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A32 246' �� ` ' �1�i11�� -� �1 � `� �r ,� ' 1 , +�' -. `Y./ � ��'� JS_ ' -" �a.-�.�<o� � �e��:�.�. I�-1��:II� Agplicant: �� Location: N��rdl� T�x Wl �� .> �:rc�e�i � �� Su'� dii:�i�s�ian h�s•e:�Scct+ia.i1.�L��t � Y�tprose;�eat �'�r�it . �'ar�at Yalad fo� � �ve 3�� I�To�F�iiration �, Type of Fac�7ity:15 cr� � t, ct��,P l�. i ru . �%w LC Addition �a�es ��pg�iy U� 1) # of Oc�auts �# of Be�rooms N Projecte3 Daiiy Flow �( �o g p,d. . Propose3 Wastewater System: RuY,� ACePr�ecdL��o ��lur�;�n 'cz Fto�..> �ChamFxr) Type: --T Proposed Re�air: � r� L�c eP � f�`�o r�i�.eki �-r� EZ �� Ch� rr,hP rl Type: Permit Conditians: �� Sl�e e�o, r, . . � ----�- i � e � �WIleI OI LE� �S�IIf�TVC Authorized State Agen� �� Date: The issuance of this pes�rit by ti�e Health Departmeat: in does not gnarantea the issuancs of other permits. It is the respons��7ity of the ��aP�Y o�rner to in sure that aIl Person Couaiy Pla�ing and Zoaing and Bu�d'mg Inspections re�ements. a:e met. '�'his Imgroo�ent �'srmit is subject to rev�cation if the site. plan, plat or tt►e intended use changes. The imp�ovement Permit is. mot �;,::..� �ffectesi Iiy a c�ange in ow�r.ship:-oi:ti�prope�ty. This�permit �vss� i�sued in_eumplianc� witb the pra�jsiosus of the.Nost3�ar.alina . ��':: fZa�+rs�=and ,��s fa�' �-�°A'�' 3'reaaar�t.r�md.',Disnosal Svsterils' (35A ,;N+�'e�::�:1:�•::1r9:Q0). Neither Persout,,��onri�.�o��h�:,�:� ��:^�,r�i`*.�nmevtal �ealtlL� - . .septic ta�k.system.�viil� . 'c#ien'sat'ssfact�a�: . , '�z - : #It�¢ates.snpply wiII � otable::� - � --- - - . =.�_::.. _ �- '= -::,:. _ r.��r: �.:,��;�:, 3..emallL.P - --- ' `'�� e�a �om to �m�� v�►� sy� �Q��g �� . ,� .T, �.. �::� :�:: -.;�.��.� � . � ��o� � . . * ses sife plan and additional attachmenis ( ,/ ). Cz �tow �- . . . . .._. - S IQ C �r � TYP�� Waste�vatez' Flo'w 4�j g.p.d. Propased Wastswater ystem: .-� New �, � Repair_ F.apansion • Soil �TAY�: - a5 g.p.cU f� 2 � . Type of Faciiity: �l (�P �i�o\e .��;� � �� (� A � �� i��. Basement _ Yes ` No '��te��ie� Syste� ��e�$s� '�ank Size: Se�rdac 'T�nk:�.�.�`�. gafl �nmP '�an�: t lk�D g�l G�sse T�rap: � gml Dr�field: Total �'ea: � �y4o sq fit Totai g.emgth y�_ i# �;;:.11$a�m� Trenc]► IDe�th �_ an ��enr3a �idtta � _ ft �uffi Soil Coaer: � im ' �: Nfmim�x 15ce�c3i Separaf�n: � . . ft �ist�ribni�on: �3fisi�ibntion �Qa Serial �istn'butioa � Pressuse 11�anafold �:w �ae rri �� ' � �� \ � �. ► � � L r• .A ♦ �.� li \ � ��i� ' • i dn�8aorize�i State Age�� Permit E�iration Date: Date: 'The t3rpe of system permittesi is Conventional � Acr,�ted Alt.�raative. I acc�t +he s}�e�ifications of the P.�- �e�12.�x� ��pr�sE�ve: • Daie: �v - 3 •O� PCED re� 11/10/05 � �� L�1�� llJ� � '— � �� 1 .�latr2vna-�sb]Cn'A�cJ]rn.c�aa� 1��<ci,m�.�lt� SITE PLAN Name `��t�l<2 Q`��1�i:�1 l i�C�.�_t� TaY Map #_P-�Parcel #�ll� Subdivision Section/Lot# -1�t1n��e �>f'�. `3�� u'r Authorized State Agent Date System componenrs tepresent approaimare contours only. The cnntractormusrflag the system paor to begianing the installatron m insure tharpropergrade rs maintained. - - —_ _ - _ �� -�^ �,.� �_� � �� /' � .