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A34 29Application Date: (o —3- �5� Amount Paid: �a r�, DD Receipt #: � ga2 0,2 H� � . ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 end) ❑ Mobile Home Replacement or Building Addition �: $150.00 if site visit re uired) Well Permit (lvew/Re lacement/Repair) ��.sf� I��.��.� �� -1Lr+.unwna-�s.��o=a.d,ai.l� IHIm�.114�. �lication for Services Services Re uested � Construction Authorization Fee is de endent on the ty e of ❑ Permit Revision $75.00 Tax Map: � 3 � Parcel#i �� `' _ � �� -�-0 � a1r�I �'�F ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name:.5' ,` - L Address: 5 �� h� b s /r, :/t �Po.¢ r� SQrr,a2� /V C � a7 3�L '3 2) Name and address of current owner (if different than applicant): Name: � Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone(home): 35�%- 5�63 -�36('p (work/cell): Phone: Lot #: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? G]-yes ❑ no Does the site contain any existing wastewater systems? � yes G�-no Is any wastewater going to be generated on the site other than domesric sewage? ❑ yes C�]-no Is the site subject to approval by any other public agency? �yes ❑ no Are there any easements or right of ways on this properiy? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential � [�I.New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Curcent number of bedrooms: � Repair to Malfunctioning System Will there be a basement? GJyes ❑ no With plumbing fixtwes? ❑ yes 0 no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well LW�xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? lfYqes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I cert� that the information pYovided above is complete and correct. I also understand that if the inforrrtation provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. /�� ' � G-3-�3 Signature (Owner/ Legal Repr�ec �` Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved ptat. A compteted `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) ��,Sf� I�I�IE�.��T �-� � � � ��i�I"�Y �ia.�sns�sa�aa.0aa�en.Il ��.m,�'�Iln. Naine ��.�.\F. �-Ca�o j Subdivision �E�� T� — � Authorized State Agent System compoaeats tepresent appm�mate conrours on/y. insrue rharpmpergrldeismzintained. SITE PLA� . Tax Map # A_� Pas�r1 # `�� Section/L b#� Date The ronmctormust tlag the system pdor to begiating the installarion to Tax Map: ��y Subdivision: �,��,sf ��.�� _ _ � � �� ' �rn�n�c-�n�n�can.��ra��n.Il � 3a��.��:�n. Parcel: a9 WELL PERMIT (New � Repair_ ) Applicant's Name: SA��.1� �� Mailing Address: Slg'� Met�r\�s tn��. K�P� Sew•ora � N � a�s � � Phone Numbers: 3`kh - yb3 - 0310�0 _ Lot: Location of Property: Sl9'i MC.v�1EE,S M�`�. �(�D Perntit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing consiruction and setbacks apply. 3.) Permits expire S years from the date o, f issue. 4.) Issuance of a permit does not guarantee a potable water suppl Other Conditions/Comments: �.x�.a� �3�.` �s-. S�� A�A�Oo.JEO Permit issued by: D�,� C\L %� . SMii� �Iew Well: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: EHSlD te D�S tc ioll`3 �./ Well Driller: Pump Instalter: �-rt�. Approved by: Date: y 1 Certificate of Completion OLiner: EHS/Date Additional Comments: �5-ct.l�c, W c,u. ��c�e�� Date Sample Collected: EHS: 1� Depth: Grout: DA6andonment: Date: Method/Materials: License #: License #: Date: �0 1 Date Results Mailed: Person County Environmental Health 325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 il/26/13 WELL CONSTRUCTION RECORD 71us form can be �cd fa siogle � multiplc wetls l. Wdl ContracMr Informatioo: � ��ll»/�f �-1/ �LL�� w�u co�w� N� �� t'� '.'� NC Wetl Coatactor Ccrcification Numlxr Barnette Well Drilling, Inc. Cort�aay Name 2. Wcll Coattraction Permit #: Lfsr a!l app/icable we!! rnnstrndron pernrits (i.e. Camry, S/aG YoriaRce, eta) 3. Wdl Use (c6eck wcll use): �Agriculhual OGcroffiermal (Fieating/Cooting SuPP�Y) �IndustriaUCommercial Noa-Water OAquifer Recharge ❑Aquifer Storage and Recovcrg ❑Aquifa Test DEzperimental Tschnology ❑Geothermal (Closed Loop) ❑Geothermal (Heatin¢/CoolinQ �MunicipaVPuhlic • �dcntial Wata Supply {single) �Residenaai Water Supply (shued) OGroandwattr Remedia[ion OSaliniry Barciu �Stormwater Ihaimge �Subsidence Controt OTracer �lain undet #2I Remarks 4. DateR'dl(s) Completed: '� 1 Wd1IiJ/t � J� Sa. Well Location: . r�//,-�:. �� Faciliry/OwturName �— FadlitylDli(ifappliablc) 5�/`� � ��'�� !h �/ R�9✓� .