
Tax Map: �� Parcel: �
Subdivision: Lot: �
Applicant's Name:
Mailing Address:
N1�`J�s 1� � 2�sNl
Phone Numbers: �3i�--S� 3- (�(e3T� �� n ��>
Location of Property: 7
Permit Conditions:
=7
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 potabde water supply,�
Other Conditions/Comments:
� air� ��n all S'� �� KS
r--
�
Perarit issued by: Date: 3- 2(�-/�
Certificate of Completion
Tew Well:
EHS/Date
Location:
Grouting: S-l! -1 S
Well Log:
Well Tag:
Pump Tag:
Air Vent: �� ��-i5
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: arn�-�`i�•
Pump Installer: '
Approved by:
AdditioHal Comments:
Date Sample Co(lected: - �
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
DI.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: '��
Date Results Mailed:
t3�c}, l�- 23-tS
Phone:336-597-1790 Fax:336-597-7808
11/26/13
�
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—; c������
I��� a-������:�.Il 1L-3C��.Il�]�n.
SITE PLAN
Name t�Ch �l�n Tax Map #� Parcel # g2
Subdivision Section/Lot# �,IIE}
'Z-2(n- f `J
Aup orized State Agent a Date
System components represent approximale contours only. The contractor must,�lag the systemprior to beginning the
instaflation to insure that propergrade is maintained
N
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IE��,���,�m,���,.Il IE3C�afl�l�
WELL PERNIIT
(New_ Repair��
Tax Map: 30 Parcel: �
Subdivision:
Applicaut's Name: �
Mailing Address: 32 e
�
Phone Numbers:
Location of Property: D�,G t�GJ S
Lot: �
Permit Condidons:
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: I.�PI� ��a�,,%w� c� ��✓rnr� __ _
Permit issued
�tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: /��, ��, ei-9t'.
Pump Installer: �
Approved by:
Additional Co`nments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5, Morgan St.,Suite C
Rnrhnrn N('J7S7�
Date: .� //— / �
Certificate of Completion
QLiner:
EHS/Date
Depth:
Grout:
�bandonment:
Date: ��j -i S
Method/Materials: �,��� o;,cre4� � l �
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
��nc�,n
WELL CONSTRUCTION RECORD
This focm can bc uscd for singlc a multiple wc11s
1. Wdl Contractor Tnformatioo:
1` t� 7� �� l� N�F �w
WeU Conaactor Namt
_� �liCi
NC Wdl Contractor C«tification tdwnlxr
Ba�nette Well Drilling, Inc.
Coa�any Name
Z Wctl Conshvction Permit tt: �'? v� 1 V Z
Lrs! a!! appJicable we!( constrr�uion permits �.e. Cnunry, Slare, Pa�iaace, etc.)
3. Wdl Use (c6eck well use):
Water Sapply Wdl:
�Agricultural
❑Geothumal (HeatinglCooli�g SuPP�Y)
�IndustriaVCommercial
Non-Wafer Supply
Injectioa Welt:
QAquifer Rechazge
DAquifa' Storage and Recoverp
❑AquifccTest
❑�erimental Technology
�Geothermal (Closed LooP)
�Geothermal (Heatine/Cooline
❑�MunicipaUPublic-
irlR�sidenlial Water Supply {single}
❑Residenda! Water Supply (shated)
❑ Gmundwater Retri ediation
❑Saliniry Bartier .
❑Stormtvatcr D[ainage
❑Subsidence Control
❑'Itacer
❑Othu (eam[ain u�er t�2t F
4. Date Well(s) Completed: t' / Wet1 ID#
Sa WeA Locatiod: J
,—�-� /� � � �r� k 5 S D � 0 �Gll,
FacititylQwncr Name FaciliCy ID# (if appticaSic)
�O �C I�OG70 ,,,�� C Z 7S�`7
Physical Addness. City. and Zip
.�+��' �^`��
Couuty Parcc) Tdcaqficatioa No. (PIN}
Sb. lafltude and Lond tude in degrees/mioutes/saonds or dectimal degrees:
(ifwcU Seld one Ialloag is sufficicot)
��—��'—�S N �C ,� C �1�' W
6.'Is (are) thc wcl!(sj: C�t�ianent or ❑Temporary
7. Is this arepair to an ezisfing:well: OYts or ��
!f (his ls a repatr, ft!! ou� brown we(1 awutrucrion injorma[ion avfderpfain rlre nature ojthe
rcpair under �21 remarks sectic�n oron ihe boek ojfhJs form.
