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A32 42Application Date: � �"�� ^� � Amount Paid: 0, Ov Receipt #: �( 3y ,�� 0 Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) Mobile Home Replacement or Building Addition � i 50.00 (if site visit required j ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ��, sf ��I�� 1 ' � �� I�.:�-� an-�a,,,.,�„��n�,�.11 IHt��.11�,]k� Services for Services � Construction Authorization _(Fee is dependent on the type of ❑ Permit Revision $75.00 Tax Map: r� 3'? Parcel#: �l. � � -}- U � �a 1 ,ue e�- ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: /"f�c�i�-�� C./�i.`-� Address: (� Y� ..�, � /� �. b� �/� �,�j� �� s�� 2) Name and address of current owner (if different than appGcant): Name: �� ,.►; �.�- �„��. Address Phone (home): (work/cell): �y y7(� Phor.e: 3) Property Description: Lot Size: Subdivision.: Lot #: Address and/or directions to Property: I ,,-�/� �✓ //� �?Q � ❑ yes Ca-ifo Does the site contain any jurisdictional wetlands? �❑ no Does the site contain any existing w tewater systems? Cl yes � o Is any wastewater going to be ge erated on the site other than domestic sewage? ❑ yes C�l-na Is the site subject to approval by any other public agency? ❑ S�es �' 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: �Residential �ew Singie Family Residence Maximum number of bedrooms: ( � Expznsion of Existing System If expansion: Cu�rznt r;amber of bedrooms: ❑ Repair t� l�ialfun�t:oning System Will there be a basement? 0 yes L�tiio With plumbing fixtures? ❑ yes C�� ❑Non-Residential Type of business: Mzx:m�::r.lumber of employees: Total Square footage of Building: i�aximum numbe; of seats: 5) Water Supply: ❑ New well ❑ Existing Well �Q Community Well � Public Water � Spring Are there any existing wells, springs, or existing waterlines on this properiy? es ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0 Any I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invali�! * Supporting documentation required. C�.s"��— Date Permits are valid for either 60 months or are non-expiring 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) �e hG4� . � .� � � � ' -�°'{ � � - C� � �T�'�'�Y �.�.��:�.. �:��.��.�. ]I�t��Il�. ��. . Building Additions/ Mo6ile Home Replacements Tax Map #:_ 3 2. Parcel#:� Address: _�D I S� �ur��r lu�'1/_s R�. Approval Requested for: Mobile Home Replaceu►ent � S�e Connm�n}s p{- bof�m Building Addition . Applicant Name: c� �I- e..1 �' J�a Address; �l � � - i . • • � � ' '� �► . Permit Located: �✓ Yes No Installation Date: /a — 22— (�9 Design flow: 3�0 (gpd) Current Contract wi±h Certified Operator on file (if required): � Water Supply: � Well Public ar Cammunity Wastewater system shows no visual evidence of failure on: �- �—� �'�_ (date) (Applicant's signature if site visit is not required) �ddition/Iteplacemen� t�pprov�d .,�- Envi onmental Health Specialist 7- 7-/5 Date � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 �`��,sf ��I�.�� --�- �c � �� IE��-��:�.Il 1H[��,.Il�]� SITE PLAN Name r � n,�1'.Jvr��an Tax Map #� Pazcel #�Z Subdid ' Section/Lot# A 7 � — S A thorized State Agent Date System components represent approximate contours only. The contractor mustJlag the systemprior to beginning the insta[lation to insure that propergrade is maintained 1 �L �f/ � _. . __ �_�i�l�.