A40 369`��. ; � �.tl:�l1L �1.� ��
� � � ����
IEa�v�aso�.��osm.�.Il' ]C-��o�es�L�7Ea.
SITE PLAN '
Name SC2
Subdivision
�:4uthorized te Agen
Tax Map#�� Parcel# ��Q
Secti�n/Lot# 7q
— 2-9-l7
Date
System components represent approximate contours only. The con�ractor rriuslJlag the system prior to beginning [he
installation to insure that proper grade is muintained. .
Note: An Accepted system may be used in place oja conven�ional svsterrr without permit authorization or madificalio.n.
��
Pa°�� i�a �x =��;� A��'3�`� .� � �
�� ��1� ��'' ; �,�`�� g
----- --_ ��a.�i,�`�� _ �`� ii'��ii
�,��;Q� S S�eM
- �i�o ��� `� BR
� � do' A��
- 22" . _ j rcrc,l� i�
- i�- boX or s�r�a l d�st*�b�ho►, �l< 1
=.s"r o!-be�c �ta�nfa►in �1u� lehgfi�
` lin�5 y �
� �
,}� ,��
?� t f2- ins�a��a'�on MQ�ng Ma^ ft'" � . u�� I'�"
� K� �� s�s{eM ov,k o� ` � � �u� ---- — r�
� i ,
d�a�n . -
` �-
.. � -
_ _. __ , - ,
��g :� ��. � � _ �e
Sc�tle: �� � � Sa �
�
,��.'`�
I �'`���-.�..,,,.�`"'�°-�
I • �`""'�-�-...
� D
I _ �
�
I�
� pc;� e t�as-t' he,
i�s�ll�.� �s sb���1
o l� � `"'��'l s �r-�-�
�r K� �r� �
�y � • �y , , � �.�� �� • �
� � ..i i. \
�� .� C� �%''1 ... - ... -.. ��,_:'`. �—((� t'�
Q � M �F�Ca C��IV�
��� 5�' �/�i
�'"�' � L~� -�; ` _ . . . .
PCHD, rev. 09/]2/01
,�,�/i�
Application Date: �02 I� lG �� Od `�� ��' ������
Amount Paid: ,�00 •O U � ..�. -"' '
Receipt #: [ ? 7D 83 i 8 ;� _ � � �T�T`7I��
]�����mm���.�Il ]E-3[��.11,�
���3 �� Application for Services ___
Taz Map: � �G
Parcel#: 3 6
u�X�.�+�,, � piw-
Services Re uested
❑ Improvement Permit (Site Evaluation) 0 Construction Authorization
$200.00/$300.00 if> 600 d ee is de endent on the ty e of system ermitted)
D Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 if site visit re uired $75.00
❑ Weq Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor ation:
Name: �� M�n �0.� kl 1J S Phone (home):
Address: (work/cell):
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
� ��
�
3) rr�perty )escripti�Y: L�t Size: Subdivision: �a r Lot #: %�(
Address and/or directions to Property:
❑ yes 0 no Does the site contain any jurisdictional wetlands?
� yes ❑ 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 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: y�
❑Residential ' ' 7
❑ New Single Family Residence Maximum number of bedrooms: �/ Occupants:
❑ Expansion of Existing System If expansion: Current number of bedr ms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of emptoyees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: � New well 0 Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? O 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 ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccuraf' , the site is subseq e tly a tered, or the intended use changes, all permits and approvals shall be invalid.
� [ �2 � f �
C� Q-�-�--�,- � �
Signatu�(Owner/ Legal Representative*)
* Supporting documentation required.
Date
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
v
��
1
� _��. 5� �3
2,3�,� 5��� �
�_�,�c. � �
���. sf ���.� ��
� � � ����
]E�s�.�na-��� ����.Il I�-���.Il�I�
Applicant: �„�
Address//L;�o�cation:
�'��� / L J _ _ J
�
/ Improvement Permit
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility:5inak �eM:t� w�ll�.� New �-Addition _
Number of Bedroor�� / ccupant �/ Employees / Seats:
Proposed Wastewater System:
Proposed Repair: �c �� p��
Permit Conditions:
..���� t�
Authorized State Agent:
(X) Owner or Legal Rf
Tax Map: y 0 Parcel: 3�
Subdivision
Phase/Section/Lot #
Water Supply: �i�
Projected Daily Flow: 4$D gallons/day
Type:
Type:
Date: - -
Date:
The issuance of this permit by the Health Depatfinent cloes not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property 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
anrl Rules for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatal
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Coastruct Wastewater�ystem
See site plan and additional attachments (�.