� ;9 �� --- - ---- ��p NC 15 � �=='�+�' I � � � C01'11 i:OL � --. __ --- --- ---- C 0 R f�l l:_ H � l I �} --------- ------------ -- �;�- \ � M n• � ��S � � 1 \ �-�"-+ '�L�-�-� � C �Q� �� v�l� � � �� a� �,s� � �-� �nS � � J � �� a�5�< �S �s�em � We� C� \\\ � � �' �� a-�h re c1X��e I�l � � � � n-,v-�! bY � r� �� , � U-� ��1 � l7ve� r\ � �s�.��l � JQ� � I "7�''IO � � � �� h�,�s c�,-lack Env- \ � �`; \ e� � ?�'� ��E ,� J , cp - � �:� � cJ� y \ � �J Ci� \ �� \ �' � 7 � �� r' - �P_ � . �s--{ � � �-� ` ��c� `�l �C��k( e Mc,��ck� �� .,a T F �� Acc� �� \ � (ez ��w�;� _ ��> > �5 l i �(� � Fi P.�� o�' Ne�d \ ci-,:�� ._ �_ .., �\ �` -�� `c�� -! �' �C�ep� ��r� l\ ia� d+2��.x�;,�,i� -�� I��h-�Y�.,��.'-1 c�� v '`> \ \Ci\ , �. �. �': �n `� 4 �� d �.n - � � '...�A o . , �� IS � 10.�2 ` � , G ,�, � il � '�. I �� S85 °07 T01_ E ____'>00 . �0 TO1-AL � �� -� �. ��.�._:__-.. ��_� i &9 . 2F -x� � �� ic � ��k � z_ �__.. V �NF sro ' �Ce ��re ��v(�1�1 c�1Ci �i Ir / ;�c�,,s�c,_ l- �40 � IS�� `s-�.��..=a-�,��-��-- _,.,_,.._u=�_��,�200 . UO��-- ��.�.�„�,��a>.__ ._� (VS 5 ° 0 % ' 0 i " pV ��d -'�-"_�•- iS I �`��.�� 1��.�� __._ __ - _ � �� '�.�.��^ �^ ��t ��.�� Owner. �� me_kQ � �el-%n �YC�� Tax iYlap: A3� Farcel #: 6s-llo Date: 31� I�R � �,a�ae �'a� �� (�c�a) �ap �o� �e �.�� o� / �oot # �i�e�er(�aa) . . ( ffi) �. '£e) , 1 ' - 5,5 4 .� � � I '� ,5 �tto •� j '� �' 9(o c7. 4 '! .5 9� o.� 5 . �1 9� � �. 6 7 � 8 � 10 . . �� ft of line x 65 gal per 100 ft=�1�0 � c ; 1fl0 = l9 gal 75°'o x ��a- ga1= ��- g� �e� �os� � gal per minute (gpm) _ �'low �� 'TIICf10II ��4� �.�ss: ��i ft per 100 ft of supply line x�a0 ft of supply.line =100 = o� ft � ft x 1.2 =�� ft of fricrion head �. I��ani$a1d Size: �" �'oa�c� Main Size: �,_„ PVC '�o#�d Dya�a�aic ��d =_ 15 ft of Elevation head +�_ft of Pressnre head +_'Q� ft of Fricdon Head = � `� TDH P�sp ltenl�airenae��: � GP1VI @ �`� . ft of Head �rawc�owaa: a3 per dose � 21 gal per inch =�� inci� dra.wdown per dose : .:-i��..:5 : '�%,:.1�•b1n�. i ��.rf. �o : .i��.ra �.t 1�� .r. � a - � �,:, — ��t0 � ..:. � : .. , , ,, � _ ,: ., , �[��?1=0m00 -�. �_a-�-�.-�-� � �-�-,-.-. -�-a--, e-<._�_�_�-<.-�-�-�.-a-,-._.._, (�1 �I 4�) III ��N!�M��lN�iR�NN�NN1lN�! :. .. :. .. �+li!!!lN�ilN�N!lr�.��l�l�il� � � � � �..�. _...� .,. _ ;. n � :i : : - •c 9 m� 7�ailYmrbm� 1ai/maadue '�' S � • ;viamioid 5i�! � Ta s ��a�i%id 11�f�a Na Taps flff oae side Siza (�dncs ll .ar tau i �oth 9.� 'i4" taT�s '/+" �Ps �" � ' Z» q 3 i 3» 9 5 3 ' iv 1 � 9 � � � 9 � �; j 72 _ I " �uw �Er Tao �i.ez _Llareriai �?m.v G�;1 ; =.� Scfie� 30 1•� � � �ciied =rJ � ".1 � ;f �� I ��f:�� ao %�,1 � i r �'ciied 10 I'= - �--�� f �� ._ .�—,.�� :1��-uu-��„-„-,� ��.11 IE-3L � �.II.�I� Tax M�� :• P��rcel # ��„ • Sul�clivision Ph�•s�e Sect;ion:tot #t NEMA 4X Simplex Control Panel ' Y �� Duct SealBoth . +F" X 4" Pressure Treated Post j Ends Of The Cozu]uit Concrete Riser SlopedTo Shed Water j2^ Sep,lrafion 24" Misi:tuun � Electrical Canduit -- !' �' ' ' ' � ' � 6" Separation . Threaded Gate Valve , . • e.. , ilxwon • :f.��' . 6" Cover • ' , Access Cover• , ' . ; � 1 ' �.rportLand Concreta Crrout • , . — _ - . ' _._ � Mutic � - - ' ' ��,' , ' `� � ." .