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A32 192E� O �: � w U � ¢ a W ¢ z unt :'aipt / paid ��Q,00 !� ' ��93 �87°� � �a��°� o�i3 � '� q �e�,�" �� . 3-4 � i i-19-�� Date Improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) ._. Repair/Replace existing Septic System _ Improvements Permi[ (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well 4.:,:, ,�<;: �, ;�._._.._.__.._ ..... ....... . . _ . Bacteria Chemical Petroleum _ Pesticide _ ea Permit requested by: . 7. Dimensions or Proposed Structure: uner/prospective owner/agent:��e-� i-, rnoorc. Width: gg — ddress: �� a-��u� C��v� CH�� d . _ Depth: 3 2 ; ��=�,�e. YY�;11 s N�- 2�� — 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility ' � that this sewage disposal system is intended to serve? ome hone #(33C��3� y- 2�� usine s Phone n: Name and ad ress of current owner: 9. Water supply t}'pe: �a�� 'J� p�� private t,�. public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No [�. H�r�1e_ Y��\ d. u�rd� ; G 5 If so, identify location: . PropeRy Description: Lot size: . Tax Map#: �� ' � � �� o� Parcel#: � �, 1 �^� Township: ��Shy- ror.K -�rp . Directions to propercy: State Road #& Road ames,�tc. ;�rdl� '(Y1�.\' . Type of structurelfacili[y: Proposed: �Existing: Q � Type of dwelling: House: [�1obile Home: Q Business: ❑ . Type of business: Number of Employees: Number of bedrooms: � ' Garbage Disposal? Yes ❑ No �i ,Basement? Yes❑ No�f so, # of basement fixtures: �6 Number of occupants or people to be served: �( ' CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COun�y T.3ealth Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the propecty. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not deiivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. � Signc� Owner or Authorized Agent . . ._ ... . T��. � r ti PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT ~ Tax Map #: t1� 2 Parcei # �� Zoning Township r� Applicant• Location: ��LI'u I� l � �$ �7 8 r1 (�) � L S� �S*1- V �(�YU�f- O-i7] V°�-c�V� ►CJ� • Subdivision: SeCtlon: Lot: Improvement Permit A buildinq permit cannot be issued with onlv an Imarovement Permit New � Repair _ Addition _ Type of Structure � Water Supply �: Y�0..�� # of Occupants �# of Bedrooms 3 Other . Basement? ,�� Basement Fixtures? N IA Projected Daily Flow: � g.p.d. Permit Valid For: pY17re Years ❑ No Expiration Proposed Wastewater System Type: �V27�2 �- l bllV2fl-� `iNl[t � Pump Required? Yes ✓No Permit Condi#ions: Owner or Legal Repres tative Signature: � Date: ��/l� Authorized State Agen • Date: � � " r The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. Thls permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinc� Permit) Type of Wastewater System b�1 �-��,'1Q.� Wastewater Flow: C�,Q_g.p.d. Facility Type: c 7�� aY1r1Q New �epair DExpansion ❑ Basement? O Yes I91Qo Basement Fixtures? 0 Yes OIDJe Wastewater Svstem Reauirements Septic Tank Size: ,�,QQ_ gallons Pump Tank Size: N W ,�gallons Total Trench Length: ,�� feet Maximum Trench Depth: ��F�Z�hes Aggregate Depth� Z in. Maximum Soil Cover: �, inches Trench Separation: �„ Feet on Center Other: � �l — Permit Expiration Date: I�`� b—' Authorized State Agent: Date:�� The type of system permitted ❑ does ❑ does not differ from the type specified on the application. 1 accept the specifications of this permit. � Owner/Legal Representative Signature: � Date: �� /% Q� PCHD, rev/ 10/12/99 � r Application #: Tax Map #: 3a Parcel #: 19 2_ Person County Heaith Department Environmental Health Section SITE SKETCH M.00c-e_. Applica t's Name , � S. Authorized State A nt Subdivision/Section/Lot# � I-' I (O"�� Date System components represent approximate contours only. Tlte contraclor �rtust fl'ag the systeni » Scale: =�4�� PCHD, rev. 10/12/99 Person County Health Department � Environmental Health Section Tax Map #: �,�7 _ Parcei #: 1q Z Zoning: Township: �(.