Propose�-Wastewater System:A�_�25��� o„ �,�k�� (*)Type� Design Flow y8o gal./day
New ►� Repair _ Expans� n T Soil LTA gal./day/ft2
Type of Facility: S,na�P �w�; i>w�tr��„� -�� Basement: Yes No
� �J
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person Counry Health Departmgnt.
Wastewater System Requirements
Tank Size: Septic Tank D00 gal.
Drainfield: Total Area 00 sq. ft.
Trench Width .3 ft
Pump Tank "—� gal.
Total Length l G�D ft.
Min.Soil Cover �_ in.
Distribution: Distribution Box V/ Serial Distribution �/ Pressure Manifold
Specifications:�-�7e��ia—,�,,,��sfiri6�rt�ie�'n, /er (.���ax D(�� Zf l7-box �►nai�
�F Irin—i ari-n�I4Y-. w,n r1we��,.Aw .YE�
Authorized State Agent:
^vrease Trap gal.
Max. Trench Depth ZZ in.
o•c.
Min.Trench Separation 9 ft.
� ts.
Issue Date: 2.- 7 /�
Permit Expiration Date: _y-1-�y
The system permitted is: Conventional /Acce�ted V/ Alternative / Innovative . I accept the conditions
and specifications of this permit. r � �
(X) Owner or Legal Representative: ` J' Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
���. sf ���.� ��
������
IE��na-��.�����,Il IHL��.Il�.
Applicant:
IkS
Location: �
�%v�e..
()peration ..�"ern�it
System Type (From Table Va): �
Type V& VI Expiration Date:
Taz Map �9 Parcel # 3
Subdivision � �r►'� vQ�
Phase/Section/Lot # 7 J
# of Bedrooms T
Produ�t {IIIg): ��¢✓'' �'�
Type V& VI Renewal Date: ��
This system has been instaUed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and liisposal, and all conditions of the Improvement Permit and Construction
Aathorization.
vk � �vv-2✓
(A • or�zad Agent)
�� L�� s
Zicensed Con�actorj
Scale �`S
PCFiD, rev. 12/14/12
2��31��
(Batej
Z—z3, i
(Date)
� C�,���- ��bb�C
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I� System Type: �= C�4�, �
Nofes:
Pump System Checktist
P� Ta.�.k a�it�aJl2at�e
State ID �i Date:
C�.paci�y:
Riser (6" min.}
N'�'NIA 4X Box
M�del:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressur� Mani¢old
Ntzrnbsr of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Natzs:
���f/� �.ai����� V
��,� `iJ � �1J ���
7������,�m,���.Il IE3C�afl ¢]�
WELIt PERNIIT
(New ✓ Repair_)
Taac Map: � Parcel:
Subdivision: �
Applicant's Name: Sa �, ,��a,� K; �► �
Mailing Address:
Phone Numbers: S�jB-Zl1_q
Location of
Lot: �_
c-sctc
Permit Conditions:
1.J See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: �w��fa;� a � <.�-bacKs
Permit issued by: �u�� ,
Certificate of Completion
�Tew WeU:
EHS/D t
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
ae
>� � ���
Well Driller: i�nn,�
Pump Installer:
Approved by:
Additional Comments:
Date: Z- 'j - �'7
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Sample Collected: ��� Z`� Date Results Mailed:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C Phane: 336-597-1790 Fax: 336-597-7808
o..,,ti,.... nir ��c�a „ i,c i„
Feb 23 17 01;08p Barnette Well Drillinglnc
'Gf�I,L CONST'�tIICTION RECORD
���,�� ��i�����
L. wat coat�nciar Iarormatioa:
/� ti
� cJ jl3 /29 1 � � /'c., LA r� -
�rza c�r�
33 � � �-i�
iac w�t co��c��oo N�
Barnett� Welt arilling, Inc.