__ Ltli��_To__�1�. �04'11�� u � _ _ _ _ _-- --__ _ — --- �Zx�shnq 36P. s�pfi� sYsk . B�'t'ore av►yon�.J Mo�eS info ('ena�a(tc� -�rM %�e �r��s�tioa ��te: � ��-2� �) y �``'��j 1[: 1Le1��1e��ll� � Amount Paid: Oc�, U `,.,: • Receipt #: 19 30 H � � �� IE��s��.Il 1E33[��.Il� �� a � � Application for Services Services Re uested 0 Improvement Permit (Site Evaluatloa) 0 Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the ty e c 0 Mobile Home Replacement or Bnilding Addition ❑ Permit Revision ❑ Well Permit (New/Replacem $300.00/$200.00/$75.00 "'a� 1Fia;i: ,�'3� Parcel#: � ce c� � � �� D� N �� 6 � t�Z 9'a � -j-� ystem erndtted � �� G ❑ Repair of Existing Septic System Application. No Charge/ CA $150.00 or $300.00 1) Applicant Information: � Name: � r�e /� c G r�� Address: b (e M� (e +� < < S� C , �.�5�/ � 2) Name and address of current owner (if different than applicant): Name: � Address: Phone (home): (work/cell): fc�f I `t \ �/5 —� �4 Phone: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: < ❑ yes ❑ ao Does the site contain any jurisdictional wetlands? ❑ yes O no Does the site contain any existing wastewater systems? O yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage7 � yes � no Is the site subject to approval by any other public agency? ❑ yes 0 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: r OResidentiat � ❑ rJew Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: � F�epair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ONon-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or e�tisting waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: �6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted � Innovative 0 Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccur te, the site is subsequently altered, or the interrded use changes, all permits and approvals shall be invalid. � ` /� � / Signature (Owner/ L I Representative*) Date �` Supporting documentation required. Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompauy any application requiring a site evaluation. .. (10/IS) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790) �..��,s� ��.��v ~-- � � ��°�� IE�.�.��.m��.�.Il IE33C��.11� Tax Map: � Parcel: -�� Subdivision: WELL PERNIIT (New�% Repair_) Lot: Applicant's Name: � �' G � Mailing Address: �p . . � �� Phone Numbers: C� � 9-� [S—h�b 9 Location of Property: Permit Conditions: 1.) See attached site plan for proposed well location. 2.J 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: _T�� i1/1l�� ;��/� ;rV /r�.�- � A 2 �� Permit issued by: Date: �� . Tew Well: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: EHS/Date -�s t -2�-(� �3/�� Well Driller: �,rn� Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Raxhoro, NC 27573 Certificate of Completion OLiner: • EHS/Date Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: Z i Date Results Mailed: r' Phone:336-597-1790 Fax:33C�597-7808 il/26/13 `" A / Legend � E-911 Addresses Easements — Conservation — Easement — Utility — AllOther Person County Environmen�ai Health 325 S. Morgan Street Suite C Roxboro, NC 27573 �� //•!f?�"/�% 11/22/2017 NOT FOR LEGAL USE / ��= �D � N A Feet 0 40 80 120 160 0 0.008 0.016 0.024 0.032 Miles WELL CONSTRUCTION RECORD (GW-1� 1. Well Contractor Informa6on: �� (K a�vi�,�`7 :t Well ContractorName � 3 76 �� NC Well Conhauor Ce[tiScation Number Barnette Weli Drilling, Inc. Company Name � � � 2. Well Construction Permit #: List a!! applicable well construction pennus ('�.e_ UIC, Counry. State. [�arim�ce, etc.) 3. Well Use (check well use): Water Suppty We1L• i � I For Intem i Use �Jnly: � I I . I l4. WA1'ER ZONES FROM !TO DF.SCRIPT[ON r�. ; 3 � "' !O 'z �'�• �/3 `� � � l5. OU7'ER GASIN for malti<ased wells �J � I(�3,fti s�BR,n. �MunicipaVPublic � fti I (Heating/Cooling Supply) x�Residential Water Supply (single) f�; i ommercial �Residential Water Supply (shaze� 18. CROUT ! Noo Water Supply Well: Recovery �Aquifer Recharge �Groundwater Remediation �IAquifer Storage and Recovery �Salinity Barrier �Aquifer Test �Stormwater Drainage �Experimental Technology �Subsidence Control �Geothermal (Closed