� � n�.T�.r� Subdivision• Section: Lot: Appiicant: �� Iwt1D1�P Location• , � � � � �� Wc�v�r�f OI� � - . erat�on Perm�t System Type (In Accordance With Table Va): 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. Tax Map #: �� 5�2�- -DD Date � �� , R�r�»►� /J �/ �7 _ / - � ! �'� 11 Parcel #: �92- PCHD, rev. 10/12/99 Person County Health Department Environmental Health Secti n Zoning: Township: -(_a5%/ll./ �%�� Subdivision: Section• Lot• Applicant: �� Y �Y� Location• � � � �� Cu�/`,� � �� c/'Z {� 1i � ' �f.l : W �era�ion ermit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requirements �_ B) Distance from system to any wells /U%� �, C) Distance from septic tank to foundation �_ D) Distance from system to property lines �/0 2. SEPTIC TANK A) Visually inspect the exterior walls and top of the tank ✓ B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet ✓ C) Date of tank manufacture — 0� D) Tank serial number S-1 —1�1 Z E) Liquid capacity of tank 1� D� gallons 3. SUPPLY LINE TO RENCHES A) Gradec�P,f C� (1/8 inch per foot minimum) B) Material supply lin � constructed from �� C) Diameter <1 �� D) Length ,�� E) Distance from tank to drainfield/distribution device 4. DISTRIBUTION DEVICE(S) A) Type � B) Is Device water tight „ j� C) Distance from the distribution device(s) to the trenches �v D) Is the device on a level foundation E) Does the device perform according to its design speci�cations F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth �� inches B) Trench width inches C) Distance between renches Z� � GV1 [:7'�� D) Number of trenches i E) Length(s) of trenches � ( .(.l �� F) Aggregate depth �Z inches G) Aggregate material and size H) Record septic tank outlet elevation ( I) Trench grade PP (� V� �� (<_ 1/4" per 1' J) Step downs a. Minimum of 2' of undisturbed earth �,_ b. Proper rise over step own �_ c. Solid pipe used d. Elevations of step downs (Record elevations and show on as built) See "as built" p�a on-�ttached sheet. PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �. ) oC Parcel # � � Zoning Township Applicant• . �/ � ,l r� /% LocaUon: ;, Subdivision• SBcti°�. �°t' Type of Water SupplV: Requirements: Well Permit �dividual Community Public Site Approved by ��'� 'C� a•a S-�o Grouting Approved by � !1i �s�r� Well Log /1z�H'� ��s-�v Well Tag i'hf�r� �..z{'- so Air Vent i / Hose Bib,/ Concrete Slab d'�►i Well Drilier Well Appro Date: � a � � **See Attached Site Sketch�""` Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 �u- �:�,u,�r�� i�:rvGi.itc�trr:::td�rni. it�,ni.��i . . , Idl•:I.1. I.fII: ��i iC: _—�--� .2 • � , O�ti�nez-: �_% a � , . . --�--,��---,�-� y�__� � � � � L-OC�(1017�ZI'C;c[zo��!�: _.._... ---____: 5��. �.. 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T�'P.C: Stcel --. .... �.,.�.. .__1'�. ,l��:u�tc�c1-: �� X.f S[ccl, docs o��vnc1-:►------�-- .:Cl�ilv;irti�cd .�tccl_� t� ��hes . �.��i c� v � :. � c::. `' �� v�ht:�� _ '�7uick�ic:�''�_--,L.f� ---.1�.[ci No-- � .. e S11oc: ,.,. � �;h��lbovc, Grow�d: � cs ✓ jUc� - . ..�,1:��h�r Werc �',roblcni� Ci,cot�►itc�,-c:c! in .�c:�tin - �.)tc � , G ��: ��y`�„ �ivc rca��,�:__...__ 1., C,,s�»r;•� a cs .. .`__ .. z-out: :.Cype; Ncat ---__.__..__.....- _.___ `-`'- �o--�, � Wic1 1 - ,�:i�icl/C�c:ntcnl__ ��` _ Co : �%;� w �ula.r.�S �acc ' c i_-------. _.... _.. 1,�c1 _. ricz'ete ' ' • `''f� z' in Aluitil.lr SIric:c;: � c::: -��cs '..;, Mc[1ioc1:� �'u,-„�x:c�;_ �� - ....... ..._.._.._ Nc>.__ � • • . __. ... 1 t':::: I l t C: .Dcp�i: I�,ron� � ��....----� .. .--�.t .`u-ccl ,� 11'Iat ' � ---..�._.�._. - �" - _ ...--- _._. � . . . • ••,. ,� cz-ia Usccl: �--- ' 1't. :., �- Nc� . ,1�5 . , y , . • `� . � mz\[t.tre s. , 'L � c�tt.I:uicl Cci��cnt` . ,.. . ,�;_�,. ( znc1, L-r.«-c:l, cui.t�r►,,,; �, . ... _.._ Wcz�;1i[ol'1•ba�-��",� Z� l�l:itcs_ �r�� ,).. I�a�i��: � tc� � lb `� N r> .. _ "_--- .. � � -� ,� �� :; I a v �� ----�-� . . - ' � .. ' '�;;�.� �— ___—._ Nc�_____... ' , �'r•a _. . .. .._ .-., �----.____._. _....... _ _...� ?l� I.l ..I .I N(;; 1.�)(.� _ • _. . De []1 � . . , ---�_______ _ _.- .FI'GIl1 � U -._... ------ -_.... _ ... _ --...._.«_.-------�-_ �- � --_....._____ — 3 __ I��;�r,-��i[' - - -----�---- -- - lUJ1 ' __�== -------- _._..