`�.N'm` - 3 6 `�
Z;v�ti cAr+se,vwoa �x,tts�: �
urr nrt appu«iblc ue!! oomcr�roe permt� fi.e. ct�7c S+� S'Q�+�x �T
3. Ndl Ilse {c6eck �scQ usc):
W�ter Suanlr ��1i:
aAgriaul4trai �►►6vnicipaUPuWic-
aGso�.erm�t �tc�on�Coo�in�suaa�Yl ��natw�so�zs(sQ►�ol
Qladuso iatlCarnmcrcial aRaidasaa! WaDecS�PP1Y i��
ClAqnifrrRec6�c �Gcouod9ret+cr�tion
❑AquiftrStarageaudltxevca �Salinitp'i�ier
�ayu�sGu a��
06�ei�aimiTedsoulogy D.�sidausC.ontmi
❑GCOt�7.G[�aL �ZiOSld 1.�l� Qi73R!
336-598-9275 p.1
Forlatam�lfseONLT .
'1,a:SkA'iSRzota�S� ��� ,
j � zb �` �-s J�"
/Z,� l3l,� 2�- 13l '
�s: o c:asn�� � _.:�..a� . � �* � - �
FAOM ��'�� �
(� �` fS3' n. 1 � �"G�f2 � G ..
Y6:�IIQNFFRCAStt��� elusi6d'd6 -
TROM 'ro � � . .�L
. � � '� � _
$ � � �
: it.•Se1t'SHN' - ' nuta srrars¢e � sr�r¢scut
7�D
� � �
R R � ,
.y ���-�•.=- ' . �� ' ' . . ME7B00�6ffi4
ss io urr.ew. �
� � 2 � n
� �
� �
:73.5i�ND16i�SVEI.pACx f � � '' �.M£R:OD -
FxoM '�'o �- -.
R �
� n
-2R7f8[fi]rF7G'I�6' - - �'aG:dind"eal�sl�if ' - - - _ "•.., _
1FR!►6i ��' . •. •- - � • -
.� � �� n r �� �c b�.. 2 a�
3 $ Z�'�
4 Ilate�Yeu{s� ComPtcted: � 2%` d11U# �77 �7�'� Z 2� 75 m
5a.l�tTtf1 Lacaups: • ? �g �
S/`i /� /LL 5< '1f�e: L9 /� ! f� � �=' � 7 � $ �
FaaTiorlOam�� ��3*�C�+�PP��) � 2
..._ � �/t �. ,. � n c � � .n 1J �9 O �.Q i_ rti /1,r O� - {r Q..
��.� �� 36�
+�i12.� a r3
�„�, I r�cata�ua,aar�a.t�n
Sb.Latit�daaad I.a�mde ia ��lwiar�fseooad�aar dedmai dc�rees
�iFwea �� ooa latAag is m�aent}
�6 #� 4�) � � H _,? % - �o t �7� �►'
6:[sL�iu�e�eIIGs). �Peimaaeat ar a'i'�Po�'Y
: �.�
3_ 1s this�a r.pcfr io aa�shdJ= C7iCCi Q I.ilrio
pmFrrasderX2[ t�arfocsaedan oran�Bfx�����lLeteumeof�ie
Forarslt¢�te tr� orna�a�trsW�PZ.P'reIIs OlYLT�ertb,F►..••»w�x3roa amf
srd+or�ane,JCvrt /1'
4.Total�ldqrt6bdaariami�rfso� 1 �'" � fTY.)
I•br�e,aessttiraude�tlsOra�+�(�F`��'��� .
� �� .
c f% r
%YYJ�1� � � f✓ .+/ _ � � � ���
sa�Go�c�awerc�.� �
�5���1� � herrsy mMb a�+rm,.eu(rl +wa ts�57 ars�cmd�a a� _
�lrJSrI11R�tC QdCAlOG ar lSI iV[:tC ��Q� C.�t+��°° �°°°°�0"�' �d dnt c
mpy�{r6tsremdl�lKmpnrrded
Ti.b4te �tau araddifma�Lwnll dctsnlx
Yoo may us� 8ze badc a£this �ape �o tuotidc s3�timml we4 sita dem�'Is ar asIl
tc�ad+catdela��s Yauma9slso�arhadd'aiooalpegrsifoeaaxy- .