Loop) �Tracer �Geotheimal (Heatin�/Cooling Retum) [�Other (explain under #2l Remarks) 4. Date Well(s) Completed: —� We►1 IDl� /� J� Sa. Well Location: _ ��eil. /�C / e Faciliry/Owner Name � ' Facility ID# (if applicable) �O< ! �� l �, �'1 %/lS Q� - Physical Address, Ciry, and Zip �i� � ,$ p� � Z County Pazcel Identification No. (PQ� Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one ladlong is sufficient) 36 •�.6 .3�" T N 7�•0 S 7 I� W 6. Is(are) the well(s) ermanent or �Temporary 7. Is this a repair to an ezis6ng well: �Yes or ��i If this is a repair, fil! out /arown wel! rnnstruction information and ezplain the nature of the reparr under �2l remarks section or on the back of this form. �� 1 JR L NER if a inWe 1m C�civess MnrEwni. .� zc lic. al clo ed-luo CKNESS MATERLIL � i �p; f�- GraveVicement ti, j ft , i fG � fL D/GRAYEL PACK �fa idbk � TO M11A7'6RfAL ft I R. fG ! h. � D f� i � fw 3 fz ,' 2 �. 2 ra t�v c�. rCd tc. ,j S,c�i rc. tc. te. ft tt. ft, fG � i � � � 22. Certitication: I i � ,�. /�-28 -�.� Si�ature of Cj ti5ed ell Contractor Date By signing this form, hereby certify that the wel!(s) was (were) constructed in accordance wuh 1 SA NCAC 02C . 100 or !SA NCAC 02C .0200 el! Construction Slmrdards and that o copy ojthis record h berr provided to the well owne . ! i 23. Site diagram o additional weil details: 8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the b ck of this page to provide dditional well site details or well conshuction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells �nstruction details� You may also attach addit snai pages if necessary. drilled: SUBMITTAL INS 9. Total weli dept6 below land surface: /�� fk) 24a. For AII Well For mulciple wel/s list a!! depths ijdifferent (esample- 3Q200' and 1(a3100� ConstruCtion Ito the '. 10. Static water level below top of casing: 25 � (ft) j Division Ijwater leve! is above casing. ��se "+ ^ i 1617 11. Bore6ole diameter: � (►o•) 24b. For Iniection Air rotary �o�e, also submit 12. Well construction method: construction to the (i.e. auger, rotary, cnble, direct push, ecc.) Division,of Wa FOR WATER SUPPLY WELIS ONLY: ' i 1� 13a. Yidd (gpm) d Method ottesr B��W� ZO Mifl. 24�. Fo� Water S the address(es) a6 13b.Disinfec6on type: Chlorine Amouor 1/4 Cup completion of wel where constivcted. Form GW-I North Carolina Depacement of Environmental Quality - Division < Submit this form ater Resources, Ic I Service Center, l Is• In addition to copy of this form Resources, Under� ail Service Ceater, ve, also submit one construction to the c Resources 30 days of completion of well ion Processing Unit, , NC 27699-1617 the form to the address in 24a 30 days of comptetion of weU I Injection Control Program, ;6, NC 27699-1636 n addidon to sending the fortn to of this fom► within 30 days of health departrnent of the county Revised 2-22-2016 ,��.. � : � The �,Di;s�ric�--Health ;Depa��rr�en�- � _ Orazige; Person;!Caswell; �Chath'am. Lee C unt�ies ` .. � � �,. . � ' � ,_ .. . : . >. ,�,� . .. � _ �. �; i .. � ��..� � SEPTiC 7'�►NK PE � �'IT; ; � �� . � , .� , � /� Da "' '� : � Name of owaer: � � ; : � Nazne of coatractoi• �� ' � 3 �/� •r, j Address and DireRctions � i.� � I C� lY 1!!�� _ � 11 N � . � . / r Person or firm doing installata�n: � �� : �,aa�s � � t �� No. of persons to be serve � Bedrooms�l��2, 3�3. ; Additional appliances to�u�b�e used: Disposal� dishwasher,..,�„washing i machine �.._� �,�� : � i - � .,.�... � � , Recommended• � }� Septic tank � �� Q'� I I 'I �� f , t �� , �_ : Nitrification line;t - �-"" i .. � � Above recommendation based on,infoiuiation received and oLiserved soil condition. Sepxi_c,�tank,and nitrification line must be inspected and approved by a me:nber_of the�Distsiet Health Department siaff�before any portion of the installation is covered. � � � �� ,�� Date Approvedr %o- =�,r . � . . � ,C'',+.