-- _��...0 f� _` ctict-� �t��n . ---�-�----- .. ,__.._ . �./� � � _.... �-� -- � -- -�_ __ ._�� .__.____ • �� ` _ __----,�J_� � c� .__ .�`�'' .. _.___-- �� .� ::� _ . � �- --�---�r --?gr�--� _____ . - ----.. ..�- _�:�-.�-:�, z ��x c��TzrY ,� - -- �- . . � f I�'Z�' •'' T � •�•�.ZL�� ,�«,1 �r . xzs w��,�, w�s corr - - , �v�.�rv�=o�zM�� f �x�� RT�- s 11�UCTL'•1.) �(V n, ._. ZS COR��C�r AND , . i�X•TkI�.�,�RSON C�U.NT�� t•Il:nr �,Ol� �,�,NCL W�TI-i REGULA�ONS� .. .. P/11�"f'MLN'1•, . .. �� . .,, ... ., . .`'"' o�y�� -l.t�vi��'�...._ _._. .�lj�ll:t(U('C: O� (,(711(i.i�:((1r' —.r_ �_; Dacc '' oPERSON COUNTY HEALTH DEPARTMENT 355A S. MADISON BLVD. ROXBORO, NC 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of O��vner or Tenant 1�0�( �D�- Address_1«�� !✓Cl� �i�(�S /�'•County �`��'� Collected By Date Collected�/ �/o Time Collected /O: 30 Source: �VVell ❑ No Charge ❑ Spring �'Charge ❑ Well Tap ❑ Other u�c� �� 9c�'c�k*�"c�k�F*:k�c>c*�k�':-k**�k***�F��c**ic�c*�c�':�F**�c�:�c�F*�':�'c�F�c�F�k9:*�'cx�'c�'c�:**x*ic�:*�'c*t��tx�c�'e*�k�cic*�t �t�cdc�'c�k�+c***�':�4�'c�F*�r9c�cdc�'c�c�F�c�F9c�'c�F�':*�'c*�*�F�k*x�':�'c�'r�c*�kic�F�c*�cdc�k9c�F�F*9c**�'c**�kx*�':�:***�k**** Total Coliform Fecal/E. Coli. Rescclts Present . Absent 0 � � o � ) r� Reported By ' IU "' Date l' %Z1 l U � infor.r�ation and Recom�rrtendations� �or Uses o� Private 1Ne111N�a��w � �or :�cjattic ��t�Ca1s �Fout�d i� 1�Va�� - . North Carolina Occupationai and Environmental Epidemiology 6ranch (OEEB) For Addf#1ona1 Information ca11919-707-5900• � Name: , °� ,.._ County : ��r.%��h . Sample =dentiflcation Number: � ': �.�d 1 Z9 �. Information on Your Private Wel� Water Your well water was laborato .ry tested fi�r chemicai contaminants. prinking water may contain chemical. contaminants wh(ch can occur naturally or be introduced into water from man-made sources. The chemicals found ln your well were lntroduced from man-made sources: � In order fio evaluate your laboratory results for chemical contaminants, your water results were compar�d to fihe national primary drinking wafier standards or maximum contaminant leveis (MCLs) (see website For basis for each MCL afi • htta://www.eoa.aov/safewater/contaminantslindex htmi,�tmdsl. MCIs are nattonal dHnking water standards that are required to be met by munidpal water supplies. If an MCL was not avallable, your water results were compared to the North Carolina 2L Groundwater Standards. •� Recommendafiions for Uses of Your Private Well Water The cancentratians found in your well water da not exceed the recommended EPA levels/North Caroiina 2L Groundwater Standards. Therefore, your water could be used for dHnking, cooking, . washing �dishes, bathing, and showering. �� Contamtnant concentratlons found in your well water are higher than the EPA recommended levels for dNnking and cooking. These contaminants include • Your weli water should not be used for drinking or cooking. if you have been drinking the well water and are pregnant, nursing, or have a child under 5 years of age, inform � your physician of the results. . �� Because of the low lev��s, some absorption of these chemicals is expected through intact skln and exposure to water vapor.•Therefore, limit showering and bathfng time to less than 10 minutes. """"�� Because of the high leveis, absorptlon of these chemicals could occur thraugh intact skin and exposure fio water vapor. Therefore, limit showering and bathing time ta less than 5 minutes. """""'� �ecause of the very high levels, significant absqrption of fihese chemicals cauld occur through intact skin and exposure to water vapor. Therefore, thls water should not be used for showering and bathing. ��. You may want to purchase a water treatment device, drill a new well thafi is dlstantly located from the groundwater contamination, use bottied water, or connect to a publlc water supply. �,�,,,�, Resampling is recommended in months, � . .�.