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A32 67Application Date: J� � 15� �� Amount Paid: �c�� , 00 Receipt #: 1�0�1 `�b� ❑ improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit reyuired) 0 Well Permit (lY�v/Benl���ment/Repair) ��,;.)f ll ����L.Yl V �.����� I��cav na-�n*,•,r,� �sa�.s.� ll�Cxi.�.]�4-.�.�a. Services for Services Tax Map: ,4� Parcel#: ls� -Ito �,arne�e � �`C`'� �(,.,_n r�� r'°.� � �J �� 0 Construction Authorization (Fee is dependent on the type of system permitted) 0 �ermit P.evisicn $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant I ormation: Name: L S Address: L - (� �, f� U 12 Y� L � `i�i r� ��.S %V � Z% l`/ � 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Lescription: Lot Size: � r?a�Subdivision: Addr�ss and/or directions to Property: (-�C�Q Phone (home): � 3(,- _��% �i 2U � wor cell): �/�/- h?�=�5�_ Phone: Lor #: ❑ yes n Does the site co ain any jurisdictional wetlands7 ❑ yes no Does the site contain any existing wastewater systems? ❑ yes io Is any wastewater going to be generated on the site other than domestic sewage? � yes � no Is the site subject to approval by any other public agency? ❑ yes io 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 � ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfi:ncticr.ing Syst�m �h�ill tk:ere be a bas�ment? ❑ yes io VG'itl: plumbing fixhares? ❑ yes ❑ r,o ❑Non-Residential Type of business: Maximum number of employe�s: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Weli ❑ Public Water 0'Sp�ri�n Are there any existing wells, springs, or existing waterlines on this property? L�es ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any I cert� that the informatian provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is sunsequentt'y altered, or the inienaea+ use cnanges, aii nermits and anprovais shail be invu�id. � c�.Q �--6. C�a.2� Signature (Owner/ Legal Representative*) * Supporting documentation required. S 1�-�2 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. i�ni� �� n,......,... /�,...«�.. �.....:..........�,.,+.,1 LTo�1�1, 27G C AiTnr�ran Ct c,,;rP � Rnvl�nrn 1�T(' �7571 (ZZ�_SQ7_17Qf11 ��� i �� ���� �� �.�-, �, ~ � � � � � � � I���.���.�-�����.11 I� 1I��.11�I�n. Taz Map: 3 2 Subdivision: W�I�L PERIVIIT (New�Repair� parcal• �0 Lot: Applicant's Name: �r' �V� � l �2r S Mailing Address: Phone Numbers: Permit i'onditions: Ij See attached site plan for proposed well location. 2) All an��licahl2 Staie and C�unty regulations gover;zing constY�action �nd setbacl�s apply. � 3) Permits expire 5 years from the date of issue. Other Conditions/Comments: - Permit issued by: I)ate• 5 �Z C�RTIF�CATE OF C�IVIPLE�'ION New Well Inspection: S/Date Location: �O Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: �✓ti'�'�� Pump Installer: w eiI rippruveu by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: T�ep+,h: Grout: Well Abandonment: EHS,�Date Completed: Method/Material(s): _ License #: License#: � � �ate: Date Results Mailed: '" Phone: 336-597-1790 Fax: 336-597-7808 snios �� ��� �l. � lE�mvw�iyam,�,�,,.,,�ana.�m.11 ]H[�mll�lia �iTE ��i?'i'CiI , , �" , Name ���✓R W���S Subdivi ' r'v� ✓�^C,/ Authorized State Agent TaB Map # 3�� Pa�cel #� . Section/Lot# 5 !� � � Date . � . ��Q�-�� e -�---- 1���-� ' . �c�K �- �� � �fl�C� ��� �t� � � � ��u�,b� u�l�- a�.��--s�� �,�.�s. r � ���- ��c,� c�� � � �,.�,. - � ��15�`�e. C��� ���� � (�r�r� tr'��s. ��� `�",'�f� 5 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and NaturaJ Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # �� � [Cj "'/� 1. L CONTRACTOR: ♦ .�N � e E . � �, Well Contractor (Individual) ame Bamette Well Driilina Inc. Well Contractor Company Name 6_11 Bamette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code . 3c 36 � 599-0015 Area code Phone number 2 WELL INFORMATION: WELL CONSTRUCTION PERMIT# � 3 Z OTHER ASSOCIATED PERMIT#(if appiicabte)� 6�% g. WATER ZONES (depth): Top�_ Bottom�Tgp Sottom Top� Bottoml�� pTop Bottom Top Bottom Top Bottom Thickness/ 7. CASING: Depth Diameter Wetght Material Top�_ Bottom�,� Ft._�?✓ 3A� � Pvc Top Boriom Ft. Top Bottom Ft. 8. GROUT: Depth Materiat Method Top_� eottom LC� Ft_ SandlCement Poured Top Bottom Ft. Top Bottom FL SITE WELL ID #[�f applicable) : 9. SCREEN: Depth Diameter Slot Size Material 3. WELL USE (Check Applicable Box): Residential Water Supply ❑ Top Bottom Ft. in. in. DATE DRILLED S" �� —/ Z ' Top Bottom Ft. in. in. Top Bottom Ft. in. in. TIME COMPLETED �� � AM ❑ PM �� . 4. WELL LOCATION: cmr fiu•R,�Ie f�: � l S couNnr a o Z 25 wolfe �� _ � 7s��. (SUeet Name, iJumbers, Community, Subdivision, Loi No., Parcel, Zip Code} TOPOGRAPHIC / LAND SETTING: (check appropriaba box) ❑Siope ❑Vailey (g�tat pRidge ❑Other LATITUDE 36 "�• U 3• d' DMS OR 3X.XXXXXXXXX DD LONGITUDE%f_�;(�� S6 •2,- pMS OR 7X.XXx�0o00oC OD Latitude/iongitude source: �PS �Topographic map (locabon of.welf must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OYVNER �� 2 fL�_iv R�1 te fL5 OHmerName Z zs w o l�e (��, ./�.,cA,� �,;.�( c Street Address 2 e-Stha �2.c.7 itJ G. 2 7 J`71� City or Town State Zip Code c336,_36x- zo�' Area code Phane number s. weu oera�.s: a rora.oePrH• Z B d b. DOES WELL REPLACE EXISTING WELL? YES � rv0 ❑ a WATER LEVEL Betow Top of Casing: Z.r FT. • (Use '+• �p,boye Top of Casing) d. TOP OF CASING IS �_ FT. Above Land Surface' 'Top of casing tertninated aVor below Iand su�face may require a variance in acxardanoe with 15A NCAC 2C .0118. e. �n�o (grxr�>: � d. nn�oo oF resr Blown 20m f. DISINFECTION: ry� HTH Amount 1/2 CuD 10. SANDlGRAVEL PACK: Depth Size Material Top Bottom Ft � Top Bottom Ft. � Top Bottom Ft : 11. DRILLING LOG Top Bottom : �/ /2. ���s _��/ ZOb / / / / / i I / / . / Formation Desaiption - Rc�c� c�.� v ?A�v / ( .4ti � ac«. 12. REMARKS: � i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ; ACCORDANCE W1TH 15A NCAC 2C, WELL CONSTRUCTION : STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN = PROVIDED TO THE WELL OWNER. � � \ • \ � / ���� ' SI TURE RTIFIED WELL CONTRACTOR vD(�1 �� ,�ti .�e x Pa �; : PRINTED NAME OF PERSON CO�STRUCTING� LL Submit within 30 days of completion to: Division of Water Qualityr - Information Processing, Form GW-1a �617 Mail Service Center, Raleigh, NC 276 9 9-1 61, Phone :(919) 807-6300 Rev.2/o9 . ... ....i-.� • .:. . . .r— . - .. .:.x... � . . . . . � . . � . . .;� . . . � _ -, North Carolina Division of Public Health . _ Occupational and Environmental Epidemiology Branch, Epidemiology Section BIOLOaICAL ANALYSIS REPORT � . . . , .. . , ..,,. � Private well water information and recommenda�ions Couti . �..-�ufb �1 Name: ��i � 1 Sam le ID Number: �� Y��3 � r Location: Reviewer 1� � Initial Sample • Confirmatio.n Sample . , .t BIOLO,GICAL ANALYSIS RESULTS AND RECOIVIlVIENDATION5 FOR USES OF YOUR PRNATE WELL WATER ('These recommenclations are based on biological analysis only.) � No coliform bacteria were found in your well water. Your water can be used forall - - purposes including drinking, cooking, washing dishes; bathing and showering. � Total coliform bacteria were d�tected in the sample which indicates that harmful bacteria from human or animal waste could enter the well. Do not use the water for drinldng or cooking unless it has been boiled for 3 minutes. You may use your water for all other purposes including washing dishes, bathing or showering. Your well water needs to be re-tested to verify that the result is accurate. Fecal coliform bacteria were detected in. �e sample. Do not use the