�� . . . S . . '... .�+.p� Sl�e� � '* Sanitariaa � By _ A� -. �.+ O. David G � arvin, M.D., M.P.H. _ District Health Officer � - � • V ...... _ Countersigned ; , . , . . . _ (Over) . � _ _ . _ �� , s -- _ _ _ __ - ---- __ ------_ _ _ _ _ _ - - -. . . _ _ _ ul�. � � o � N � N ""'r . �� N� �� 5� ' d .� o 0 � � � r. ? � 0 ,,�, � pW�,' " .� � H :� �� +_ � °J � � .� .� � � 0 o .� w � � � � � � �� o� �� a� 0 �� ' � � • �. c� ci d d � � � � Qo ° � zo .� p HWr' i� � � � , m � � H � �.� � � cba � w N � ! H � O � z � � ■��'� ��n��l■ ��n��■ ��■■�� ,� ■■�S ■■��. �� ■■.■.■,�■ ��.■�■■■,�■ ■.�;��,■■ �� 5�� ?�� ,��■ ��ei�� r�l��■�� 1�� u��1� ��::�� ;�� ■■��■■■ � ■�� ■��1��■ ■�i■ � ■��■■�■��■��■ ■�ti��s�■ ■■��■��■��,�� I ��. �� ■■��■� ■�� ■�f��l��1� ■�►� ■��s��■ ■�� ■�■ ■�� %�■�■ �fr��i■ � �■■■.�■.■��■ , ..2�,�� `'�03�'� ,1 � f` 11'��1'.� ��V Apptication Date- � 6, d �,� 4 I �►mount Faicl: a06 . �� ""'"' „"' � ;x'`� �� Recei�rt #: � a a �7 �^��'�� .. —�—�---�---- �# /oO�un•is�naaac-an4.�a� :E—;Ii-en�2:�n Q,,red� 1' � a�,b� 3 36 - 59�- - t�-9t� cO`'� �}pp�ication for Services , Imp t Permet (Site Evataatipn) $200.00 340.00 if> 60�L Mob► e ome Replacement or Buitdin� �ISQ.04 (if site visit reciuired) Well Permit (New/Replacem $300.001�200.00/$75.40 Tax Map: Parcet#: 2 Sex�vices Re uested Construction Autbarization ee is d ent an the e of stem rmitted Addition Permit Revision $7S.d0 � Repair of Ex.isting Septic System Application: No Charge/ CA $I50.00 ar $300A0 1) ApplicAnt Information: � . � , �_ Name: v � �c�ii�rt hone (home): Address: � (worklcetl): c�( t �? 2. � s 2 � ( � � . 2) Name and address of c rrent aw�ner (if different t6an applicant}: Natne• c Phone: �-- � �� d�-O Adclress• (., �e�v h�; r�'��..� .� �_„_ , i 3) Praperty Deseription: Lat Size: —.�.U,�c Sut�division: Address and/or directions to Property: i 0 t � lLot #: ,._ �� U G � yes � no Does the site contain any jurisdictional �vettands? ❑ yes �no Does the site rontain any existing wastewater systems? ❑ yes no ts any wastewater going to be generated on the site other than domestic sewage? �Q �� 0.� a ❑ yes �,no Is the site subject to approval by any other public ageacy? l,� O yes �no Are there any easements or right of w�ys on this property? %� ( (if `yes' is checked, please provide supporting documentation) �C'T� i�� 1) Propased Use and Type of Structure: L7Residential � ,� New Singte Family itesidence Maximum number of bei3rooms: [7 Expansi�n of F.�cisting System tf expansion: Current number of bedraoms: CJ Repair to Malfuttctioning System �Vill there be a basement? � yes j&i no With plurnbing fi�hmes? ❑ yes ❑ no L7Non-Residential Type of business: Ma.Kimum number nf emplayees: Tatal Syuare foatage of Building: _ _. Maximum number of seats: 5) Water Suppty: � New weil ❑ Existing Well ❑ Coinmunity Well C7 Public Water ❑ Spring Are there any existing �velts, springs, or existing waterlines on this property? D yes C) no b} If applying for `Authorization to Constract', please indicate preferred system type(s): (�j Conventional O Aecepted CI Innavative D Alternative ❑ Clther CJ Any 1 certifj.r that the infarmation provided above is cvmptefe arrd correct. I alsv understand that if the information pravided is inacc ra�,-or if the site is subsequently altered, or the intended use chunges, all permits and approvaXs shall be invulid. r' ' /j�' ' 'a... Signature ( svner/ Legal Repres tati ) Date * Suppnrting d�umentation required. • Permits are valid for either 60 months or are non-expiring w6en acconspanied hy an approved ptat. • A completed `Lnt Prepurntion' form must accompany any application requiring a site evatuation. ��, s� ��.� �� { � � �� ]C��.u-��.�,m¢�.li IL��.Il�I� Appiicant: Address/Lc Tax Map: �� Parcel•� Subdivision Phase/Section/Lot # 1�l Irriprovement Permit Permit Valid for: Five Years Non-expiring Type of Facility: ' New �Addition _ Number of Bedroo �/ Oc upants Employees / Seats: Proposed Wastewater System: ,S Proposed Repair: �e�c�� y/ �--- - ' -- - _ - . - - � . _.. � ;: Water Supply: Projected Daily Flow: $0 gallons/day Type: Type: � PermitConditions: �P�� Sub;p�f � Fl�(- /{;ve�r a�CrS{►�d ��I�ur�,ar�cc. �u�.rc Authorized State Agent: Date: Jo-7-/S (X) Owner or Legal Repre entative: Date• l 1 The issuance of this permit by the Health Department does not guarantee the is ce of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement 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 mrrl Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai Health Specialist warrants that the septic system witl continue to function satisfactorily in the future, or that the water sapply vvill remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (✓ Proposed astewater System: �P tCf�On �/� (*)Type Design Flow g0 gal./day New � Repair _ Expansio � Soil LTA� Z gal./day/ft2 Type of Facility: S; �(Q ��(u_1'� - Basement: _ Yes No ��r— (*) Systern Types Illb, II18g, IV, and V, reguire pPriodic system inspections by the Person Counry Nealth Department. Wastewater 5}�stem Requirements Tank Size: Septic Tank � ODb gal. Drainfield: Total Arza �� sq. ft. Trench Width �_ ft. Purnp Tank gal. Total Length 4 R D_ ft. Max. Trench Depth � in. d.C. Min.Soil Cover � in. Min.Trench Separation __�__ ft. Distribution: Distribution Box Y/ Serial Distribution ✓/ Pressure Manifold ^vrease Trap ---- gal. Specifications: _ D-�ox or Ser�e � c� i5f,r��u}�,� r's OK ; S� d-�ox a►'��a�� ,, lr,�e5 Agent: �/,,�-' �j,____--�! Issue Date:1�-4'!5 Permit Expiration Date: �D -Q�2d The system permitted is: Conventional /Accepted �Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: ` Date: �( � Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph.• 336-597-1790 (rev 5/12) ��,Sf ��$.��T `--�= � � �� .��.� ��.�� SITE PLAN Name G '� J�a„ Tax Map #� P•cel #�2 _ Subd' isio Section/Lot# /0 -/p,.-ts uthorized State Agent � Date System components represent approximate contours on[y. The contractor must,/lag the systemprior to beginning thE installation to insure that proper grade is maintained _ __. __ --....__ __. _ _ _ _ _ _ � _ _ _._ __ -- _ . _ -- - ------ — _ _�` _ - `,` .l.y„�-;a Sicr� , \ .`, — �SD GP� �1 �3R �� ct ; `,�g� ,1 684 - _ .__._ _____- _/� � ��a �� nC.� �r� 1 d isf+n�� D- ba�c or S{��a l oK; =.F .d-1ooX �"p�„�k►�n �� f , � ,� - l e,q GA I''"t�N�N1 � �AtLS � ^ . :0 _�..._.._.,..�____.. 692 .�---� �� ' �Y _ ___. i� ._J .i�� in � 0 a� / . - __ ....___ i�2 � .�� N ^ � 0 �\. , 50 100 , ,�st. . ,�� . o� � -;�--- ; ,� I , � _ � 200 d� \� ��6 300 F � �5� _�_Jr_. �� 1 inch = 100 '� a �f ��. sf ��.� �� I��.�a� � ��.Il I�3L ��.Il�I� Applicant: Location: O�eration Permit System Type (From Table Va): � Type V& VI Expiration Date: Tax Map� Z Parcel # �Z Subdivision Phase/Section/Lot # # of Bedrooms Product (IIIg): �iZ �o � Type V 8c VI Renewal Date: 1, 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 Authoriaation. � nc ��'� �� tl.horized Ag�nt) �. G�( �'c� y ense Contractor) V Scale 1� �� PCHD, rev. 12/14/12 ��-Z� �� (Date) � �23� r (Date) � CQ►�'�— Y�ttr w'-e� S`� d u�- l�e t- Line Length �, z Qd � 3 120' r�� S �.� � Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� Noies• System Type:.�'� �2 Pump System Checklist Pum Ta�k Iatitial/Date State ID & Date: Ca a�ity: Riser (6" min.) NEMA 4I� Bo� Model: Piggy back lug Hazd wired Alazm functioning Mounted on ost Above grade (12") Conduii sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• W1�.LL I;VPIJ11tUl:lllllV Kr:I:VKl) T6is form can be used for single or multiple wells 1. Well Cont r Ioformatio�� V 1 - , ro �: Well Contractor ame �17� NC Well Contractor Certification Number ��s6�--�—`�� -��--^-� Gy Company Name 2. R'ell Construction Permit #: List all applicnble well permits (i.e. Cormty, State, {�miance, etc.J 3. Well Use (c6eck well use): Water Supply R'ell: �Agricultural ❑Geothermal (Heating/Cooling Supply) ❑IndustriaUCommercial Non-Water Supply Well: OAquifer Recharge OAquifer Storage and Recovery OAquifer Test �Experimental Technology OGeothermal (Closed Loop) OMim �pallPublic esidential Water Supp]y (single) �Residential Water Supply (shazed) ❑Groundwater Remediation �Salinity Barrier �Stormwater Drainage ❑Subsidence Control ❑Tracer OOther (explain under #21 � 4. Date Well(s) Completed: 2- ��-,(�„� Well ID# Sa. Well Location: ('.�-.rcU /''1� G► l,�e� �c.� �� FI3 Z acility/ er Name � Facility IDtk (if applicable) � t% ll7 � �ac.. r'[�l �8 / l i�� R G( Physical Address, City, and Zip ��son �7 ��ty Parcel IdentiScation No. (PII� � Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one laUlong is sufficient) N W 6. Is (are) the well(s): C�� anent or OTemporary 7. Is this a repair to an eaisting weli: ❑Yes or �o Ijthis is a repair, fill out /rnown we!! construction information and explain the nature of the repair under #21 remarkr section or on the back ojthis form. 8. Number of wells constructed: / For multiple injection or non-water supply wel[s ONLY with the same co�u�uuction, }roa can submit one form. For Intemal Use ONLY: �. Certification: � (Q �/` ''� .�,— ll ��b Si�a f Certified Well Contacror Datc Bv signing this form, I hereby certrjy that the well(s) was (were) constructed in accordcmce with I SA NCAC 02C .0I00 or /SA NCAC 01C .0200 R'e!l Construction Standardr and that a copy of this record has been provided to the we[I owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well constructio� details. You may also attach additional pages if necessary. SUBMTI"I'AL INSTUCTIONS 9. Total well depth below land surface: �� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multip[e wells list al! depths if different (example- 3�00' and 1(a3100� COIIstruCtlon to the follOwing: 10. Static water level below top of casing: �O (fG) Ifwaterlevel is above casing, use "+" / 11. Borehole diameter: � �� (in.) 1Z�'e�l construction method: /.i �� s n. (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELIS ONLY: 13a. Yield (gpm) �V Met6od of test: /7' /' 13b. Disinfection type: �i. % . � Amount: �j �s Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniection Wells ONLY: In addirion to sending the fortn to the address in 24a above, also submit a copy of this form within 30 days of completion of well const�uctioa to the following: Division ofR'ater Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Weils: Also submit one copy of this form within 30 days of completion of well wnstruction to the coimty health departrnent of the wunty where constructed. � s ��.�� .. .� .�: ��-�� I��.��.m��.Il lE3L�all�]En. WELL PERMIT (New� Repair_) Tax Map: � Parcel: �2 _ Lot: � Subdivision: N Applicant's Name: isr c �b ' ,r d� n 1Vlailing Address: l� G'� 71 Phone Numbers: 9�Q A 1 S' ��O . . ..�,r � I_. _I�. ., � -Jl� ,Q�I. 7 � Location of Property: Permit Conditions: 1.) See attached site plan forProposed well location. 2,) A11 upplicable S'tate and County reSulations governing construction and setbacks apply 3,) Permits expire S years from the date of rssue. 4.) Issuance of a permit does not gucrr'antee a potable water supply Other Conditions/Comments: _.� �fw � 1 Se �_ Permit issued by: ( 1ew Well: EHS ate Location: � o Grouting: 'Z�� OU`"� Well Log: �— � Date: %D��Z �S Certificate of Completion QLiner: EHS/Date Depth: — Grout: — Well Tag: _— pump Tag: ____-- Air Vent: _--- Hose Bib: _-- Casing Height: __ Concrete Slab: �— Well Driller: �' `�� a � Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: DAbandonment: Date: ---- Method/Materials: _ License #: �— License #: �— Date: �-- Date Results Mailed: Person County Environmental Health , Phone: 336-597-1790 Fax: 336-597-7808 325 5. Morgan St.,Suite C 11/26/13 � North Carolina State Laboratory Public Health Environmental Sciences il�icrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02�3-15 StarLiMS Sample ID: ES072915-0061001 � �� u �� u �� u�� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: MICHAEL WHITT P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh. ncaubticheatth.com Phone: 919-733-7308 Fax: 919-715-8611 10185 HURDLE MILLS RD HURDLE MILLS, NC 27541 Coltected: 07/28/2015 10:00 Received: 07/29/2015 08:02 Sample Source: Well Sampling Point: Well J Smith Susan Beasley Well Permit Number: A32-42 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colile�t Present Denise Richardson 07/30/2015 E. coli, Colilert Report Date: 07/31/2015 Absent Explanations of Coliform Analysis: Denise Richardson 07/30/2015 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. 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: MICHAEL WHITT P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slqh. ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 10185 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES072915-0051001 Date Collected: 07/28/15 Date Received: 07/29/15 Sample Type: Raw Sampling Point: Well Sample Source: Well Temp. at Receipt: 3.5 Sample Description: Comment: Time Collected: 10:00 AM Collected By: J Smith Well Permit #: A32-42 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 32 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.23 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 10 mg/L Manganese 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L PH g,3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.10 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 123 mg/L Total Hardness 120 mg/L Zinc < 0.05 5.00 mg/L Report Date: 08/05/2015 Page 1 of 1 Reported By: Arno/d Holl � � �� w�� ..�-..,�• s�'�+ � � � �..'' �� ]U7t'6�A�'QD7CIi]CiC}hsDlCbtEaTzt� 1(�:�eQ•�7h�Lt��CIL Date: 2-- / � `� / � � � Name: �� cGi �� Address: � � �' 1 S � ��.� ,�ir � 7 -�� Re: Bacteriological Test Results Dear Well Owner: Tax Map: 32 Parcel: 42 �� Your well water was sampled on 2/ ��/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: No coliform bacteria were detected in the sampl.e. Your well water is safe to use for drinking, cooking, washing dishes, bathing and sho.wering, based on the bacterialogical results only. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in.the sample. Total coliform bacteria ar� naturaljy found in the soil. Fecal coliform bacteria arz associated with animnal and/or human waste. Tha presence of either total or fecal coliform bacteria in well 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. If coliform bacteria are present in your water sample, the water �nay not be saje for us� Young children, the elde�•ly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A wedl that tests positive for total or fecal coliform bacteria should be pro,verlv disinfected and retested prior to resumin� normad 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, � �v�-2,✓ Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Em�ironmerrtzl Health; 325 S Morgan St., Sui[e C, Roxboro, NC27573, Phone: 336-579-1790, Far 336-597-7808 . •�:. _ ,.