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A34 46Application Date: �— �� [2 �� S� �� Tax Map: � 3� AmountPaid: �.0(�r00 .r,: "�.,�- Parcel#t __��___ Receipt #: 2l� �' � �� IC-?:�rav-u.m�,•r,•,m�sn�.s..11 JL�Lao.�.11dll�. � � Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Regla�eme�t or Buitding Addition $150.00 (if site visit re uired) Well Permit (l�tew/Repiacement/Repair) $3 00.00/$200.00/$75.00 �lication for Services Services Re uested 0 Construction Authorization (Fee is de endent on the ty e of system ermitted) Q Permit Re•r.sion $75.00 ❑ Repair of Existiag Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Info mation: Name: S Address: �' �em�,rck , lUP 2) Name and address current owner (if different than applicant): Name: o�s�h �;pA �1�imbex'C . Address: �S`3�j �j r`1� �P,�s �"I <<� ( �?� CSeyn�aU(', 3) Propzrty Descrigtion: Lot Size: Subdivision: Address and/or directions to Property: � ��' Phone (home): (work/cel l): �`�(R — �5 d - g�s 7 Phone: 3,�(0 —�G � ' C�.�1`�J �/ ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes � no Does the site contain any existing wastewater systems? ❑ yes ❑ no 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 ❑ 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: ❑Residential � New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: � Re�air to A4slfi.zr.ctioning Sys±em V��ill there b� a basement? ❑ yes L' co V�'ith plumbi:.g fixtures? L� yes G' no ❑Non-Residentia! 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 existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative � Other ❑ Any 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequentiv altered. or the intended use changes, all permits and anprovals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. 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) . . ' . �1��, \� �11L(��/ �� J J� �..� � `U � �p1 �l�7 ��-7 ��fT �CaL3'PaY•�an'•'•�w �773�.JL JL71��II, , . .. . � � SiTE S�TCH .� . Name rol ose � �.�1a %S . Taz Map #�3� . Pa:tcel # �� Sub io . � Sectian/Lot#_ -- ____. __ �_._.__._.Y _ . y-�� -/ Z . Autho�ized State Agent . � Date . System cumponents represent a�bproximate�contours only: The contractor mustflag the system prior to beginningthe instaTlration to in.sure thutprnpergnade is maintained ��yi�� Jl�� _." �' C� � �L.T�7�� 1�.��. � � �n�. � � �.�, ll IE3L � �.11 -�.II�. . WEI,�, PERMIT (N w �tepair� ��e� ace.Menf Ts� Map: Parcel• Subdivision: Lot: A�plicant's l�tame: ' � � Mmiling Address: � PhoneNumbe�s: _ - �.33�-SD�i- o29g �'1 ��itn�) r-- L�rcation of Property: �7 lu1 ��rl, e.e S �� 1 � �d • Permit C'onditi��ns: 1) Seg attached site plan for proposed well locaiion. 2) �ll applicabie State and County regulations governing constYuction and setbacks apply. � 3) Permits expi�e S years from the date of issue. Otker Conditio,�s/Comments: - �n Q ac S � P�anit issued l�y: I)ate: �/ 7-/� CERTIFICATE O� CO11dIPLE'1'IOl� Nc� Well Tns�ection: Liner �nspection: EHS/Date EHS/Date Location: Gr�uting: W�1 Log: We�I Tag: Pu�p Tag: Air Vent: Has� Bib: Casing Height: Cc�►crete Slab: _ Zq-1Z Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ We#1 Driller: �,� y�� License #: Pusaip Installer: License#: �V�3 Approved by: -� Date: S- 2�f -(Z Da�: Sample Coilected: ,� � Zq -1 Z Per�n County Environmental Health 325 S. Morgan St., Suite C Ro�oro, NC 27573 Date Results Mailed: '�� - Zd-( 2 Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Departmen: of Environment and Natwal Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # ��C�' � 1. WELL CONTRACT R: /� �(, , i<A �1 / ' �A / E Z Well Contrador (individual) Nam Bamette Well Drillina Inc _ Well Contractor Company Name 611 Bamette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code . 3L 36 i 599-0015 Area Code Phone number 2 WELL INFORMATION: � WELL CONSTRUCTION PERMIT# OTHER ASSOCIATED PERMIT#(if applicable) SITE WELL ID #(dapplicable) g. WATER ZONES (depth : Top�� Bottom Top Bottom Topz � � Bottom�,[_ Top Bottom Top Bottom Top Bottom Thickness! 7. CASING: Depth Diameter Weight Mate�ial Top_Q_. Bottom�.