� � � • � ,~ � � Zip Coxd . , ' Opening Filled With �., Openins Filled With Anti Siphon Hole •'r�s Supply poztlazud Cement Crrout Inlzt Fmm'Septic Taxilc Portland Cement Gzrnit �D� g;ll� „ I Lina •• Outlet To D'utnbutiox d" SCH 40 PVC Pipe � Check .�.p�y�n 2" SCH40PVC Pipa Valve �Pe F1oat Wire� .� � Hig�t Water Alarm Level : � ' (6" Separation� Hi�t Level- Pump On i• ' fiVaporLock i � Floats . � + , ; � ��., . � _L� Drrxd�owst �Up Hill) . • ' �Removabk "•�. � � , � ,� F1vat Tree , , �� , ' , Law Levei -Pump Ofi' . • . ,... �p : � M !„ D � - r /�f-, �I Precast Coxucrete Tank 4" Cozucrete - � � ' �;.; Material Strengtk>3500 PSn Block � I " . '•`,• ' .' . ' • ' ' . ' • , . ,' ' ; . , 't ' • • \ 1 • � • ' � � � � GAtLC�IV FULV�.' TA1VI� • , � ,� N -� '�� v•� � t' � r` ,: : ; � V � � � �� ' w _; t. C'] , _ ` , :.._......� .. . . l . . .. . _.--'�'_........ ' — 1 i i — � � ^= � �. A =� ac1'� ' �- r', . C i wm �. w Y�� . o � �,- ;� r r �' � �'• � N 1 m � C'1� � � N�@ � ' s �•"l�• � .�i y �" �" �� ¢,,�C ►��''S N . n`S �" • � � � Dam �. � � "�� ^� �� C r ` � y W �' � � ♦ � C• % � ..� � y .., ti 'C � ':�; � ��: /, n 4 o �nll ��t � ~ � `� 1' y� �' `T ~ n � ��K � \ � � • � ` � � �a � a wb 0 ,�. � o ,�� t,, �. o m � N� � 4 V n' � � �� 'c. � r.� � � � `s� cr � � � _ � tp „��..�„ �.„,,�-. :,� G-��,,� � t � ;� �`dc�: c � �o � i �� j ? ° ^/ 3 a Z�I ' r/ �, �.sZ•S' � s � � � 7 N � .�'3 �� , � 0 � _.� • Ly j7/:� ttir �'- d�+ �'j � �' \ ..�.._....,.,�.,_.___...._...�._,..,Y.__.. '. � � � � �� : .,...�:.__... _ _ _ _ .. z I o� 0 0 � 012 O • N �� = u.� �<�- •�-�- _ � � :q� .-^z*,� �i -�n� i ......`v.+ _':� � y, ' ny�s:n.A�:, sfiz. 1 A�� / �.a• V _ _ `+s ��i �-'�-°��`� C� � �T�� .e �1�.z- � �"� �'TM'� c�� .�I. �� 1.�'��n. Applicant: S Locaiion: 1� � � v -� ivy I'f` ;'� P ti a Cj' S 1 _ A . �-tl .� \ ��P O�a i o�► (��v I / [� %� � � � ' : rC ' / � ubc�ivisian Pha.se Sec io«:Lot of Bedroom.s � iR� d" So�h C.�-,�vt � ��'�� ' i� �-z-�16�,, . System Type (ln Accardancr Wifih Tabie Va): "b THla S`f5�� A� �EE� II�STA,LLED (tV COfVIP!_.1�1AIC� UV(iH APP�lCA�LE . E�ORTH . Ci4R�Ll�e� GENE�L STATdlT�S, RU�.�S F�R SE�V�,GE ?RE�TI�lEUT A�iD DISPOSAL, � ,�1VD ALL COiVl3lii�i�S (�F � T�31E ffVIPR�if�EiVtE�iT �E�li' �►ND C�NS3'RUGTION �t!?HO � • - - �`� _"d� - Aut rized State Agent � Daie . installed By: /� i�F L P�-J �� Date: ��/ d�ld �Q . '-�C-�-PavvE�tr 31" S,� p,, S,�o,, ��8�� G�B�� s �o ,, � 3a �' 8 � ,,, -� ,„ '--�� ✓ G,. , >,. � �6� ._ ��,�,h L, ��av' ,�� ,� t��. = 1 av' S 1a " � �� = 1 a-c7 ��6�. PT � � pR�'VE . �z L�t � � �b , 7"v7"�L '- ��p: , S��u-��efi SPPr��; �4/� �16� PTs�r�� S T J3 �'�,3�� PuM�; p S�a3� o � PTS- cv��, Pr-�S - P�"► �s Pd �}�j�� s�� Qo t4ps i� .� So►1 c�P S4o�1� bP G�PGr�J �v =� :��.,. -�- � �0 u �, lp .� - r� � __ l�.IAlr ��l''P c�2UPrS1c��t c)�?`"�� S(,,oulJ bP G�PGI�-P c� I j �`��1�1 c)^-t !H 4 U��'�"` � P P �, �' PCHD, rzv. 07/29/0� � ,c.