SUBl1dIC1'AI. �i�73FUCIiQH.S
�, F'or �'VPdls ��s fo� vn`1hm 30 days u� mm� ot v��eli
t�'nardnLti 9xYu�iowing
� I�iYis7aa of Wata'�.ipfoimsiion PnoorsiuSUnit.
ra ss��,��.a t,aa�. �t► at'��: 2-s (�) iszn�u s«.�a cros� , s�. �c �-16s7
�,��ta���'}'
I l. BtvlhOlt di�aeters � (is.) ,1+4b. Fnr iin� R►d{� TR �ddib�n ���te TOms � tbe 8ddtrss iu TAa
� ahoRe, elso 5ubm� : ee� of �is fnffi w3kin 30 da36 a� �nt� � wtll
' �iT'i lrc�t�71' �R/�� �:oam�cfc�o�
12 Wdt �onstracGoa me�ad:
L+� ��Y. �, a� Pa*4 �1 I)ivuim etRai#a.' Qm�flys��d IRie�ost C'w�s'dP�grsm.
' . i�6 b3m't Smioa Ctnter, �e.l`�C 27W9-Ib36
i+�R�A"CSR SIIPPLY�F'ELiS OPtLY_ ,
J, $IOW31�D8l1A 2Rt�p,r�tiRes'S�v�Yniedio�Wd3� 6�add"+ti�ntusatd-mgBu£arata
i3a.�F3d (�pm2 5 U 1�aTeut thv aAdcesa(es) sTw�C, �so dro�mic rose oopg oitlus fa� �++ithm 3Q da}$ oi'
s � HTH 1�f2 Ca�P �ur�' ar� ��� m� d,� �a► n�w, ��� �a,�
13tr. D"�infafau dP� A�A� v�eom�sor3e�
� i • . ut.�a�...sms
�.Cscu�� rTo�,C.wsaa��°'tma�co�tR�c�—n�.mo.�Kv�Q�
� �
----- - - '-�— — '...._ . — -- - __.��..�----- _..._---- -. . . • -
��
��
*.�.., �
�,..-.. � �"''s� � �..J� � �� � �
��fm�n�u�a�r�rnu�:��n�t�,�t.� ��..��c:,tm:. ���n
Date: �/�/�
Name: f7rltl'�t ��2
Address: �MdrC� r.
�, 9 �,�/' C ? S7�
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map: �fl Parcel:��
Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria.
Your water sample test results are noted beiow:
No coliform bacteria were detected in the sample. Your well water is safe to use for drinking,
cooking, washing dishes, bathing and showering, based on the bacteriological results only.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total colifor�r bacteria are naturally found in the soil. Fecal coliform bacteria arz associated with
animnal and/or human waste. The presence of either total or fecal coliform nacteria 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
tnay not be safe for use. Young children, the elde�•ly, and the individuals with compromised immune
systems are especia�ly vulnerable and their physicians should be notified of the test results.
A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested
prior to resumin� normal use. The well may be disinfected using the enclosed disinfection procedure. A
weil 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.
S incerely,
�
5��.�r
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person County Environmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579•1790, Fae 336-597-7808
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
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: ES052317-0102001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
SAMMY HAWKINS
100 MARCO DRIVE
ROXBORO, NC 27574
Col lected: 05/22/2017 11:40
Received: 05/23/2017 08:46
Sample Source: New Well
Sampling Point: well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
A. Sarver
Angela Heybroek
Well Permit Number:
A40-369
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Absent 05/24/2017
E. coli, Colilert Absent 05/24/2017
Report Date: 05/24/2017
Explanations of Coliform Analysis:
Reported By: Cindv Price
�il �%i.�.CZ
�
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.
�_.