�.. Other Comments . n. -� 'r�. . . , i1�; `,J��l.S :�E,�,�i;,� 1:1 NC�: � . � t�?ADI�UM �BODttCA ' � h0 i RiNSF. . �� . . � : N.C. Department of Health and Human Services . • Division of Public Heatth � �� R�� J��g�� ",—�G State Laboratory of Public Health ��.� � '' F.�:�ox 28047, 306 N. Wilmington S�, Raleigh, NC 27611-8047 Environmental Sciences �Analysis Report � � Name of Owner, Patient � � Or Supply: . �, �. t�fi{"�- Telephone.� (��') ��{- `f iD3�5 ' Address•�75� �G(r��: �r'l�$ �p�. County:__ / •�Y ti,r1 � . 1 r61� �'t��I�� Zip: a`�%.� .. .........■..:.............■ ...:.....................................:......................� Report to: � �� Il�. �' � � . . —� -�' • p con��a By: .��v�e�� . Telephone # (�� .� �4 7� l L I `� . � � � r � g fi Telephone � �� f ` � Address• 3�� i� ,n'(�v-�a,,� �� . Dak Collected• z f �7 � 'If�Jv-c� �NC- . n��l S� 3 � '. � AnalJ�sisDesired: ' � � �r;^ � : Laboratory Numbar Sam le �4�` Sam le Descri tion or Remarks .. � Results In :.. .1 � 0 �. 2 �� • 2 _ �rv� � : 1 G, -zj � �°(J . . � � � � �- l L �� .. � ES012210-0013001 . � � oo� zs .� . . . SE� �1fT�CHED S�E T(S) . . ' 01 /21 /2010 � . Petroleum ES012210-0013002 - � . . 100130 �� . .. 04/20/2009 �i'�±� VOA 524.2 (47) . � . � .� � Q 1 � G � .i�'iP �NK T�: 'n�-C� � O EE �TTAGHE �6�EET(S) � � Date Received: �JQ� � b �GU��'"� � �_ • �Qltl � $ � . . . � . . � , Dak Repotted: �, �0 . � � � Date Extracted:1-22-- ��C� /(� .n � . P ��c . �1.5 . Gc.� H �, b . . . Date Analyzed: - ' . ��-2�! ,Ci�i�, . • � • ' Reported By: O,J - DHHS Fonn 2364 . . � . � . � . ' . . Laboratory (Rev.06✓99) � . . �. . . . . � . F anlrpt , : � ' . ' ' . : , • • � � � North Carolina State Laboratory of Public Health Sample Group: ES012210-0013 �nvirorrmenfal Scfences Organic Cheonistry Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Attn: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://sl�h. state. n c. us Phone: 919-733-7834 Fax: 919-733-8695 Name of System: MOORE, RODNEY 11450 HURDLE MILLS RD. HURDLE MILLS, NC 27541 County: PERSON : Well Permit #: Sample #: ES012210-0013001 Collected: 01/21/2010 Received: 01/22/2010 Sample Type: Water Sampling Point: Sample Source: Temp. at Receipt: 5.5 DEG C Sample Description: Comment: Organic Chem - PETROLEUM Method: Petroleum ADAM SARVER 08:11 MNICHOLSON Client Sample #: 100129 GPS #: Analyte Result RL Units Qualifier(s) Petroleum No Petroleum Products identified VOA 524.2 (47) Analyte Result RL Units Qualifier(s) Chloromethane Not Detected 0.5 ug/L Vinyl chloride Not Detected 0.5 ug/L Bromomethane Not Detected 0.5 ug/L Chloroethane Not Detected 0.5 ug/L Trichlorofluoromethane Not Detected 0.5 ug/L 1,1-Dichloroethene Not Detected 0.5 ug/L Acetone Not Detected 2.0 ug/L lodomethane Not Detected 0.5 ug/L Carbon Disulfide Not Detected 0.5 ug/L Methylene chloride Not Detected 0.5 ug/L Acrylonitrile Not Detected 0.5 ug/L trans-1,2-Dichloroethene Not Detected 0.5 ug/L MTBE Not Detected 0.5 ug/L 1,1-Dichloroethane Not Detected 0.5 ug/L Isopropyl Ether Not Detected 0.5 ug/L cis-1.2-Dichloroethene Not Detected 0.5 ug/L 2-Butanone (MEK) Not Detected 2.0 ug/L Tetrahydrofuran Not Detected 2.0 ug/L Page 1 of 5 North Carolina State Laborato of Public Health P.O.Box28047 ry 306 N. Wilmington St. Environmer�tal Sciences C}rganic Chemisiry Certificate of Analysis Sample Group: ES012210-0013 Chloroform (T) Not Detected 0.5 ug/L 1,1,1-Trichloroethane Not Detected 0.5 ug/L Carbon Tetrachloride Not Detected 0.5 ug/L Benzene Not Detected 0.5 ug/L 1,2-Dichloroethane Not Detected 0.5 ug/L Trichloroethene Not Detected 0.5 ug/L 1,2-Dichloropropane Not Detected 0.5 ug/L Dibromomethane Not Detected 0.5 ug/L Bromodichloromethane (T) Not Detected 0.5 ug/L cis-1,3-Dichloropropene Not Detected 0.5 ug/L 4-Methyl-2-pentanone Not Detected 0.5 ug/L Toluene Not Detected 0.5 ug/L trans-1,3-Dichloropropene Not Detected 0.5 ug/L 1,1,2-Trichloroethane Not Detected 0.5 ug/L Tetrachloroethene Not Detected 0.5 ug/L 2-Hexanone Not Detected 0.5 ug/L Dibromochloromethane (T) Not Detected 0.5 ug/L 1,2-Dibromoethane(EDB) Not Detected 