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A31 184uo �i'��- ��`E—�-c� — C'�Q� �� .t�c l-f - C�- Application Date: �� .�% pv �� S� ��q ��(�� Taz Map: � 3� Amount Paid: � 60, 0 0[ �� ✓ •�l- ��` Parcel#: I 8 Receipt �#: �' �1, 3 �3 7 —�5 � � �� aaviros'=a�uIIaim� �viaIl4:�ia C I-e� � �1- C.a �c,� q/� °// 5 _ _ _ _ _ Apalication for Services Services Improve�ent 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/ReplacementJRepair) $3 00.00/$200.00/$75.00 Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name:-�ENNI��R M . PPrVLOVECH Address: 3� UNIUN C�. ROVE CHURCN 120f1D HURDL� Ml LLS, NC 2754► 2) Name and address of current owner (if different than applicant): Name: P�T�R D/JENN►��R M. P�AV�oYIC{-1 Address: Phone (home): (worWcell): (q l9) gs9 – � 523 Phone: 3) Property Description: Lot Size: �.1G Subdivision: Lot #: ► 8Q Address and/or directions to Property: U N I O N � R OV � C HU RC[�1 ROA D ❑ yes �no Does the site contain any jurisdictional wetlands? ❑ yes �no Does the site contain any existing wastewater systems? 0 yes }�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? ❑ 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: C�Residential NeC�w S�ingle Family Residence Maximum number of bedrooms: 4 ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes C�no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: M�imum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: CE New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no 6) If applying for �Authorization to Construct', please indicate preferred system type(s): C� 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 �e site is s�bsequently alt�red, or the intended use changes, all permits and approvals shall be invalid. (Owner/ Legal Representafive*) g documentation required. 2� Au6 2ois Date • Permits are valid for either 60 months or are non-ezpiring 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) -- _.___�� r �U� �� I �___1 �� ---- NS �- �- - ` --- ""'-�__-�. _ —�� __ S�1 °37�2 �� ' � 2 E ' - - r� 228. 06 NS �. _ _ r7 __� VERETT P. 514 �_ _ - I r- ,v 1 - ---_ _ _ ! o j� �_ _ I � �� -� � I 19I I I � � � � � � W J I � � I N �- � N � � I- � � � �. � � � � `� `� � �� ° �� a� � �,a`.� �a � � � ��, ��" � �: � � . � �� 1 �' � F- V�'� � � ��' �� J � a i- .� �' o � � �n � � Tr � � �- ,� �. . '�3 � R� � � � � � o• � � �-_ � 1-12 =� ,��,��j,�� `� ��--�-� � �+: '�.S �, � 1 - a�'' 1h , L j ba� �' o b��- z. s�'—�E � h � �"' �+a�,,uQ> >Nua -��{.tio� S�no`y,�at� � � � o � � � la�i2�.��/� S ��./'� -�' �✓► o �! 7 a��'� l�,�s ( � �o,'�� '�� 8 � � , � �� s�o� ��`� ,, Z I � � �,�� ,o��— a �' ��'� ��_ �i � �� s � I r � �� IF 256.62 CONTROL N�4°45'2g��►y CORNFR � ' ��) � . _5 � _��, ss �� )C�o�rn�a�r-��ra�� m�rn��.Il ��n,�.��a Tax Map: �t Parcel: � � Subdivision Phase/Section/Lot # Improvement Permit Permit Valid for: Five e��fs� Non-expiring j Type of Facility: /'� . New � Addition _ Water Supply: ��1 Number of• Bedrooms / Oc upants Employees / Seats: Projected Daily Flow: gallons/day Proposed Wastewat Sys e: Type: Proposed Repair: Type: � Permit Conditions: !.� i su�12 e�— �-a -�q (�S G6c�Q i�%l��'� 1'il �'p5 'f ' 1-e Q% - Authorized State Agent: (X) Owner or Legal Re Date: �'7?