` <w North Carolina State Laboratory Public Health Environmental Sciences I�icrobiology 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: ES021418-0120001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: GREG MCGIBNEY P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://siph.ncpubiichealth.com Phone: 919-733-7308 Fax: 919-715-8611 10161 HURDLE MILLS RD HURDLE MILLS, NC 27541 Collected: 02/13/2018 16:00 Received: 02/14/2018 08:24 Sample Source: New Well Sampling Point: Well head Angela Heybroek Well Permit Number: A32-42 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present 02/15/2018 E. coli, Colilert Absent o2/15/2018 Report Date: 02/16/2018 Explanations of Coliform Analysis: 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. ✓' ,{ � � � i � ; , � r� . l r f ` 5. �.., � ;t j , .5z � ��, 1 � � � � Ef � � ; - r � " t� "�:(`� `�'` �; ; i =�`t r—� € � F 1 f ��6 S L.i �' << 5�1 II i �� i i./� i t i i�} �... ��, i � 4 � •�--••. . .--�•, � r-� ;�� ,-. r.;� ,, ,:--�.... l� �,-.0 .-,, ,-� - � �i � Y � � 'e. r� �--�� :._ � �__(p � `f � . � ��,tr t , �a) 1['� : , � � --� r- ; ' {�c� i t \•a .....'� �r" '�.�� ♦� Ll ��..1' �.=! E € a f � i ✓ 9l j ',i =J: i_ E �,t [ F �V �l For Inorganic Chemical Con�aminants County: �'o Name: � i �..e Sample ID #: 32- 2 Reviewer: r�f TEST RESULTS AND USE RECOMMENDATIONS 1. �Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinkmg, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. ❑ The following substance(s) exceeded federal drinking water standards orthe North Carolina 2L calculated health levels. 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). However, it may be used for washing, cleaning, bathing and showering based on the inorFanic chenrical results onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride Lead Iron Manganese � Mercury � Nitrate/Nitrite Selenium Silver Maenesium Zinc nH 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's�(USEPA) Health Advisory level for sodium of 20 mg/1. 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 washing, cleaning, bathing, and showering based on the inoreanic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, sta.ining of porcelain, etc. 4. ❑ Re-sampling is recommended in months. 5. ❑ Re-sample for lead and /or copper. 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 I S minute sample at the wel l 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 chemica! resu[ts onlv, but aesthetic pro6lems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Man�anese Selenium Silver pH Zinc For more informalion regarding your well water results, please cal! the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: C�i :Z Xrl �5 C�� I=3 . f�'1 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta:!/siph. ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 10161 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES021418-0063001 Date Collected: 02/13/18 Date Received: 02/14/18 Sample Type: Raw Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.5 Sample Description: Comment: Time Collected: 4:00 PM Collected By: Well Permit #: A32-42 GPS #: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 m /L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L ca�cium Chloride Chromium 26.00 < 0.01 < 0.20 250 0.10 Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese < 0.03 0.05 m /L Mercury < 0.0005 0.002 _ mg/L < 0.1 1.00 6.5 N/A 5elenium < 0.005 0.05 mg/L Silver < 0.05 0.10 m /L Sodium 17.00 m /L Sulfate < 5.00 250 m /L Total Alkaliniry 19 mg/L Total Hardness 34 m /L Zinc < 0.05 5.00 mg/L Report Date:02/23/2018 Page 1 of 1 Reported By: Deddie .�loncol