0.5 ug/L Chlorobenzene Not Detected 0.5 ug/L 1,1,1,2-Tetrachloroethane Not Detected 0.5 ug/L Ethylbenzene Not Detected 0.5 ug/L Total Xylenes Not Detected 0.5 ug/L Styrene Not Detected 0.5 ug/L Bromoform (T) Not Detected 0.5 ug/L 1,1,2,2-Tetrachloroethane Not Detected 0.5 ug/L 1,4-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dibromo-3-chloropropane (DBCP) Not Detected 2.0 ug/L 1,2,3-Trichloropropane Not Detected 0.5 ug/L Report Date Raleigh, NC 27611-8047 htt�://slph. state. nc. u s Phone: 919-733-7834 Fax: 919-733-8695 1/28/2010 Reported By: Nancy Jones �`�. Page 2 of 5 North Carolina State Laboratory of Public Health Sample Group: ES012210-0013 �nvironmental Sciences Organic Chemistry Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 . Attn: P.O. Box 25047 306 N, Wilmington St. Raleigh, NC 27611-8047 http:l/siph. state. nc.us Phone: 919-733-7834 Fax: 919-733-8695 Name of System: MOORE,RODNEY 11450 HURDLE MILLS RD. HURDLE MILLS, NC 27541 County: PERSON Well Permit #: Sample #: ES012210-0013002 Collected: Received: Sample Type: Water Sampling Point: Sample Source: Temp. at Receipt: Sample Description: TRIP BLANK Comment: 04/20/2009 KMN 01/22/2010 08:11 MNICHOLSON Client Sample #: 100130 5.5 DEG C GPS #: Organic Chem - VOCs Method: EPA 524.2. VOA 524.2 (47) Analyte Result RL Units Qualifier(s) Chloromethane Not Detected 0.5 ug/L Vinyl chloride Not Detected 0.5 ug/L Bromomethane Not Detected 0.5 ug/L Chloroethane Not Detected 0.5 ug/L Trichlorofluoromethane Not Detected 0.5 ug/L 1,1-Dichloroethene Not Detected 0.5 ug/L Acetone Not Detected 2A ug/L lodomethane Not Detected 0.5 ug/L Carbon Disulfide Not Detected 0.5 ug/L Methylene chloride Not Detected 0.5 ug/L Acrylonitrile Not Detected 0.5 ug/L trans-1,2-Dichloroethene Not Detected 0.5 ug/L MTBE Not Detected 0.5 ug/L 1,1-Dichloroethane Not Detected 0.5 ug/L Isopropyl Ether Not Detected 0.5 ug/L cis-1.2-Dichloroethene � Not Detected 0.5 ug/L 2-Butanone (MEK) Not Detected 2.0 ug/L Tetrahydrofuran TRACE 2.0 ug/L Chloroform (T) Not Detected 0.5 ug/L 1,1,1-Trichloroethane Not Detected 0.5 ug/L Carbon Tetrachloride Not Detected 0.5 ug/L Page 3 of 5 � North Carolina State Laboratory of Public Health Environmental Sciences Organic Chemistry Certificate of Analysis P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http:l/siph. state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 Sample Group: ES012210-0013 Benzene Not Detected 0.5 ug/L 1,2-Dichloroethane Not Detected 0.5 ug/L Trichloroethene Not Detected 0.5 ug/L 1,2-Dichloropropane Not Detected 0.5 ug/L Dibromomethane Not Detected 0.5 ug/L Bromodichloromethane (T) Not Detected 0.5 ug/L cis-1,3-Dichloropropene Not Detected 0.5 ug/L 4-Methyl-2-pentanone Not Detected 0.5 ug/L Toluene Not Detected 0.5 ug/L trans-1,3-Dichloropropene Not Detected 0.5 ug/L 1,1,2-Trichloroethane Not Detected 0.5 ug/L Tetrachloroethene Not Detected 0.5 ug/L 2-Hexanone Not Detected 0.5 ug/L Dibromochloromethane (T) Not Detected 0.5 ug/L 1,2-Dibromoethane(EDB) Not Detected 0.5 ug/L Chlorobenzene Not Detected 0.5 ug/L 1,1,1,2-Tetrachloroethane Not Detected 0.5 ug/L Ethylbenzene TRACE 0.5 ug/L Total Xylenes Not Detected 0.5 ug/L Styrene 1.2 0.5 ug/L J Bromoform (T) Not Detected 0.5 ug/L 1,1,2,2-Tetrachloroethane Not Detected 0.5 ug/L 1,4-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dibromo-3-chloropropane (DBCP) Not Detected 2.0 ug/L 1,2,3-Trichloropropane Not Detected 0.5 ug/L Report Date: 1/28/2010 Reported By: Nancy Jones Page 4 of 5 • n �� . , � North Carolina State Laboratory of Public Health P�o.g°X28°4' 306 N. Wilmington St. Raleigh, NC 27611-8047 �17VI1"UI�CI'lG'I?fal SCIf,'i7CBS http:us�on.state.nc.us Phone: 919-733-7834 Q i'g a 11 i C t. �1 @ i111 S t i'�/ Fax: 919-733-8695 Certificate of Anaiysis Sample Group: ES012210-0013 Environmental Qualifier Descriptions Code Description - * Result exceeds MCL � >ht - Entered past holding exp A User choice 1 Ach Above ULC Amt Non-default amount used B Blank over RL C Possible Lab Contamination Cg