� ��G �'�� M��`��Oh� ��3E�i�.9S 9 �� - �� 2 �� W Tax Nlap � ! ► `�� arce! # � �� Sys�em Type (Tabie Va) � b � OwnerlApplicant S�el�� 7"'v�►-, Si�bdivision Address/Location �� G4��;s A-�. Ser,fPhase Lot # State�ID/date ST�-��t/o�-a Capaciiy �v�o .g21. Tee and F�lter � Bafffe Sealant Riser (ifi app(icabie) Tank Outlet Sea! Permanent Marker Puan�s �'ank �apac�ty � o v Waterproof ISeaiant Riser 1Na��r Tiaht � ChecSc Vaive/Gate Vaive �larm (visable and audible Electrica! Camponents Rate (gpm) Approved Pump Niodel Slocic Under Pump Pum� Removal RopelChai . ��Disi�ibu�aon. Sys�n Serial Distribution �o�nr Pressure Pipe Appr. Pi�e i�iaterial and Grade Valv�s ga�i�sa�l�at� �o��ca��ra !�n�s s aw og�a�� Trench UVidih ft. � Trenct� De th 1 a in. Trenci� Len th �t v ft. Trer�c� Grade Trencf� S acin � Roc� De�th and Quaii� Dams/Ste�dov�rns ��c. 3'ressure Laterals � Hofe S�acinq � Sieeve �ciors Seibac� From� Wells From Propertv lines Surface 1/V�ters Public 1Nater Suppi Verticai Cuts (�2 ft. Water Lines Vei�icle�Traffic � �Eas�mentslRi hf of U' �ttaee� �/.�F Easements Recorded Cammen� /o�l 0�/07/� Qc:�d rev. 3113l01 PERSON COUNTY HEALTH DEPARTMENT SiJBSURFACE WASTEWATER SYSTEM MONITORING REPORT D� S - (� -13 �,.� 3 2 2yG of Insl p ction System Installation Date Typ Tax Map Parcel # �� J0.f�i( �►avi5 �. Property Address Instructions: Check yes or no for appropriate iter�s aad explain in space provided for remazks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps p:esen: & functional ? High water alarm operating properly 7 Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids 7 Inches of solids(pump/dose tank):� Elapsed time readings ? Counter readings ? Drawdown rate: ,,,� D aor�__ YES / NO ❑ � ❑ ❑ � ❑ " ❑ / ❑ _ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ / Evidence of effluent ponding in trenches ?❑ / Surface water effectively diverted ? � / Diversions/swales properly maintained ? []� ! Vsgetaiive cover maint3ir_ed ? � ! Protected from tr�c/unauthorized uses ? [� / Distribution devices in good �ondition ? ❑/ Field free of settled or low areas ? �/ REMARKS 5.�� -�a�� G►� rQ de. `� ho-f a.cce,ss� 61�; 6�elow C�i� SuS�e.�t- wef sP�' �e�wee � b�inn i n o� � ��'� ��,� a�� 2 �in�-� I�e ec�e � onPS Qf ar�d C,�l[ E�v, 1-(ealf� i� if� ts wo�se, � P ❑ r 4i �veS CovC�C� wcCn So� �°�' ❑ ❑�I��ceSsuYe, Man� o �Nal( yA ❑ ra 65 PRESSURE DISTRIBUTIOi1 SYSTE\YI: Tumups/cleanouts/valves/taps intact & �a`Y�/ �� na,� �,�� e � (3g�acJ G��% accessible 7 ❑ � � � �� Pressure head properly adjusted ? ❑ / COMPLIANCE: Compliant Non-compliant Needs Maintenance AiiDiTiOivr�L. � ■ � EHS i; :=C:::::>:::...:+.. , .:�.::: :�_:.. �� ..�.� . : � �\.: b; �... -!.. �� /ti�•' �`".. ��); �•��'.';��\\\��•'�j.� �:'(v'4ii.:::i.:.�'i:•�,`:..�.�.:::.:+•i1 r._�„••"��' ••.i;T�!:.•-:•,�i•'Z.: V•.:•�..••:.::: .. ..... :•.• ... ....... . :.. : nw.::: �..:.:: �: :yi:.�.y:: •': "": r �• . . ♦ ..�t••...s..• :•�....:�.. . . .v. . ' ...... . '. •:. . ,-...i:.. .;• ,. . , . . . vn .... . . .... Q3J�L:'�'.r�5' ;";" '-- .]'�:;.�i7:7J<]i;,4ti`le-n�•�r:+rd�.: . • ' � : � .. .. . . . ... • . .... .. .. ..:::-�^.C.^. . .. .. ..... ..... .... .. . .. . . .. °�'sSL�'�� '. ��., �°�1�i ��+ �IE �� t'�'3�� tC��.r'�1 � �+`�I�i �� ,�� 3�.e��`�N'T' Tax 11+Yap �3a Parcel # �-ll� Tovv�shi�: Appli�aut: ,�h'�r-c�al�, � c�) �`�i�� Subdivision: Lot # Location: Hurrl\e ��\\ �c1 �,� t�n ��e^��(R, �� `C"('ark � ��i� l�i � � ��21a� . L . '�y�� f �I�$�� S�n��g�: jc Iudividu�l � Cammun�ty P�ablic ]�a��aa��: Site Approved By: `� I? c.J o� oS�c>� Grou�ing Appra��ed By: Well Lag: � D1IIy1p iag: _ b ��o�b� �Iell Tag: . Air Vent: � Hose Bib: � Casing I3eight: �Concrete Slab: � / � Lis�er: 'Installed by: _ Depth set: _ Groutad: �3ate: �Tate� �ample: Weil Driller. !S2 ('�P't�"fe W e�� !'