�lS Date: I � 5E p1` l5 The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This (mprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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 aird Rules for Sewaee Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants t6at the septic system wiil continue to function satisfactorily in the future, or that the water supply wiil remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (___). Proposed Wastewater System: �— o� �� J✓ (*)Type � Design Flow �` � gal./day New � Repair _ Expansion Soil LT� 02 r? ga(./day/ft� Type of Facility: ��5� Basement: _ Yes �No (*) System Types Illb, lllbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank l�d � gal. Pump Tank � gal. Grease Trap gal. Drainfield: Total Area �7 �i � sq. ft. Totat Length �� ft. Max. Trench Depth � in. Trench Width � ft. Min.Soil Cover �P in. Min.Trench Separation � ft. Distribution: Distribution Box �/ Serial istribution / Pressure Manifold Specifications: �— he+c l�► i�� 0 D� l`�Q s r �- � rc S�� `�'� [9v�r- .-�A� �, . �e Authorized State Agent: rn �t �+� Issue Date: ��z� f Permit Expiration Date: —2?^Z � The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: t o SEP� 1 S Person Countv Environmental Health, 32S S Morgan St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/ 121 ----`._ - • ° � � U� _�_ 6� ' — � �/ W � q � -: �:�z �. � � — _ �: - -�. Ns ��Iiu�l �9 �� c ;�g _ � _ �. � � :�;: . o V {�``°('� - o� �. .�' - , o S81 "37 � �2 ��E � _ _ �k� � . ' �_ _ _ � � 228 . pg NS �. � � —_ .� �. , IF j'`--_!_ � '`` p' � �00 _ _ •�.n, cn. a ' ' �� c�i S` � Fo' _ _ '�-- M fJ : � � '�� " C � ' Y�- � IS �� , . � 1U�SP �. �� ono�al• ST � � ��, s' � � � ��p _ ;r � yga` a�y� �'� . � p(�a;�n b��2 �, y � �m� w � , j�-Y-e,g� �� e ) � ,� �'�e"�� P�-�' � � � � . 0 _ ¢ , n� � . ��. N� c p—}�ox. � �r'� VERETT p- � / � � P. 514 `O � �0, b � (j►�� W � o � � � ^ z `� � � � � � � � �. -� foo � , � _ °4 �,,��t� ; __ __ _ �,_� so' _ _ : � IF n � �0 �' � olo� i � �, —� � � ^ 2v'r 4C�, 7 M �� C�cla� g ��e � , 5�� 0� IF CONTROL CORNER 256.62 N84"45'29��y S6� � r 0 �s� ^Sr. � � ��1r S"v�'s" �p'�� I l �-�%� s � �a� a �� s y�.��(,�. ��q`�—17�� J � �(Oi-�-� V! p c.c.�t- �-�" ✓✓Gt (rQ. a � o � � ~' `� v� IVI Sc�-� � �A,� a �'1. �o �- .o ^ � � �—�'' ��'►�►�� I sd� I c�� c� ,�.-�.e��P. so% f � � ��. I5 0�--�� o��'- la-F. v`� Do vtv-�-� �� s�r �(��ve+�a►r .�t r�t 1�'{' �4 i Y' Q►',20( . �� 1� �D--bo�c w� Gl-ea��l— _ D� f � �� , ss ��.� �� _ � � �� I��.�aa-�� .71 IFa��.]L�II� Applicant: �e��.�g�E Location: �n � „�, C�ro�e System Type (From Table Va): Type V& VI Expiration Date: . � dh 1� Operation Perrnit Tax Map � Parcel # �� Subdivision Phase/Section/Lot # of Bedrooms � Product (IIIg): �r� 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 Construction Authorization. ` uthorized Agent) �elYaG �W 1S (Licensed Contractor) \ � ' '3 � g �� i � Z v2 -��a � ��a �k��„ � -��t '1"�O y,�,��,�� G �"avl � cu�-t�.�- �-�� Scale J� i� PCHD, rev. 2/14/12 �� .�' Z� —� L (Date) 3-2�(-I� (Date) Line Length I 2 �Z 3 2 �g 5 g2„ � ! o+c�( — �(SD' Tax Map: 3l Parcel #: �g1 Septic Tank System Checklist (Type II-I� Se tic Tank InitiaVDate State ID & Date: - �2 _2�_( �-5- ✓' Ca acity: 5 - o0 Tee and filter �/ Baffle ✓ Vent ,/ Riser Outlet boot Perm. Marker Distribution D-box (levels set) 3-Z , Serial Pressure Manifold LPP Notes: ID & �ate: Riser (6" NEMA 4X Box Model: Piggy back plug Hard wired Alarm functionin Mounted on post Above grade (12' Conduit sealed �� System Type: � �=vrF) Pump System Checklist Tank I InitiaUDate Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: Tax Map: � � Subdivision: Applicant's Name: Mailing Address: _ Phone Numbers: ��, sf ��.