8. Number of wells constructcd: 1
For multipfe injectioe or nwr-mater.ta�ily wt!/s ONLY wi/h !he same cons�irtcYiaa; you am
subm.ir one form.
9. Tot�l wdl dept� belowlind snCfue: 1 l� (It)
Fo� miJriple weUs listal! depths rf drfjerent (etmnple-3�200' and 1(a�IQD�
I0. Sta6c water level6dow top of casing: �0 (fL)
/JsNatei leve! ls abm�e casing, ase '+" 1
11. Borehole diameter: / (ia)
t�. well constr,«aon m�ttioa: � l h ���
(i.a. augex. cotary. cable, dicect pus� dc.)
For [utemal Use ONLY_
14. WATER ZONES
FROM TO UFSCR[PTIOIV
l 2 " I 70 f` Z p
� �, « o f� 2
I5. OUTER CASING (or tnnlu-ca.ud tvdls OR LINER if a inble
PROM TO DCAMECQt THICIOVE55 MATFA[�L
b ft ! 0`f �'- �` y'°- 1 4 9 �,
16. QVNER GASING OR'TQBWG eothecmal dosed�oo
FROM - TO D��MEfER THIC[QVESS MATERIAL
i4 R ia
ft fL �a
17. SCREEN
RRDM .TO DUMEfER S[ATSCLE TR/CKNESS \tATER1AL
ft ft �-
(4 CL �
18= GROUT
FROM . . TO . .� MATT.RIAL EMPLACF7NEMMEI'HODQcAMOI1NT
O 2 .� v ft Cement our
ft fc
ft R
19. SAl+[DlGRA'VEL'PACK �f a' lirsbk � ' .
FYtOM.. . 7'O M1tATER1AL FINPLACeMINf M£'I'ROp
ft ft
tt ft
20, URILLiNC LOG'aHae6 gdditionai sheeB if nece3sg
FROM TO DESGWP170N coler 4arda �sdVr�ek 'a�du;da
� it L/� it �' N 7"'
L� fc / OU tc tf�S `f�.tl�P
OC% fc tt p� �
fL (t
ft rr.
ft f4
ft ft
Zl. REMARKS
22. CertiGca6ion;
��o ,��% /�cz�� .SS
SigaaturaofCeitifitdWcllGonttutor D _
$y ri�ntng ihis form, f hertby certiJy rlinr the weU(s) was (wereJ constnresed in aacordance ,
with !SA NGC OIC.OZ00 or !SA NCAC QZG .�Z00 Well Consuvction Standdnds artd �lui( a
copyofthv iec»rdhar beea pr»vkled w: �he Mell owner.
23. 5ite diagrtim or additionalwell dettils:
You may ase die back uf. this paoe ta provide additional weU. site details ar well
cansGucEion details. Yon may slso attach additional paaes if necessaty.
SUIIMITI'AL INST[lC�`IOh[5
24a For All Wdls: Submif tfiis.fortn within 3D days af compldioh of well
�uction to thc fotiowiirg:
IIivisioa of WsterQnality, Information Processing Uoit,
1617 Mail Service Ceater, Raleigh,l�C 27699-1617
24� For InicctioH Welts: In additian to sending the foim to the address in 24a
above, also submit. a copy of this form within. 30 days of canpldion of well
canstruetion #o the foilowin�
Division of Wnter Qnality, Uadecgroand Injection Gonirol Program,
FOR W:4TER SUPPLY R'ELIS ONLY: 1636 Mai1 Servicc Ctnter, Raleigh, NC 27699-1636
13a. Yield (gpm) `I � Met6od of tss� B�own20 minute 24c �or �i'ater SuaWV & Iniation �i'dts: In addition to sertding the fortn to
the addiess(es) above, also submit one copy of this forti� within 30 days of
136. Disinfeefion lype: HTH Amoant 7�2 CUp �mpletion of wdf conshucLon to the county hcatth dcpartmcnt of the county
whue constructed.