� 1� t� `� �Iell A�proved by: ��,�-ra�� f /C,,,�� ;::�:�� .�� $e 5��$��a*.;;; ;. �Vells must be 10 fee# fr�m praperty lines. ;Nalls must be 100 feet from septic systems. �Nells must be at least 25 fee# from any bl:ildi�g foundation. flther canditions: i�ate:, 0 ��bl.�� C7� r�� Ol!?7/C�� North Carolina State Laboratory of Public Health Department of fHealth 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: Torain, Shelton Address: 711 Leasburg Rd Roxboro, NC County: PERSON Zip: 27573 Report To: Person Co. Health Dept. ATTN: Jonathan Wiley 325 South Morgan Street (336) 597-2371 Roxboro, NC 27523 Courier: 02-33-15 Collected By: J WILEY Date: 9/11/2008 Location of sampling point: Well head Source of Water: Source of Sample: Type of Sa �il�� Type of Trea er�; u Type of A �13r�,is Time: 1:10:00 PM Remarks: Parameters Results Units Date Analyzed: Silver <0.05 mg/l 9/12/2008 Alkalinity as CaCO3 163 mg/l 9/12/2008 Arsenic <0.001 mg/I 9/12/2008 Barium <0.1 mg/I 9/12/2008 Calcium 40.0 mg/I 9/12/2008 Cadmium <0.001 mg/I 9/12/2008 Chromium <0.01 mg/I 9/12/2008 Copper <0.05 mg/l 9/12/2008 Fluoride 0.25 mg/I 9/12/2008 Iron 0.40 Y � mg/I 9/12/2008 Hardness as CaCO3 (Ca,Mg) 148 mg/I 9/12/2008 Mercury <0.0005 mg/I 9/12/2008 Magnesium 11.8 ' mg/I 9/12/2008 Manganese 0.34 ` r�g/I 9/12/2008 Sodium 11 mg/I 9/12/2008 Nitrite as N <0.10 mg/I 9/12/2008 Nitrate as N <1.0 mg/I 9/12/2008 Lead <0.005 mg/I 9/12/2008 pH 8.0 Std. units 9/12/2008 Selenium <0.005 mg/I 9/12/2008 Zinc 0.08 mg/I 9/12/2008 Date Received: 9/12/2008 Today's Date: 9/30/2008 Report Date: 9/30/2008 Ref: 12644 Login Batch: �-I E� D Pn a%�� Reported By: ��.,...., `�'� Y �� Sample Number: AB78137 Explanations Coliform Analysis: If coliform bacteria aze 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 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc r 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 In�orma�ion and Recommendations for Uses of New Priva�e 1lVells North Carolina Occupational and Environmental Epidemiology Branch (OEEB) For /�dditional Advice and Information call 919-707-5900 Name• 0�� Sample Identification Number: ��`�� County : 6�� Information on Your Private Well Water Your well water was laboratory tested for chemical contaminants listed in table below. Drinking water may contain chemical contaminants which can occur naturally or be introduced into water from man-made sources. In order to evaluate your laboratory results for chemical contaminants, your water results were compared to the EPA national primary drinking water standards or maximum contaminant levels (MCLs) (see website for basis for each MCL at http://www.epa.qov/safewater/contaminants/index.html#mcls). MCLs are national drinking water standards that are required to be met by municipal water supplies. If no MCL was available, then your well water