� �� ---�- � � � �� I� ��n u- � � � m .� �.�.Il IH[ � �. Il �I� Parcel: � Location of Property: WELL PERMIT (New� Repair_) �i�r�c�pr- �avinH�� ■ Lot: G-�e c�� Perrnit 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. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: M" � Certificate of Completion �ew Well: � � EH ate Location: Grouting: — �`�— t �A Well Log: Well Tag: Pump Tag: Air Vent: � —24 -( l� Hose Bib: Casing Height: Concrete Slab: Well Driller: /�►'K�� Pump Installer: � Approved by: Additiona! Comments: Date: � 2? Y � OLL,iner: EHS/Date Depth: Grout: DAbandonment: Date: _ Method/Materials: License #: License #: Date: � -- 2y—/f� Date Sample Collected: �� 3°'� y' Date Results Mailed: EHS: � . Person County Environmental Health 325 5. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 11/26/13 Mar 18 16 01:OOp Barnette Well Drillinglnc wEc,L corrs�rRucr�or� u�coRn n� r«mu,. � �a � s�� «m�►a� a�ns !. WellCoacraetor laformadoa: /�i1 { � �i+.t t • ! Welf Gontractor Nune �on�n,� l�rv�-�`� 3.�7b t3C Wd] CanuutorCvriF•eation tluu�ba' 8a�-nette Well Drilting, Inc. CO�i 1'11mc . 2. WeU ConstrnttiOn Pertnit �. � � � Lisi a1l oppliaable xcll conusuctian pernairr (t� Cm.nry, Sfare. Yorinrace. erel 3: Wt0 Use (check wciR usc): Q.4gcicuSniral aMunicipat/tiiblic • OGeothea�al (Fitaang/Cooliag SuPP�Yi ��Suppl��(siagle) QTndtatriallCammccFai R.Residcntial VSrater Suppi) (shactt!) Supply Wdl: OAqtsifcc itochatgc OGcditcd�vater i%niodiatiat QAq�iifcr Staiage and Rccovul OSalinily B3rriac OAq�xifc Test �3tarta.waecr Ihaiaage Q�aimeatalTetGnology ❑SubsidrnceContxn[ �f'amthe��aial (Glosed l.00p) ❑T�acer QCieadutn�al (kteatinglCooli� Rentrit) QOth¢ {r.i�laiu tmder /f21 Raaa'tis) s: Duce v+rett(:j eomp�cr�a� 3'� wa� � Sa.'Wc0 LocaOian: p �-2:�� .'Jer l�✓��1�c�, %� .3! %�'� FarititytQa7►crName Faali4y IDk (ifal+piieab[e) ��► t,�� o� ��. cr� � � � �;'�i�• ��P ��.�sa.-� �- �� I � K c�� a�a��a. c� Sb. Istit�dc aad X:ongilndc iu degrclsfmiqpt�slset4nds or' decimal aegczcS: {�fwall Sci� vnc lstllcng is saCGe�MI) ' 36 t� .37� �� 7� 3 3 s�� w 6.'[stxre)thewtA{sj: i�7Pctmantut or �Temporary _ ' 7_ is this�sr+eps+r to ao t�cts�ng:weLk QXes o� qFlo .� �i �S a ICPN . f7�iOMf�WawP 1�� OOti7f71R3iG�c �r�aTvsaliOn ��R!R !% 7l?Rlrt�Cf!%C •Q,alf fM�l LiI lt+�L sCtbtr Or�OR Bit Lt7[� Of7ltiSfOMI. 8: LYumber o( wcUs coastructed: • For anitip�c Afettioa or ima-..dcr sry�P'fYr*e![.c ONCY �tlr +�e tmwt roa.iiwcEtaR Y'��avrt ssrbmNoee jorrn. 9_Tnfai'�+dl de�tlfi bdowlaQdautfice: � Qt� (ft� Formulrtplc�vellclvtalldcpahsijd+j�'erent(mar.pfe-3(g`200'ardZ 00? 336-598-9275 p.1 Fa t�� u� or�.r: 3 4: R'ATEE4 ZCl[VES . - FRO!1t TO tiF5G7�IPF10t'7 . '�l «' �� Jlf� / b5 n- r?J rc -� r�,7�,,� ' i�OiTl'f:R+CASIl+tE'r forlupld-c�sedy5'il.Is:0IiL1lY[iR tf;a` licabli::._-: FROt[ TO DC�TfEIFR T[RCIQVTiSS MA7FANL d �. 62 �. �. Yc.nanex•:e�ns okTosu�rc = ' _ _ - a��a , ; : . . , ; . FROM ' TO DLUNi'[EQ T1i[C[QESS 1tifATFRIAL �. � �c. ft +� !t R ia� . . _ _ . ,. :, . :1T:•SCAtEB[�I%." � - '�� FRAQ�( .70 �01AMETER.... SIAT&17.E TH[GSNiSS�.. ` MXl'tR L�.. ft ft �°- ft ft �e- • .._. . , ; : .._ -. . �:.yG'-�i�n r�+ ... . . . . : . ._.. � � �o f� � � !c fc s;axnrGtr�►vtr:'rxci iM 70 �t R. it tt bR1i;LiN • UG aiti itt � � R. !c � ft 3 s !4 � rti � r..