� �,yu�► naa�. c�d tia �'P �sr�.n� z� Cwnty Parcct idauificuiooNo. (PIN) Sh I.atitnde and Longitnde in dcgrces/minates/saonds or deeimal deErreu: (f well fidd, a�e lat/loag is sofficieot) 9� zr'-3`l' N rS' -D�. --iS w 6. Lt (an) t6c well(s): �Permanent or OTemporarp 7. Is t6is a repair to an uisting we[I: OXes or � If rhis 'v a repa(r, fill ow hnown wd/ caurrvdion tefororaGan cridcsplain the na+ure ojthe rclwir ra+der L'11 remarkr ruxian or on ll,e baeh ojlhlsJorm. & Namber otwells constracted: � For mulrrple injecrion or �n-water su�ly we!(s ONLYwith the smnt tonsArac6ax, yasr am+ submtronejorm. For iatemal Uu ONLY: 22. CcrOification: �/Y�� s � � ✓ ..�lt.t-� Cy `_/t�_ �T� s�occ��a w�u coo,� D� By sibming drir jornr. / henby crrrrjy rhat d+e wd!(s) »ns (x•ereJ consrnrcted le accordaace , wirh /SA NCAC OIC .0100 or ISA NCAC OIC .0100 i7e!! Construcrion Standards and tha� a mpyofthis reco�ha.r bem pmvlded to the wd! owner. T3. Site diagram or additioual we11 details: you may use the back of. this pagc to provide additional weU site details or well consttudion details. You msy also attach additional pagcs if necessary. SUB1N[TTAL INSCi1GTIONS 9. Total wdl dept5 below land snrface: � Q C� (it) 24a For All Wdls Submit this fortn within 3� days of completian of v�clt For mulfiple wef/s lis[ a/! depths ijdrfferent (eumtple- 3Q200' md 2(a)(00� ConstnlCGon to the f011oWin� 10. Sta6c water level bdow top of casiag: 2� ��) Ijn+aterleve! is above cosing, ase "+" 11. Bore6ole diameter. � (in.) 12. Well constroction method: �� %�. "c� ��g'd� S� (i.a a°&ea. mtary. eablq direet P�uh, de.) FOR WATER SUPPLY R'ELLS ONLY: 13a Yidd (gpm) � Method of test Blown20 minute 13h Disinfection type: HTH ,�,�� 1/2 Cup Form GW-1 IIivision o[ Wata Qaality, Information Processing Uniy 1617 Mail Serv.ice Center, Raleigh, NC 27699-1617 246. For Iniection VPells: Tn addition to sending tl�e fortn to the address in 24a abave, aLso submit a copy of this form within 30 days of c�pl�ion of welt cmist�udion to the followmg: Division of Water Qualily, CJndorgronnd [njectioa Controt Program, 1636 Mai! Service Center, Italei�h, NC 27699-1636 24c. For Water Suootv & Iniection NeIIr. Tn addition to sending the fortn to the address(et) abovq also submit one copy of lhis fortn within 30 days of c�mpletion of wdl construction to the county hcalth dcpariment of the counry where constructad. Nertl� Carolim DepaRmrnt of Eaviroamcnt and Naural Resotaces- Division of Water Qualiry Rcviscd Jen. 2013 WELL ABANDONMENT RECORD This form can be used for single or multiple wells 1. Well Contractor Informallon• � K,o.1�� G�� ./l� Well Contractor Name (or well owner personally abandoning well on his/her property) For Intemal Uso ONLY: WELL ABANDONMENT DETAILS 7a. Number of wells beiag abandoncd: � For multipfe injection or non-water supply wells ONLY with Ihe same construction/abandonmenl, you can submit one form. `�/ (� 7b. Approximate volume of water remaining in well(s): �_(gal.) NC Well Contractor Certification Numbu �� ' FOR WATER SUPPLY WELLS ONLY: Co pany Name 7c. Type of disinfectant used: L7"� 2. Well Construction Permit 1�: List all applicable we/l permits (i.e. Covnty, Slare, Yariance, Iy'eclion, etc.) ijknown �d. Amount of disinfectant used• � 3. Well use (check well use): Water Supply Well: ❑Agricultural ❑Geothermal (Heating/Cooling Supply) ❑IndusViaVCommercial ❑Irrigation Non-Water Supply Well: ❑Aquifer Rechazge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑Eacperimental Technology ❑Geothermal(Closed Loop) ❑Geo[hermal (HeatinaJCooline 4. Date well(s) abandoned: � `� ❑Muriicipal/Public j�' Zesidential Water Supply (single) ❑Residential Water Supply (shazed) ❑Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage ❑Subsidence Control ❑Tracer ❑Other (explain under 7�e. S ling materials used (check all that apply): Q Neat Cement Grout ❑ Bentoaite Chips or Pellets ❑ Sand Cement Grout ❑ Dry Clay ❑ Concrete Grout �ll Cuttings ❑ Specialty Grout ❑ Gravel ❑ Bentonite Slurry � Other (explain under 7g) 7f. For each material selected above, provide amount ot materials used: if�'��`��G�...1 L 7g. Provide a brief descripNon of the abandonment procedure: F�� t�� l� C c.