Confluent Growth D User choice 3 Haz Hazard Level Exceeded Hirec High recovery J Estimated Value Lorec Low recovery Ofe Over 48 hours Sp Sample processing problem Susp Suspect result T Trihalomethane T Turbid Culture c Temp Temperature Range Exceeded Ti Tentative Identification Tntc Too numerous to count U Beneath MDL V User choice 4 Page 5 of 5 ► , ... �-�z— �a2 North Carolina State Laboratorv of Public HealthP.o.g°XZ$°4' 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 http://siph. state. n c. us inorganic Chemistry Faxne� 919-733-8695 Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 StarLiMS ID: ES012210-0004001 Date Collected: 01/21/10 Inorganic ID: Date Received: 01/22/10 Sample Type: Raw Sampling Point: Well head Sample Source: Ground Temp. at Receipt: Sample Description: Comment: Name of System: RODNEY MOORE 11450 HURDLE MILLS RD HURDLE MILLS, NC 27541 Time Collected: 10:30 AM Collected By: ACS Well Permit #: GPS #: Inorganic Chemical (Profile) Analyte Result Allowable Limit Unit Qualifier(s) TotalAlkalinity 123 mg/L _ _ __.___. ---_. Fluoride 0.22 2.00 mg/L Chloride < 5.00 500 mg/L Sulfate 5.50 250 mg/L Arsenic < 0.005 0.010 mg/L Copper < 0.05 1.3 mg/L Lead < 0.005 0.015 mg/L Manganese 0.20 0.05 mg/L Zinc < 0.05 5.00 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Chromium < 0.01 0.10 mg/L Silver < 0.05 0.10 mg/L Selenium < 0.005 0.005 mg/L Iron 0.14 0.30 mg/L pH 7.9 N/A Calcium 34 mg/L Magnesium 4 mg/L Total Hardness 100 mg/L Report Date: 02/15/2010 Page 1 of 1 Reported By: � xucq � . OCC1tpAt10118� 811� $11{►j�p Cat1D� D1Y�021 O�POIf�C �081f11 � � . :, ' . • . . . . . . . . nnaontal��BpidemiologyBreri�, Bpi�emiology Secbton• INORGANIC CHENIYC,4I, ANALygIS �EPORT . ' � Prtvato weD wster inform�tlon �nd recommendatlone � Coun , . � �.e�.�v� . a�e , �'' Namo. �� . , Samplo Id Numbo�: �/6 4 , ; . � � Location. � . ' ►`!' ,'. �taviawer ��11Q,,. Your w ANA�°YSI��ItEI'ORT � � - ell water was tested for 15 motals, plus nitrat�;,bitdtes, arid pH. Tha rosults were evaluated using the federal 'dri.nkYng q,ai�r stand�, �o pH is a measure of the acidity of the watar. Drinking water may contai.n substaacas that can occur naturally in wator or can ba intmduced into the wate�r flom man_made sources. ('Thesa recomnaenda�ions sre based on inorganic chomical analysis �,) , TEST RESITI,'�S AND USE RECOMIVV�1vDATIONS Your well water meots federai drinldng water standards, yo� �►ater can ba used for drinking, cooking, washing, cleaning, bathing, and showering. . Tha following substattcc(8) exceeded f�� '' g�t� ��.ds. Your wator can.be used for drinking, cookin w . S, ashing, cleawng, bathing, and showering, but aesthetic problems such as bad taste, odor, staining of porcelain, etc, may occur. You may want to �install. a household water � treatment system to addross aesthotic nroblems. The following substance(s) exceeded federal drinkittg water standards: We recommend that your ,J� well water no_t be used for drinldne or cookin� unless you install a water treatment system to remove "�'` the circled substance(s). I�owever, it may be used for washing, cleaning, bathing, and showerin�. Re-sampling is recommended in mont,hs. : Re-sample for lead and %r copper, Take a first draw, S minute, and 15 minuta sample inside the house (preferably the kitchen) and if possible a�rst draw, S minute and a 15 minuta sample at tf�a well head to deter�nine t h o s o u r c e o f t h e l e a d an d lor copper. Contact your local health department for re-sampling assistanca. .��,,f , - Routina well water eampling for the abo e�sub �Ce3s�E �TOONS � u nded every two to threa years. .Satnp�e your well water when thero is a kaown problem or contamination in your area, after repairs or replacement of your well, or after a flooding event, Contact your local health depattment for sampling instructions. Contact your locAl health dep�rtment lor more lnformAHon or go to httu;//www.eel,etate,ndenUolUhefactahee -h+mi � March 10; 2U09 �, . �/� �JJ�►!.S :��*��1'� 1'1 IiC►_ . +. � . � , . p�pLEUN PROOttC�i �� i�� N.C. Department of Health and Human Services Division of Public Health �� R�� Jt� t�� State Laboratory of Public Health � �'�. �„ �.�:�ox 28047, 306 N. Wilmington St., Raleigh, NC 27611-8047 �'�4� o Environmental Sciences Analysis Report Name of Owner, Patient Or Supply: Qd � Address•_��75� %7T�tvQllr� ��l�S �OP� ' �� <<� �� Zip: ��t�.%� � � Z ,�.,1`� -� Telephone �! (��1 �� y - �� 33 ' County: __ / -Pr'Sti �^ ............. ..............................................................................� Report to: � �-�r4� �OJ • N �'`� � '�'� - � c�X�yv'2.�% ,�' Collected By: Telephvne �i (�� 7� l� �`D � Telephone #� SQ �— j 7 4 C7 Address• 3�S `�7� ,�'��r-��,,� S`1'' Date Copected• ? O YJ'�'rt� `/vC ��j s�,� Analysis Desired: ' � � �v�-� � laboralory Number Sam le � :.P I�O12� ' - ES012210-0013001 100129 �'� 01 /21 /2010 Petroleum ES01221p_0013002 100130 t 04/20/2009 .�� VOA 52q,2 (47� ��i� I Z- w► l � � L r�� i�' W.AHK �DAT'�• Date Received: �~� � � �U�� ,� V�^�— Date Extracted:�-22� �(� ��/�w /� DHHS Form 2364 Laboratory (Rev.06/99) F anlrpt . �escri tion or Remarks Results In � � �� "°l� SE�.�I Ti�Ci-��D .^��EC-}T(S) '� -LU �.�1 �� ATTACHEp s Date Reported: � JA� 2� 20�0 . � /��v�c .M.S . GL��-� � Date Analyzed: - 1-�-%i�! ,Cvi� Reported By: �• . North Carolina State Laboratory of Public Health Sample Group: ES012210-0013 Environmental Sciences Organic Chemistry Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Name of System: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://s Iph. state. n c. us Phone: 919-733-7834 Fax: 919-733-8695 MOORE,RODNEY 11450 HURDLE MILLS RD. HURDLE MILLS, NC 27541 Attn: County: PERSON Well Permit #: Sample #: ES012210-0013001 Collected: 01/21/2010 Received: 01 /22/2010 Sample Type: Water Sampling Point: Sample Source: Temp. at Receipt: 5.5 DEG C Sample Description: Comment: Organic Chem - PETROLEUM Method: Petroleum ADAM SARVER 08:11 MNICHOLSON Client Sample #: 100129 GPS #: Analyte Result RL Units Qualifier(s) Petroleum No Petroleum Products identified VOA 524.2 (47) Analyte Result RL Units Qualifier(s) Chloromethane Not Detected 0.5 ug/L Vinyl chloride Not Detected 0.5 ug/L Bromomethane Not Detected 0.5 ug/L Chloroethane Not Detected 0.5 ug/L Trichlorofluoromethane Not Detected 0.5 ug/L 1,1-Dichloroethene Not Detected 0.5 ug/L Acetone Not Detected 2.0 ug/L lodomethane Not Detected 0.5 ug/L Carbon Disulfide Not Detected 0.5 ug/L Methylene chloride Not Detected 0.5 ug/L Acrylonitrile Not Detected 0.5 ug/L trans-1,2-Dichloroethene Not Detected 0.5 ug/L MTBE Not Detected 0.5 ug/L 1,1-Dichloroethane Not Detected 0.5 ug/L Isopropyl Ether Not Detected 0.5 ug/L cis-1.2-Dichloroethene Not Detected 0.5 ug/L 2-Butanone (MEK) Not Detected 2.0 ug/L Tetrahydrofuran Not Detected 2.0 ug/L Page 1 of 5 North Carolina State Laboratory of Public Health 06 N. W�mOngton St. Raleigh, NC 27611-8047 Environmenfal Sciences Organic Chemisfiry Certificate of Analysis Sample Group: ES012210-0013 Chloroform (T) Not Detected 0.5 ug/L 1,1,1-Trichloroethane Not Detected 0.5 ug/L Carbon Tetrachloride Not Detected 0.5 ug/L Benzene Not Detected 0.5 ug/L 1,2-Dichloroethane Not Detected 0.5 ug/L Trichloroethene Not Detected 0.5 ug/L 1,2-Dichloropropane Not Detected 0.5 ug/L Dibromomethane Not Detected 0.5 ug/L Bromodichloromethane (T) Not Detected 0.5 ug/L cis-1,3-Dichloropropene Not Detected 0.5 ug/L 4-Methyl-2-pentanone Not Detected 0.5 ug/L Toluene Not Detected 0.5 ug/L trans-1,3-Dichloropropene Not Detected 0.5 ug/L 1,1,2-Trichloroethane Not Detected 0.5 ug/L Tetrachloroethene Not Detected 0.5 ug/L 2-Hexanone Not Detected 0.5 ug/L Dibromochloromethane (T) Not Detected 0.5 ug/L 1,2-Dibromoethane(EDB) Not Detected 0.5 ug/L Chlorobenzene Not Detected 0.5 ug/L 1,1,1,2-Tetrachloroethane Not Detected 0.5 ug/L Ethylbenzene Not Detected 0.5 ug/L Total Xylenes Not Detected 0.5 ug/L Styrene Not Detected 0.5 ug/L Bromoform (T) Not Detected 0.5 ug/L 1,1,2,2-Tetrachloroethane Not Detected 0.5 ug/L 