-.rc 2.� .7��Q %�'i/•'� 2�. Ccrkr�aon: � `- c_�_ .�j i � J �.` � s;�,uuc 4rcaus�a wdre�,mx �. s�r ��„� rr�.�«,�,. f �.�ay � �r .�,�a{� � �,�} �,�a �, ��, w7d fSA�N�iC0�Al00.orlS�LNCdCO2C.A200fgetlCau�foi�.SYaadarilsmtdGfiala �PY°�i6is rrc+ordhai heuiprvvcie�n d�e arlt owrt�r. �..�t�tt �I11 OI' �d�01�9111't� dti7li� ' You M&y use Uie 6acj� of. this pa�e fn ptovidc additiona[ wdt sitc ddails Ur wcll bctittru�ionddaitS. Yonuiaraisb.attath.ad�riocialp9ges:ifiil�G:sa[y. SU�`NJ�[AL �.i A'iJC I'lON5 24a. For A11' Wt11� Submit E6is fo� w►�}nn 3fl days of toiup]dibti of well o�istiuctido fbtbe'fc[io�vu�g: I�Sb�6eRtater[cvd6dowrtopofcasi�ig: ^� (ft) ��ma��"atcrQoalitp.[nforauflon.ProccxtiiagIIait, lJwalerlt�sl.isaTwe easing, u.tb'+' 161,7 MaT Serviae CeaGrr, Raleigfit,tvC�7G99-1617 1L Soreha3e diunecer �� ) 24b. For Iniectioe Wei1s: h► additioti to sazding the (�tm W the addrcss ia24a slwve, ai5o Suhrmii al copy of thu £orni �+idrih..36 days of sbmp.ktion of wrll 1Z WcLL censtractioo,.uscihad_ r� �'r 5� car�ttrui�i�oCi ta thefoUowii� f � �. �r. �t�1a a��a ��. w�-) DiKitiad e[l�f�,at�r Qwliiy,. i3adeigroaad.Injcction Condv! Ptogr�m. FOit'.WATER SUPPLY WELLS ONLY: 1636 Mwi.Scn'ive Ceitu, k2�ia�b+ NC 2T699-163i 13�. Y►dd (�+m). [� ib[eei�od a�f't� Blown20 minute 24� FarZV�tsf Sabblv & Iniectiaa Wdl� 1n addidonto cending Wc farra w th� aadiess(es) afiavS, dso �iC one oopq of. tliis fadm v,ithin 30 da}+s ot 136.;1isinfcction typc HTH Amoaat _�� Cil1�i �Pidion of wcll uais[nic4oa W tho awn[y hcalili dc�rtiaail of thc cmuity v�firre caistriuf�a Fam GW-i AlortL Carolina.0epat4ncotn#Eavimwncot ad NaAeal Eiaa�ccrs - Division o[WreQi�ality I�evis�d Iaa 2013 �� ` ` � � ; � E r� , � f ` 5.._..+'� �'" }; 't f ! f`S -� � /�� `F ! � � J 2 EF � � j r l, '" i"`,�`j r",� ' � ; ;�� t ; J ��5 5 L:' L E� F f LJ a 4 �� !,,` i f ! € L;� ; ��/ � `r t r--• � � � a �:--c.�^ � ti i-� i–�, • �� i-- - '- �~j l;Y t �'e� j�� ;� t�i � �-�j �'�t� �� i!�� k! t f j �� + � t"� �—�; R � � ......� S� '�:� �� 'Z L.F ��' �-J E � e P i `i a ^ � �,; �� .. i �,� � �� i For Inorganic Chemical Confaminants County: d� Name: � � e� � TEST RESULTS AND USE RECOMMENDATIONS 1. �Your ��ell water m�ets federal drirlcing water standarrls,�+ror iKorganic ch�nicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inareanic chemical results onlv. You may i►ave other water sampling results tnat are not taken into account in this report. � 2. ❑ The foliowing substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levefs. 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). :iowever, it may be used for washing, cieaning, bathing and showering based on the inorganic chemical results onlv. Arsenic � Barium � Cadmium � Chromium Copper Fluoride Lead Iron Manganese Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. 0 a. Sodium levels exceed the U.S. Environmzntal Protection Agency's�(USEPA) Healih Advisory level for sodium of ZO 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 washirig, cleaning, bathiag, and showering hased on the inorFanic chemical resul[s onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. 4, � Re-samplino 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 ftrst draw, 5 minute and a 15 minute sample at the wel) head to determine the source of the lead and/or 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 inor�anic chemfcal results onlv, but 2esth�tic preblems such as bad taste, odor, staining of porcelain, etc. may �ccur. You may �ant to install a i�,ouszhold water treaiment system to address aesthetic problems. � Barium � Cadmium � Chromiu� Fluoride � Iron Manganese � Selenium Silver pH Zinc For more injormation regarding your wel! water results, please ca[t the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3012 Di t�ct�Drve Environmental Sciences Raleigh, NC 27611-8047 htta://sloh.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: JENNIFER PAVLOVICH 325 UNION GROVE CH RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES083116-0033001 Date Collected: 08/30/16 Date Received: 08/31/16 Sample Type: Raw Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.9 Time Collected: 2:05 PM Collected By: A Sarver Well Permit #: A31-184 GPS #: Sample Description: Comment: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium Calcium Chloride Chromium Copper Fluoride Iron < 0.001 13 < 5.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.005 O.U05 m m 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m Magnesium 6 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L 10.00 Nitrite < 0.1 �H 7.3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 10.00 mg/L Sulfate 8.20 250 mg/L Alkalini Hardness 58 Zinc < 0.05 5.00 mg/L Report Date:09/12/2016 Page 1 of 1 Reported By: Deddie .r'�toncol �� ,+�.� � t a � �_..., �-�- �� `'� ��m�nvTzi:c-�cb�r��tnz�c:�ta��1�� 1��:-tn6:�ti::lEn Date: �/�/� � 1 � " ,► � � � . — t "�� a � � �.�/: ti , Re: Bacteriological Test Results Dear Well Owner: Tax Map: 3� Parcel: � � Your well water was sampled on �/�� /�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: 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 bacteriological results on[y. � Total coliform bacteria were detected in the sample. Fecal coliform 6acteria were detected in the sample. Total colifc�rm bacteria are naturally found in the soil. Fecal coliform bacteria are associated with animnal and/or human waste. The presence of either total o: fecal coliiorm bacteria in ��vell 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. IJcoliform bacteria are present in your water samp[e, the water may 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 proverlv 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 additional 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, J�1 ` ��`'�,� Environmental Health Specialist Person County Health Department (rev. 4/20/16) 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: ES083116-0092001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JENNIFER PAVLORICH P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 325 UNION GROVE CH. RD. HURDLE MILLS, NC 27541 Col lected: 08/30/2016 14:05 Received: 08/31/2016 08:39 Sample Source: New Well Sampling Point: well head A. Sarver Susan Beasley Well Permit Number: A31-184 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Darneice Owens os/o1/2016 E. coli, Colilert Report Date: 09/01/2016 Absent Explanations of Coliform Analysis: Darneice Owens 09/01/2016 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. 0 �'� � �" � �