� ��i,� �c� �( D �'d a� l' � c�,� % t,t d Sa Well location: �',�.f �� L.o� Fa iry/Owner Na e Facility ID# (if ficable) 8• Cer6fic on: L Physical ddress, City, and Zip S' ature of Ceetified Well Contractot or Well Owner Datc `Ci%'L � �) —/ 2� By signing lhis farm, I hereby certify that the wel!(s) was (were) abandoned in Counry Parcel IdentiScation No. (PIN) accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards and lhat a copy of this record has been provided to the well owner. 56. Latitude and longitade in degrees/minntes/seconds or decimal degrees: (if well field, one lat/long is sufficient) ��n z 7 � C% N/° L�� W 9. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well abandonment details. Yo� may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELLfSI BEING ABANDONED SUBMITTAL INSTRUCTIONS Altach well cons7ruclion record(s) iJavailable. Far mullrple injection or non-w�ater supply H�ells ONLY with the san7e conslruction/a6a�ulonment, you can submu o,re jorm. 10a. For All Welis• Submit this form within 30 days of eompletion of well 6a Well ID#: 66. Total well depth: � � (fk) 6c. Bore6ole diameter: � (in.) 6d. Water level below ground surface: 1�� (fL) abandonment to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 lOb. For Iniection Wells: In addition to sending the form to the address in l0a above, also submit one copy of this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Undergroand Injection Control Program, 1636 Mail Strvice Center, Raleigh, NC 27699-1636 IOc. For Water Suoolv & Iniection Wells: In addition to sending the form to 6e. Outer casing length (if known): �f�-) the address(es) above, also submit one copy of this form within 30 days of completion of well abandonment to the county health department of the county 6L Inner casing/tubing length (if known): �t�� where abandoned. 6g. Screen lengt6 (if I�own): (fL) Form GW-30 North Carolina DeparUnent of Environment and NaUual Resources — Division of Water Resources Revised August 2013 North Carolina State Laboratory Public Health Environmental Sciences f�licrobiology 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: ES062414-0055001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: SALLIE LONG P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://siph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 5194 MCGHEES MILL RD Col lected: 06/23/2014 13:15 Received: 06/24/2014 08:50 Sample Source: New Well Sampling Point: Well head Derrick A Smith Angela Heybroek Well Permit Number: A34-29 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte � Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 06/25/2014 E. Coli, Colileft Absent Susan Beasley 06/25/2014 Report Date: 07/01/2014 Explanations of Coliform Analysis: Reported By: Susan Beasley �CEYVED JUL 0 7 2014 BY: / � / 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 ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES062414-0039001 Date Collected: 06/23/14 Date Received: 06/24/14 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.6 Sample Description: Comment: Name of System: SALLIE LONG P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncqublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 5194 MCGHEES MILL RD Time Collected Collected By: Well Permit #: GPS #: 1:15 PM Derrick A Smith A34-29 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 94 mg/L Chloride 61.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.36 4.00 mg/L Iron 0.22 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 34 mg/L Manganese 0.15 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 8.2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 26.00 mg/L Sulfate 78.00 250 mg/L Total Alkalinity 260 mg/L Total Hardness 380 mg/L Zinc < 0.05 5.00 mg/L Report Date: 07/02/2014 JUL 0 7 2014 Page 1 of 1 Reported By: Arnold Holl