1,4-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dibromo-3-chloropropane (DBCP) Not Detected 2.0 ug/L 1,2,3-Trichloropropane Not Detected 0.5 ug/L Report Date: http://slph. state. nc. u s Phone: 919-733-7834 Fax: 919-733-8695 1/28/2010 Reported By: Nancy Jones /l - Page 2 of 5 North Carolina State Laboratory of Public Health 3 6 N. W?mo gton St. Sample Group: ES012210-0013 Environmental Sciences Organic Chemistry Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Attn: County: PERSON Sample #: ES012210-0013002 Collected: 04/20/2009 Received: 01/22/2010 Sample Type: Water Sampling Point: Sample Source: Temp. at Receipt: 5.5 DEG C Sample Description: TRIP BLANK _, Comment: Raleigh, NC 27611-8047 htto://slph. state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 Name of System: MOORE, RODNEY 11450 HURDLE MILLS RD. HURDLE MILLS, NC 27541 Well Permit #: KMN 08:11 MNICHOLSON Client Sample #: 100130 GPS #: Organic Chem - VOCs Method: EPA 524.2 VOA 524.2 (47) Analyte Result RL Units Qualifier(s) Chloromethane Not Detected 0.5 ug/L Vinyl chloride Not Detected 0.5 ug/L Bromomethane Not Detected 0.5 ug/L Chloroethane Not Detected 0.5 ug/L Trichlorofluoromethane Not Detected 0.5 ug/L 1,1-Dichloroethene Not Detected 0.5 ug/L Acetone Not Detected 2.0 ug/L lodomethane Not Detected 0.5 ug/L Carbon Disulfide Not Detected • 0.5 ug/L Methylene chloride Not Detected 0.5 ug/L Acrylonitrile Not Detected 0.5 ug/L trans-1,2-Dichloroethene Not Detected 0.5 ug/L MTBE Not Detected 0.5 ug/L 1,1-Dichloroethane Not Detected 0.5 ug/L Isopropyl Ether Not Detected 0.5 ug/L cis-1.2-Dichloroethene Not Detected 0.5 ug/L 2-Butanone (MEK) Not Detected 2.0 ug/L Tetrahydrofuran TRACE 2.0 ug/L Chloroform (T) Not Detected 0.5 ug/L 1,1,1-Trichloroethane Not Detected 0.5 ug/L Carbon Tetrachloride Not Detected 0.5 ug/L Page 3 of 5 North Carolina State Laboratory of Public Health Sample Group: ES012210-0013 Environmental Sciences Orc�anic Chemistry Certificate of Analysis Benzene Not Detected 0.5 ug/L P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph. state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 1,2-Dichloroethane Not Detected 0.5 ug/L Trichloroethene Not Detected 0.5 ug/L 1,2-Dichloropropane Not Detected 0.5 ug/L Dibromomethane Not Detected 0.5 ug/L Bromodichloromethane (T) Not Detected 0.5 ug/L cis-1,3-Dichloropropene Not Detected 0.5 ug/L 4-Methyl-2-pentanone Not Detected 0.5 ug/L Toluene Not Detected 0.5 ug/L trans-1,3-Dichloropropene Not Detected 0.5 ug/L 1,1,2-Trichloroethane Not Detected 0.5 ug/L Tetrachloroethene Not Detected 0.5 ug/L 2-Hexanone Not Detected 0.5 ug/L Dibromochloromethane (T) Not Detected 0.5 ug/L 1,2-Dibromoethane(EDB) Not Detected 0.5 ug/L Chlorobenzene Not Detected 0.5 ug/L 1,1,1,2-Tetrachloroethane Not Detected 0.5 ug/L Ethylbenzene TRACE 0.5 ug/L Total Xylenes Not Detected 0.5 ug/L Styrene 1.2 0.5 ug/L J Bromoform (T) Not Detected 0.5 ug/L 1,1,2,2-Tetrachloroethane Not Detected 0.5 ug/L 1,4-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dichlorobenzene Not Detected 0.5 ug/L 1,2-Dibromo-3-chloropropane (DBCP) Not Detected 2.0 ug/L 1,2,3-Trichloropropane Not Detected 0.5 ug/L Report Date: 1/28/2010 Reported By: Nancy Jones �� Page 4 of 5 North Carolina State Laboratory of Public Health Sample Group: ES012210-0013 Environmental Sciei�ces Organic Chemistry Certificate of Analysis Environmental Qualifier Descriptions Code Description " Result exceeds MCL >ht A Ach Amt B C Cg D Haz Hirec J Lorec Ofe Sp Susp T Tc Temp Ti Tntc U V Entered past holding exp User choice 1 Above ULC Non-default amount used Blank over RL Possible Lab Contamination Confluent Growth User choice 3 Hazard Level Exceeded High recovery Estimated Value Low recovery Over 48 hours Sample processing problem Suspect result Trihalomethane Turbid Culture Temperature Range Exceeded Tentative Identification Too numerous to count Beneath MDL • User choice 4 Page 5 of 5 P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph.state.nc.us Phone: 919-733-7834 Fax: 919-733-8695