Form G W-1 Tiorth Carolina Dcpacdr�cat of Env�•*�+��t and Natml Resotuccs - Divisiou of Wa�u Quality Reviscd Jan. 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. W ontractor Information:
II [? /1J/I�,/c� !� . �.�LL� �
Well Contractor Name (or well owner personally abandoning well on his/her property)
% � 76-,�
NC Well Contractor Certificauon Number
Company Name
2. Well Construction Permit #: /% � �
List a/! applicable well permi/s (i.e. County, Stale, Yariance, Injectio� etc.J if known
3. Well use (checkweil use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
Non-Water Supply WeII:
❑Aquifer Rechazge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal (Heatine/Cooline Retum) ❑Other (ea;plain under 7g)
�
4. Date well(s) abandoned: � �/ � � ��
Sa Well location:
�i�f �iv-�'/ So/d�,�r
Facility/Owner Name Facility ID# (ifapplicable)
•`/�55�/ �/a.2�oeJ ����
Physical Address, City, and Zip
�pQ S �� `�
Counry Parcel IdentiScation No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, oue lat/long is sufficient)
3l -r� ��� rr %� ' d��-/� w
For Intemal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: �
For mulliple injection ar non-water supply wells ONLY with the same
constrvction/abandonmen{ you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: �of � G`'� f"� l�'7
7d. Amount of disinfectant used: �C�� C� r�
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
� d Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
�,�„ R e�-
8. CertificaHon:
♦ C�
�v�Z��i� �: �.-s1� �-/� /�
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandaned in
accordance with 1 SA NCAC 02C .0100 or 2C .0100 Well Constnrction Standards
and that a copy of thrs record has been provided to the well awner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCI'ION DETAILS OF WELLfSI BEING ABANDONED SUBMTPTAL INSTRUCTIONS
Attach wel! conslruction record(sJ if available. For multiple injection or non-H�ater supply
wells ONLY with rhe same constructia✓a6m�donmen{ you can subm,r one jorm. 10a. For All Wells• Submit this form within 30 days of completion of well
6a. Well ID!#:
f �f �+ �
6b. Total well depth: � (ft)
6c. Borehole diameter: � �C� �l (in.)
6d. Water level below ground surface: �� (fk)
abandonment to the following:
Division of Water Resources, Information Processing Uait,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb. For Iniection Wells: In addition to sending the form to the address in IOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
163611�il Service Center, Raleigh, NC 27699-1636
� lOc. For Water Suaniv & Iniection Wells: In addition to sending the form to
6e. Outer casing length (if known): (ft) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the courity health department of the county
where abandoned.
6L Inner casing/tubing length (it known): �(fL)
6g. Screen length (if I�own): (iw)
Form GW-30 North Carolina Department of Environment and Natwel Resources — Division of Water Resources Revised August 2013
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
___..__ ROXBORQ, N.QRTH_ CARQLINA 27573 _._._ _. __ _
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant 6
Address ,?� I�Cct 5�.�_ Y�'en 1�, County �'��
Collected By ` 1 �
Date Collected '7 -�-a-� � Time Collected �% 3�1
Source: �I ❑ Spring ❑ Other
Location: ❑ House Tap �NVell Tap ❑ Other
❑ No Charge ��harge
�, -Sa ��
�
..............................................................................�
*********************�*******************�****�***,�*****�*�*****************
Total Coliform
Fecal/E. Coli
Results
Present
❑
❑
�
�
- . . - . '��- �� '�� � � �r.
l�
,. -.. -. •
Report Called o YES ❑ NO
Called To
Absent
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slph. nc�ublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
ANTHONY SOLOMON
328 HASSELL HORTON RD
ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541
EIN: 566000331 EH
StarLiMS ID: ES061715-0025001 Date Collected: 06/16/15
Date Received: 06/17/15
Sample Type: Raw Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 5.5
Sample Description:
Comment:
Time Collected: 2:15 PM
Collected By: J Smith
Well Permit #: A30-82
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 8 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 3 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate 1.50 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 7.3 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.70 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 39 mg/L
Total Hardness 31 mg/L
Zinc 2.90 5.00 mg/L
Report Date: 06/24/2015
Page 1 of 1
Reported By: Arnold Holl