levels were compared to North Carolina 2L Groundwater Standards. If the concentrations found in your well are greater than these levels, you should not use your water for drinking or cooking. Alternatively, you could install a water treatment or filtration device or use another source of drinking water such as bottled water or municipal water. Your well water was also laboratory tested for biological contaminants (total coliform and fecal coliform bacteria). Total coliform bacteria are found in soil and fecal coliform bacteria are found in animal and human waste. The presence of coliform or fecal coliform bacteria in well water indicates that the well may have structural deficiencies or that the well was not properly disinfected. Your Well Water Results Com ared to MCLs Your Well Water Results MCLs Arsenic 0.01 mg/L Barium 2 mg/L Cadmium 0.005 mg/L Chromium (total III and VI) 0.1 mg/L Copper 1.3 mg/L Fluoride 4 mg/L Lead 0.015 mg/L Iron* 0.3 mg/L Magnesium 100 mg/L and higher Manganese* ' � 3 � 0.05 mg/L Mercury 0.002 mg/L Total Nitrate and Nitrite (as 10 mg/L nitro en Nitrite (as nitrogen) 1 mg/L Selenium 0.05 mg/L Silver* 0.02 mg/L Sodium 20 mg/L Zinc 5 mg/L pH Desired range of 6.5-8.5 Total coliform bacteria ln order to protect public health, coliform Fecal coliform bacteria and fecal coliform bacteria should not be resent. _a...a u inc crn rvn,� waa n�iavauauic �iiuv.iirivvrv.cva.vvvi�uicrvu�c�iw��a��in�anuini�cn.�iu�a�*n�..��, u�c�i u�c ivviu� �.ai�iuia LL VIVUu4vruw� ......, were utilized. Form Date March 2008 �t`€$�C�c��f3t`� c��C.� ��:�f3��lC��ECi�� f�i" �..�� t�l �i'6'��G ��E'�� !' �ar ��-��ie �I�eE��l� �o��c� ia� ��e� i�arth Cara(ina Uccup�Yiar�ai anc� Environmentaf Epicsemiolog� Branci� (OE��} For Acidi�ia��{ t�civice ar�d Infarmatior� cali 9��-7Q7-590a t�ame• ��.c�� Informa�ion an Your Private 1�/ell 1�Jater G�`��c�D o- Your weil water was IaboFatory tested for incrganic chemicals. Drinking water may contain inorganic chemicals such as arsenic and manganese that can occur naturally in water or lead that could be introduced into water from man-made sources. Ir order to evaivate your laboratory results for chemical contaminants, your water results were compared to the national primary drinking water standards or maximum contaminant levels (MCLs) (see website for basis for each MCL at http://www.epa.qov/safewater/contaminants/index.ntml#mcls). MCLs are national drinking water standards that are required to be met by municipal water supplies. If an MCL was not available, your water results were compared to the health based North Carolina 2L Groundwater Standards. Recommendations for Uses of Your Private 11Veli VJater The concentrations found in your well water do not exceed the recommended EPA levels. �� Contaminant concentrations found in your well water are higher than the EPA recommended leveis for drinking and cooking. These contaminants include j�/cav►� 4U2I� Your well water should not be used for drinking or cooking. If you have been drinking the well water and are pregnant, nursing, or under 5 years of age, inform your physician of the resuits. Very little absorption is expected through intact skin. However, having open wounds or burns could result in a greater absorption of these chemicais. Therefore, ig yau have open wound§ or burns on your skin, limit showering and bathing time to under 5 minutes. You may want to purchase a water treatment device, drill a new well that is distantly located from the groundwater contamination, use bottled water, or connect to a public water supply. Resampling is recommended in months. Resample for lead. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead. Other Comments North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047 COLIFORM ANALYSIS - PRIVATE WATER SUPPLY Name of Owner or Tenant: Torain, Shelton County: Person Address: 711 Leasburg Rd Roxboro, NC ZIP: 27573 Source: Well Type of Sampling Point: Well head Collected By: JW Date: 9/11/2008 Time: 1:10 PM Signed By: Wiley, Jonathan Analysis Type: Private Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27573 (336) 597-2371 BACTERIOLOGIC ANALYSIS CONTAMINANTS RESULT Total Coliform (ColilertRoutine) Present Fecal/E. coli Absent Sample No: AB12680 Date Received: 9/12/2008 Time Received: 9:00:00 AM Date Reported: 9/15/2008 Today's Date: 9/15/2008 �/,y� Comments: New well Person Co. Health Dept. ATTN: Wiley, Jonathan 325 South Morgan Street Roxboro, NC 27573 Courier 02-33-15 In�'�rma�i€�� a�d F�:ecc�mn�encia�i�n� for lJses o� �riva�e �efl �a��r For B�o�ogica� Contaeninan�s �ound i� 1li�afe� North Carolina Occupational and Environmental Epidemiolagy Branch (OEEB) For Additional Advice and Information ca{I 919-707-5900 Namdx °�� Sample Identification Number: I"rQ��d County : ��fb� Information on Your Private Well Water Your well water was laboratory tested for biological contaminants (total coliform and fecal coliform bacteria). Total coliform bacteria are found in soil and fecal coliform bacteria are found in animal and human waste. The presence of total coliform or fecal coliform bacteria in well water indicates that the well may have structural deficiencies or that the well was not properly disinfected. Recommendations for Uses of Your Private Well Water No coliform bacteria were found in your well water. Therefore, your water could be used fcr drinking, '�°� cooking, washing dishes, bathing, and showering. " bacteria were detected in the resample which indicate that —�--� Total coliform and/or fecal coliform pathogenic bacteria from human or animal waste could possibly enter the well. There may be a problem with the construction of the well, the water source, or operation of the well. The�water may not be safe. If you have been drinking the well water and are pregnant, nursing, have a child in the household under 5 years of age, or immunocompromised (such as an individual with AIDS, cancer, hepatitis, dialysis or surgical procedures) inform your physician of the results. The well needs to be inspected by the local health department or a local well contractor to determine the problem with the well and to give guldance on how to correct the problem. You should resam�le your water after proper well inspectlon and disinfection to make certain that the problem does not � recur. If the contamination is a recurring problem, you should investigate the feasibility of drilling a new well or installing a point-of-entry. disinfection unit which can use chlorine, ultraviolet light, or ozone. V .