water for drin�Cing, cooking, wash�ing dishes, bathing or showering. If the re-test shows contamination by bacteria contact your local health department for . assistance. There may be a problem with the conshuction of the well, the groundwater source, or operation of the well. The well needs to be inspected by the local health department or a local well contractor to determine the pmblem with the well and to give guidance on how to correct . the problem. - . Your well watez was tested for biological contaminants (total coliform and fecal coliform bacteria). The results were evaluated using the federal drinking water standards. Drinking water may contain substances that can occur naturally in water or can be introduced - into water from man-made sources. Total coliform bacteria aze found in soil and fecal coliform bacteria are found in animal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well may have structural problems or that the well was not properly disinfected. If you have been drinking the well wa#er and aze 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 these results at your next visit. If the contamination continues, you should investigate the possibility of drilling a new well or installing a point-of-entry disinfection unit which can use chlorine, ultraviolet light, or ozone. _ For further information please contact your county health department or the Occupational and �' - Environmental Epidemiology Branch at 919-707-5900. � Y A � �.1' ' � . , � . . . ' 7 . . . . . . . . . . _ � . . '�*. 0. � . . .� i � � . �� vFfii�; ..Aya,"'4�Z�' ��l � y^. ..i�.�. � i�� 'y' � �,�• "� >y''`� 4rNh �..k;'�'r'. ...._ . �.fe,.:p tf`ya �� . �'R. .. . �•:� '� . �.�..'. .,,,.+.i 1.•.i`� �:.'. . �.f:.' ^"5' .. . �'�M: North Carolina State Laboratory of Public Health Report To: ADAM C. SARVER Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: BARBARA WALTERS 225 WOLFE RD. P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://slph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES072412-0026001 Date Collected: 07/23/12 Date Received: 07/24/12 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.5 Sample Description: Comment: Time Collected Collected By: Well Permit #: GPS #: 1:40 PM Adam C. Sarver A32-67 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 37 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.21 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 9 mg/L Manganese 0.31 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 8.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 9.50 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 147 mg/L Total Hardness 130 mg/L Zinc < 0.05 5.00 mg/L I Y� �Y� /� Y� �Y `! Y 1." yti a v`� `i��� 'v' i:i<.1 Report Date: 08/10/2012 AUG 15 2012 Reported By: �e66�e �1LaKeol �3X:�T..�_ Page 1 of 1 North Carolina State Laborato Public Health P.o.B°X2$°4' ry 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 htto://sloh.ncpublichealth.com M i c ro b i o i o Phone: 919-733-7834 gy Fax: 919-733-8695 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: ES072412-0094001 � ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: 38403 GPS Number: Sample Description: Comment: Name of System: BARBARA WALTERS 225 WOLFE RD. HURDLE MILLS, NC 27541 Col lected: 07/23/2012 13:40 Received: 07/24/2012' 08:22 Sample Source: New Well Sampling Point: Well head Adam C. Sarver Angela Heybroek Well Permit Number: A32-67 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 07/30/2012 Test Result Absent Absent 'A'71"� !1. ir-�ir�c r ���.�.� J�'� AUG 0 3 201Z �X: Explanations of Coliform Analysis: Analyst Susan Beasley Susan Beasley Date 07/25/2012 07/25/2012 Reported By: Susan Beasley 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.