�. Ft. � y S�•Z/ �UL Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Top � Bottom � Fc. Sand/Cement Top 8ottom Fl Top Bottom Ft Method Poured 9. SCREEN: Depth Diameter Slot Size Material 3. YYELL USE (Check Applicable Box): Residential Water Supply �y' Top Bottom Ft. in. in. _ DATEDRILLED `t `t2?-(L. Top Bottom Ft. in. in_ _ TIME COMPIETED � pM p pM � - Top Bottom Ft. in. in. _ 4. VYELL IOCATION: = 10. SAND/GRAVEL PACK: /� Depth Slze Materiat CITY: ��{Ms /Gt COUNTY /��.�50� : Top Bottom Ft. � 3ci!'1 �� G��S �j`f � Top 8ottom Ft. (SUset Name, Numbers, Community, Subdivision, Lot No.. Parcel. Zip Code) . 70p Bott0t11 Ft. TOPOGRAPHIC / LAND SE7TING: (chedc apprnpriate box) ❑Slope pVatley lat ❑Ridge ❑Other LATtTUDE � " C_� ' S, L" DMS OR 3X.X)0o(�(XXX DD LONGITUDE ��' �. a " DMS OR 7x.XXXXX�Wc DD Latitude/longitude source: PS piopographic map (Ioca6on of.wel! musf be shown on a USGS topo map andatfached to this fom� if not using GPS) 5. WELL OWNER / q^1l�GlS Ovvne� Name S��l � �/!� t s �2�1� �'� Street Address �l/�to�ti �(J,C- 02?57� City or Town State ZiP Code �� 0�1-�OT� Area code PhorTe number 6. WELL DETAILS: L a TOTAL DEPTH: 0 r b. DOES WELL REPLACE FJClSTING WELL? YE�O ❑ e. WATER LEVEL BelowTop of Casing: Z S F1'. (Use '+` if Above Top of Casing) d TOP OF CASING fS � FT. Above Land Surface` 'Top of casing tertninated aUor below land surface may require a variance in acco�dance with 15A NCAC ZC .0718. e. �n� �9�,�: �- nnEn�+oo oF resT Blown 20m f. DISINFECTtON: -rype HTH amoum 1 2/ CUp 11. DRILLING LOG Top B om / / ��` ��-_� �LIiD / / / / / / / I / � 12. REMARKS; Formation Desaiption � so� t � I DO HEREBY CERTIFY THAT THIS WELI WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDAROS, ANO THAT A COPY OF THIS RECORD HAS BEEN PROVIDED O THE WELL OWNER. -a7-�z SI N E OF C TI (ED WELL CONTRACTOR DATE a�ir M i��i ��• PRI D NAME OF SON CONSTR CTING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form Gw-1a �617 Mail Service Center, Raleigh, NC 2T699-161, Phone :(919) 807-6300 Rev.2/os Report To: North Carolina State Laboratory of Public Health 306 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27611-8047 htta:!/sloh.ncpublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: ANDY CHAMBERS 5347 MCGHEES MILL RD. ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES053012-0038001 Date Collected: 05/29/12 Time Collected: 11:00 AM Date Received: 05/30/12 Collected By: J Smith Sample Type: Sample Source: New Well Sample Description: Comment: Sampling Point: Well Head Temp. at Receipt: 7.0 Well Permit #: A34-46 GPS #: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic Barium Cadmium Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date: 06/11/2012 < 0.005 < 0.1 < 0.001 89 47.00 < 0.01 < 0.05 0.27 < 0.10 < 0.005 34 0.35 < 0.0005 < 1.00 < 0.10 7.9 < 0.005 < 0.05 21.00 69.00 284 360 0.63 i.`a.�v�� v Y.�L JUN 13 2012 Page 1 of 1 0.010 2.00 0.005 250 0.10 1.3 4.00 0.30 0.015 0.05 0.002 10.00 1.00 0.05 0.10 250 5.00 mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L N/A mg/L mg/L mg/L mg/L mg/L mg/L mg/L Reported By: De�ie 7'llaKecl North Carolina State Laborato Public Health P'O. Box28047 ry 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 htta://slph.ncpublichealth.com M icrobiolo 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:566000331EH COURIER #: 02-33-15 Name of System: ANDY CHAMBERS 5347 MCGHEES MILL RD StarLiMS Sample ID: ES053012-0096001 Collected: 05/29/2012 11:00 J Smith �� Received: 05/30/2012 08:50 Darneice Lyons ES Microbiology ID: 36994 GPS Number: � Sample Description: Comment: Sample Source: New Well Well Permit Number. Sampling Point: Well head A34-46 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert E. coli, Colilert Report Date: 05/31/2012 Present Absent Explanations of Coliform Analysis: Darneice Lyons Darneice Lyons 05/31 /2012 05/31 /2012 Reported By: Susan Beasley ,. ,._�: �_�.. -.-.�;G� ,� � ;; � _ ' ; ., � . . _ �'� � � T^. ,t� _------- _ � 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.