—o qther Comments Do not use the water for drinking, cooking, washing dishes, bathing, or showering unless you boil it for at least one minute. May 2008 s -e " � North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047 COLIFORM ANALYSIS - PRIVATE WATER SUPPLY Name of Owner or Tenant: Torain, Shelton County: Person Address: 711 Leasburg Rd Roxboro, NC ZIP: 27573 Source: Well Type of Sampling Point: Well head Collected By: JW Date: 9/11/2008 Time: Signed By: Wiley, Jonathan Analysis Type: Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27573 (336) 597-2371 BACTERIOLOGIC ANALYSIS CONTAMINANTS Total Coliform (ColilertRoutine) Fecal/E. coli Sample No: AB12680 Date Received: 9/12/2008 Date Reported: 9/15/2008 Today's Date: 9/15/2008 Comments: New well �`� ' RESULT Present Absent 1:10 PM Private Time Received: 9:00:00 AM �. Person Co. Health Dept. ATTN: Wiley, Jonathan 325 South Morgan Street Roxboro, NC 27573 Courier 02-33-15 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 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Ivot less than 6.5 units 5.0 mg/1 D��-�ZG� � � a, � t3v�n e�-� 1� G11 I�� II � �S o� o�DODa�I _R-�r� � g , . .. Qwaer_ S�`c� k�`-� �,��ur GroIIt Log - T-4L o / Tau�. Map �� Parcel # Z�f G �:dilOtl: �7 U � � 7 -^� % �GG �t (. �/lQ V i � !� % fY� L subd�v�sl�: Lot # � WeII Consttnction Distance From n� Pmpeity Line (]1�inimum 10 feet) �(� Distance fi�omSeptic Sysi�em (M'mim�nm 60 feet) 6 O� Total I3epth: Zon ft Yeld: I�L GPM - Static Water LeveL• Z- �� $ Wafier Beazing Zone� Depth 1 y D ft ft ft $ � - - , De�: From . O to 6� #�. niameber: �'�`'I in � - Z`ype: Gal�rauuived St�eel �� . - Weigh� 2 clmes� . Height above Gro�md: _ in - ; Drive Shoe: • Yes No Any problems encotmtened wh�e setting casing� Yes If `syes" give reason: ' G�ra� - . . _ • . No • Neat Sand/Ce�ut Conq+ete GraveUCement - '- i�nnul,ar Space Width • mohes Waber in Affiulaz Space Yes ' No Meti�od of Gmu� Pumped Pr� � Poured Depth ' to Ft Mate�iais IIsed� - . Ianer: No. Bags Portland cemeut ' If mndune (sand, gravel, �ng) — Rati ID p1a.� _ Yes _, Na Weight o� 1 Bag Pamds o to 4x4s1ab_Yes_No - .:,. �h: Date Insialled: Grou� �nsiaIled by:� Dri�iag Log Location Drawing F�+om fio RormAt�oa . - � � 0✓tr �j�r��. . � Zp � rt I c�G(!• • . - , - _ � � , � , . �� C� ��C �OV+�' ]I�O�[� 1S �t 9II� � i�IS WCll �V�S C�$'� I!1 �CCOY�IICC WI�l 1�t1�110I1S SP.t ��1 E�jI � �CI'S0Q �II�j/$C3�1 �I�tl#. • . �e of cu�xa�ar �- /�i - m # �5Z G 7 � , � - �/ � n � _ � Pamp In�me�tt Pt�p InstaIIation Conbrac,�: (3 a �n c f-1� W c t l 1�� ( �; n�_ state R�ation Numbcr: 3 z G�� Pump ."�..,- �'Z n $ SYahC W8%a' LCVel: z S� $ � � �t Nt«�e1: � � �. �'U � lfer �, si� � x� _ f l—z � � � ��Y �fy t�t t�s p� was insattea a�a t�e weu I�a c�l�d a�d�g to t� Pe� c«mty weu R�i� m eff�t xi t�is dabe and ffia# a c�py of �is �coi+d has 1�een p�nvided to �e weIl owner. . �P �' � //�" " �� . . Dat� r�• �i- PCHI? rev Ol/27/04 � V � � ro �