�! r,
,���
ne d¢parfmant
of health and
humen serviees
co��y: rs�
t.12 ` ' %•� I � � � �-, f �
1�;� �. F._.,, i i E i- i.n�
_""� � �S � �,�� i �i: � "� � �l �"' � 3 r-4 . . p , ;,—.�
s• � 't 1�
� " � y f ��f � L.: �; t i` �� � � ! �� I ! ;,` � f � r ��; �. E �i� r' 4
�--��. �—I f^.9 � � �,'-. ��� `�' !�` � `� �,i,� ^ �`."--� ��! •r � C �-� j� % �-� � �.,
��_+ i ! �•' ...,.�' t� `L � •t �.: 4�` �-1 E a 9 � + ✓ a / � �,, :�} � i S/� � ^� ~'V
- �_ ��
For Inorganic Chemica/ Confamir�ants
Name: �'v�/h �l i
� TEST RESULTS AND U5E RECOIVIlVIENDATIONS
1. [] Your wal! vyater meets feder�l driaking water sta�dards for inorgani� c�re�uca�s. Your water can be used for
drinking, cooking, washing, cleaning, bathin� and showering based on the inor�anic chemical resulls ohlv. You may
hava other water sampling resuIts that are not taken into account in this repo�.
2. (] The following substance(s) exceeded federal drmking water standazds or the North Carolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your weli water not be used for drinking and
cooking, unless you install a water treatment system to remove the cu�led substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inoreanic cheinical resalls onlv,
Barium Cadmium Chromium Co er Fluoride Lead Iron
Mercury Nitrate/Nitrite Selenium . Silver Ma�i►esium Zinc nH
3. [� a. Sodium lev�ls exceed tha U.S. Environmental Pratection Agency's�(USEFA) Health Advisory level for sodium of
20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no ar !ow sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning; bathing, and showering bz�e� or.
the ino�Panic chemical results onlv.
❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. � Re-sampling is recommsnded in months.
5. � Re-sample for lead and /or copper. Take a first draw, S 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 and/or copper.
6, � The following substance(s) exceeded federal drinking water standards. Your water can 6e used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inor�anic chemicalresults nnlv, hut aesthetic pr�blems
such as bad t2ste, odor, staining of porcelain, etc. may occur. Yeu may want te in�tall a household water traatment system
to address aesthetic problems.
Barium Cadmium �hromium Fluoride Iron
Man�anese Selenium Silver pH Zinc
F�r more injormation regarding your we!! water resuits, p[ease call ihe North Carolina Divlsion of Pubfic Health at 919-707-5900.
North Carolina State Laboratory of Public Health 3012 D st�ct Drve
Environmental Sciences Raleigh, NC 27611-8047
htto://slah.ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: ADAM C. SARVER Name of System:
PERSON CO ENVIRONMENTAL HEALTH SAMMY HAWKINS
325 S MORGAN STREET
ROXBORO, NC 27573
EIN: 566000331 EH
Courier # 02-33-15
StarLiMS ID: ES052317-0042001 Date Collected: 05/22/17
Date Received: 05/23/17
Sample Type: Raw Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 3.5
100 MARCO DRIVE
ROXBORO, NC 27574
Time Collected: 11:40 AM
Collected By: A Sanrer
Well Permit #: A40-369
GPS #:
Sample Description:
Comment:
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
i`�rlmi� �m �!1 !1l11 n nn� mn/I
Calcium
Chloride
Chromium
Copper
Fluoride
Iron
Lead
Magnesium
Manganese
Mercury
N itrate
N itrite
pH
Selenium
Silver
Sodium
9
< 5.00
< 0.01
< 0.05
< 0.20
< 0.10
< 0.005
3
0.039
< 0.000;
< 1.00
< 0.1
6.9
< 0.005
< 0.05
6.30
11.00
0.10
1.3
4.00
0.30
0.015
0.05
0.002
10.00
1.00
0.05
0.10
250
Total Hardness 34 mg/L
Zinc 0.06 5.00 mg/L
Report Date:06/06/2017 Reported By: Deddie .�toncol'
Page 1 of 1
Z��`� �C��-
�.� �`�,
.�
��. �f� � � �. �, ra ,�
�
����� � 3 �� �.
-�ina(5 in�-a Zo�eP�o --�
3 �j-�7 C�kr� -�
