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A40 44�� ) � �`"'� , . , � `r'�^�,r � � ��T��'" ��-! f�i`nt�r n:t• Q1� 1i'ti iim .� �•%3i:i il.ve,'i.11 1F"lr i(�,ei4 i� +L 1�� Date: 1�/�Q/� Name: �Jan�� tW S Address: , e ern. Alf'- �ti5�� Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel:� Your well water was sampled om�/_�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: 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 on[y. �Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil. Fecal coliform bacteria are associated with animnal and/or human waste. The 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 may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total orfecal coliform bacteria should be properlv disinfected and retested prior to resumin� normal 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, G�/ Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person Counry Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences f�iicrobiology 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: ES092916-0085001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JANET HAYES P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 3947 HURDLE MILLS RD. ROXBORO, NC 27574 Col lected: 09/28/2016 11:00 Received: 09/29/2016 08:08 Sample Source: New Well Sampling Point: well head J. Smith Angela Heybroek Well Permit Number: A40-44 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present 09/30/2016 E. coli, Colilert Absent 09/30/2016 Report Date: 09/30/2016 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. --_•---- - ��1�Tn _ ne department of healfh and human services County: Sample ID #: e r; r � s ` �fi�� - � ,-- : � � �"F� ; � � g , ¢ r-,. �- � �_--� k � ; �� 1' �I? s ;� � r � -� � t € k ~� t �,� �~ ! � E �4 '�� f �� f f ._ ! ; � ; --•� ,r••. ;-� �— r" , 4 �' 1 �^„ .5.. ' � �...�, r> .�'f �'^ �{ t•� � ��.: �--a . � d�.. � t k f�"'� � � ..[ r.�I �� `��R{1 S S � � � 1•� 4 � '..,t 0—�_� : G `.. 4 1 �� •� • C 1 d 1 4 __l' P f •i €,f �. % `r' ! [ � �i �.,,�� _} _: � ,�`� `, ... `_ For Inorganic Chemical Contaminants Name: Reviewer: � � TEST RESULTS AND USE RECOMMENDATIONS 1. 0 Your well water meets federal drinking water standards for inorganic cfiemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorganic chemical results on[v. 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 wetl 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 inoreanic chemical results onlv. Arsenic Barium Cadmium � Chromium � Copper � Fluoride � Lead � Iron Man�anese Mercurv Nitrate/Nitrite Selenium Silver Magnesium �_Zinc � pH 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 inorPanic 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 recommended in months. 5. � Re-sample for lead and /or copper. Take a first draw, 5 minute, and I S 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 be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorPanic chemical resulis onlv, but aesthetic problems 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 Maneanese Selenium Si(ver pH For more information regarding your well water results, please cal! the North Carolina Division ojPublic Health at 919-707-5900. � 0 North Carolina State Laboratory of Public Health 3012 Distnct�Drive Environmental Sciences Raleigh, Nc 2�s„-ao4� htta://sloh.ncoublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH JANET HAYES 325 S MORGAN STREET 3947 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES092916-0056001 Date Collected: 09/28/16 Time Collected: 11:00 AM Date Received: 09/29/16 Collected By: J Smith Sample Type: Raw Sampling Point: Well head Well Permit #: A40-44 Sample Source: New Well Temp. at Receipt: 3.1 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium Cadmium Calcium Chloride Chromium < 0.1 < 0.00 83 24.00 < 0.01 2.00 0.005 250 0.10 Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L s Iron Lead Magnesium P Manganese Mercury Nitrate N itrite pH Galanium 2.40 < 0.005 7 2.300 < 0.0005 < 1.00 < 0.1 7.6 < 0.005 m m N/A Silver < 0.05 0.10 mgi� Sodium 14.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 218 mg/L Total Hardness 240 mg/L Zinc < 0.05 5.00 mg/L Report Date:10/05/2016 Reported By: .xennet!'i Greene Page 1 of 1 Aug 0516 12:25p Barnette Well Drillinglnc WELL CONSTRUCTION RECORD This fonn on 6c iuod foc siaglc or muSriplc aclk L Wdl Coptraeto� i.aformarioa: /� �f � � L v \ � /7f f v / � � �.J�. � Wel1 Conbactor Namt 3.� �� --� AIC WdlContractarCertifiaoion PFam]xr Barnette Welt D�rilling, lnc. Coaqnay Namc � Z W�il Constructiou Permi� N: �� cc+� ar•��r�,�r «,��►;�p � �i.t c�y. s+o.a ��.,u, ur,� 3: Wdl [Jsc {check wdl use): wsurs�P��w�3: QAgiculau�al OMpnicipaUPublic- fl{'reoihumal (HeatinP��t��B S+�PP�Yy ��a! Wat�r SuP1�Y �single} Q�ustziaUCommavat L]Residcntiai WatrtSup�ly{shan�) wdL OAquiEec Rcdiarge DCsroundvrattr Reaiediation: �hhquifct Stotage and [txova} QSaIiniiy Barriec �Aqui�'a Test OStortnxater Drainag� Q�acpuimenta[ Technology �Subsidcstice Controt � f��d i.aop) QTraoer ❑ceoth«u+sltHeatis,Alcnolra�Rdz,m) ❑olhrztcim7aiuundcri�zlrLi�a 4. b�te''Wc11(s� Gomplrxed: �—�7�'-%�i Wet1ID# � T'� sa. Wen Laca6oa: v�'l�E� 7'� f} C� �J -. FeciGrylQa.actlame � Facili[yf�C ifi�pl�ablc) J /�% �'� C }%tL . �l�� !� � ,Si rt�� S.c��. �e z.� c l�� r�14S�fJ - r�,�y rx�oa �a�,aE�rra t��l Sb. Latihsde aad Loo�pifndria depreeslmiaµtes/setonds:or ded+mi �egr�es_ (i#'xeU Gcic� one lasltaas is saffiecqt3 . 3N,35U9'� rt 79'� �ii.n8� � ��Is(arc}t4ev�e11(s): �m neir[ or E77'e�pora'rp 7. Ts iLis arey�air to an e��ng:welk ❑Yts or 19�i� If d�i� tca repatr,ji�ow+Gfo,wr,.dimaruvaiwr t,q'w,P,arra.+e.dc.pfirin rbe �ujil,a ►eAoir readrr C11 �+aanl: seesion w oR thc 6aekofilutfomr_ 8.'Namhcr o! we!(s wnSlruckcd: J Fcrwrtry,rc r�ycu;a, or.m.r-,�rcr.w�;tyy�e(tr ONtI xarh tlxsa�xe coni6racaioR�,}buaa+ ndw�naiejorm. 9.Tbtai�edlde�t5belowl3adsar[ace: / � `' (1tj ForaiulRp'e we!!r IistaAdeP� 1��++� C��3��'�1�� 336-598-9275 p.1 �'�}"e� � c..� 5 �" / � Fa mr�,si uu on�v: . � fd� WA7ER�.ZDIVF_S.. � � � . �. . � . �. � .. . � � . .. . � . rz J �G rc !� � � � �L r �+6 « �� r CfERC.�.S'�IG f6r.:ti�eid-;c�SedwdLc l3R � nR DL4MEYFR .. . 'iKfCiQ�l` � 1�3�� s� �- Sr�re� re�e c;�� x:��uvc. .. . . a� �ra-�� SO DIANE.TiB SHiCKiVES t� ft ia fc. tt �- 'RLEN . .:, . . . TO � DNME'[ER. � SlATStLE�.. � 71 rr. e. �+. fi it T �- EDilT ro MtiFrxu[. : �a�vuc� (c �� [t �and! oufe ment tt ft (t Et %11�lGltA"f�iC,'PAC(f iEa `" tobfe - TO MASERWL � �N [t . ic. tt ' tt �1Li,�'fG'[':OiG stit&tli�dditra�l'shetxsiCutirrisstii TO - PL+St.RlMIUN c.l.r W.dn rc. �T rc Q U'� R,(a c.�. 2�. r� 3�-E� T�N �� '� W� � " o�'�- "�t`- ' 66 t6 c�i�/� (a o � ft. tt � n u, R 22. Cd�tifialtio� �,� r � �; _ �-.,�_tr�� r�—' 4� `/� s�� ofcanfie� wctt �u�c ��. �'l' �+b ��'• f feaebX eertlfy dr� rhe• pru{a) nn.r (vrrel caunvded ue aetarti�ace ieffli f31! NCAea?G.0100 or 13ANCACOIC.tlZ00�iPd! Coru�nicrlunSwridarids mid rJwt a �PY9fJih recad Jtt� bcra proxded ta the urlt o+vacr. - 23. 5tt� diagram or ad�#io�talweu at�l.�: Yote m8y us� �it �aCk of thia pm�ge t�o prm�id'c,additional vvcll. siic dtta;ls tsr we]l �«iddaiLs. roaniayets6sUaci�aadiuoaalpab-cs.�enc�sSary. 5U81FtiTCALQfSTUCfIOi+[S . 24a. For Ai� W.dtx Submit tLis .f�nu within 3U days o€ canpkti6n of w�d1 �truc�tioa tbt5c folidwu�;: 10. Slx6eKstertevd bdo�rfapotcasisg. z� (fG) A'n"►s�on o6WatarQnaGty, itdor�a�eo.I`rocessing Uni� If �wrer lerel B aliave casirr� are '+- k617 Nfa►� Secvix Centa, Raleigtr I�C Z7@99-I'617 2l. Boreiott dimtieter: L� ('in.j 24� �dr Iaitt6on Welts Tn �+idition tq saidiag thb fatm to the address in 24a � abovq aLsa SntsttmE � copy o€ dds iorsd iviihia.30 days of canpidiou oP �il L2.'@VeIIwnsbRctionmqhad: ,F%�,,,�, J[��",,�1e4/ m�truCtiaa�boffiefollowici� �'ia avgu. mtaY. eabk. diced Pcst� �te.) � Di:isioQ of W.�Lu' Qualitp,. qade�Cua6d iajec�oa Contrd Prosram, FOR Wi4TE#t SUi'PLY FVELIS OTTI.'Y: � 1636 i�{ail5crriiae Ceater. RaIe�4. NC 2769�-163G I3a.Ydd(ggm). MetLodeftrs� Blown20minete 2dc�ariVAter.Soppl�BtiniectimVfrdis� lrsadditionwsendinglhe#o�nto tht addrss(ct) efiove, efso sib�ait one cqry of �is ioiin wi#hin 30 days o£ 13b.I3�siufeetion tygc �"�TH Amoaot '�'�� Ci1Jp aomple�on of wdt eotrstNdiart to the oouniy E�caitfi depa?�art af tfic casnty whv�e co�istriuitd. Fax GW-I Nath Gxntina Dcp� afEavitonmat aad Natc:al Ruoacecs— Diraiw of Waccr Qualiry Revixd Iaa. 30 l3 Application Date: 2�i 1 � ta Amount Paid: r�oo.°�` Receipt #: �� Ck� �uu9 ��: f I�IEI�� ' IGna�vnn-caaa naaona�inll 1Hlvinll i�� Application for Services Services Requested ❑ Improvement Pertnit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) �Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 Taz Map: Ay� Parcel#: '-1�1 �� r�,��le ❑ Construction Authorization (Fee is denendent on the tvpe of � Permit Revision $75.00 ❑ Repair of Existing Septic System Annlication: No Charee/ CA $150.00 or $300.00 1) Applicant Information: Natne: j2�,,�-f- -e.s Address: ,3 9'!7 Nu ✓�1.� � I I s �, �b,�;� �1c. a�s�� 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): ,�3 � -a�,?�- �i � 7 (work/cell): 3310 - �O �5- 5/0 9 p_,�� 12 ,` 9 � � - o?.� �% - /!o �,.3�'� �Z.,� ` s�'i '�►�r.ti e c\ � �y�' � I �%' Phone: � �c / d� �' },�,y� 3) Property Description: Lot Size: �c_Subdivision: Lot #: Address and/or directions to Property: N ouse e�-� i��rsPc�-;v,., �� •�.-!k /1�`7 9- (3PsS;-e. Da.n %z ��i y.�S -{�i'a�, a 1 cQ I�}a e mc�.s�'s S � ❑ yes no Does the site contain any jurisdictional wetlands? � yes D no Does the site contain any existing wastewater systems? ❑ yes �ZI no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �$j no Is the site subject to approval by any other public agency? ❑ yes i,Y( 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: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: `�l Repair to Mal� tioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no +'2,,� p►o. csL o l� �v �l l ONon-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: LJ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? l�yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If applying for `Authorizallon to Construct', please indicate preferred system type(s): �� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any I cerhfy that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. � (Owner/ Representative*) * Supporting documentation required. � �a'9 -�O/( 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. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��.sf ��.�� --�- � � �� IC�m�n�r�aa�ran.o�ra��.lL ��eBlL��a WELL�ERMiT (New �� Repair_) Taac Map: � Parcel: �_ Subdivision: Lot: Applicant's Name: ,) e Mailing Address: Zi 5 �. � ZZ l PhoneNumbers: 33 - -R 33�- 4�S- StaR Location of Properiy: Permi3 Cor.ddtinns: 1.) See attached site plan for proposed well location. ?.) Ald appldca�le Stats �rcd Cor�zty r�gul�ticns governin� construction and s2tbac(�r a�ply. 3.) Permits expu^e S year� from the date o,f'issue. �� 4.) Issu�nce o�'a pe: �mit aiaes �ot g�rar��tee aFvtuble w�rt�r suyply Other Conditions/Comments: AM a,n al _ S c��'S Permit issued by: -� �ew Well: Location: Grouiing: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: EHS/Date ✓SS y-lto ✓ ✓ T'S Well Driller: �a r..�.}-�C Pump Installer: Approved by: /1. Adrii!i�:�a! Comments: DateSamp:eColl�cted: q-2S�-(4 EHS: SS Ferson County Envirunrr�ental Health 325 S. Morgan Si.,Suite C o...��.., nir ��t�� Date• $-(-1(� �ertificaie of Completion QLiner: EHS/Date Depth: Grout: DAbandonment: Date: ivlethodiMaterials: License #: License #: Uate: . �I -� � -�-- Date Results P�Iailed: Phone:336-597-i750 fax:336-597-7808 1'1 /'iG/1 ] ��.s�� 1�I��.�� ]Faaarasoassmca�o�m.�.Il' IE-]L�ars,lL�7is. SITE PLAN � Name � Tax Map# Parcel# �K Subdivisi Ssction/Lo�# _2._l � Authorize Sta:e Agent �ate System components represenl approximate contours only. The contractor must Jlag the system prior to beginning [he insra(larion tn insure that nroDer prade ts muintained. Aug 0516 12:26p Barnette Well Drillinglnc wEr.�, �aNnorr�rr� xEcoRn This form can be used for single or multiplc wells 1. Well ontracrorluformation: `` �` ��2` r^ � � � �� —j � We11 Conuactor Namc [or well oavricr persomlly abarsdonit� we]1 on hisAtcr property) � � / �1 � J / NC WeII Conaartor Certi6cation Num6u 336-598-9275 p.2 For lntcrnal Use OYLY- ]VYELL ABr1TVT)(1NMF,NT DF.T.4R.S 7a Num6er ofs�clls being abandooed; f F'w muJtiple infrcrion or r�on-batcr supply NeUs pNLY wfth the aomc coastrucllorvdmnJairee� yauc�.cqburi�nnrfa�q. 7b. Approximate volnme of wster remaioing in well{s): (gaL) FOR 1YATER SUPPLY �VELLS ONLY: Company Name 7e i'ype of disiefectant used: Z �' 1-L 2. WdlConsirucoon Permit#:. � 7 � � Ust o1i opphcable u�el1 permil� (�.e Caunrv. S�a1r, 6nna�. Injruinur, elc j iJkno�nr 7d. .4movnt ol' disinfeetant nud: �'-�.- �� 3.1Ye11 use {check weli nse): l�'ater Supply Wotl: 7e. Scatiog materiais ased (thcck a!1 that apply): ❑Agriwt[ural GMunicipaUPublic ❑ N�calCemen[Cnout ❑ BentonitcChipsorPdlexs OGeothertnal (Heatin,r�/Cooling Supp{y} �ential Wata 5uppiy (single} �'$�d Cement Grout O Dry Ctay O]ndusL-iallCommercial GResidenria[ WaterSupply {shared) 0 Cencretc Grout ❑ Drill Cutpngs a� �� Q Specialty Grouc ❑ Gravet Non-WaferSapplyVVd): Q BentoniteSlurry � O Othu(eaplainunder7gj DAquifer Recharge DAquifzr Scorage and Recovery ❑AquiferTest ❑Experimerrtal Technology aGeorherma[ (Closed Loop) ❑GCOChetmal fHra[in¢/C�nline 1 ❑ Grourtdwa[er Remrdia4on OSaliniry Barri�r �Stormwater Drair�e Q 5ubsider,ca Cortrok OTracer ❑Otha � exnlain under 7g) 4. bat<well(s) abandoned: �'J J�` e Sa Well location: _� ._� Lt� f �I,r� �f' � , Fa;ilin"/pH'� Name Facilicy ID! (if zpp3icabEe) J��? r`��vcr2 0� N��/e h�:Ir r�-�� Pli�sica I Addres5. Ciry. and ZiP Za�A�= €- /,_, ��. �P ,�5� ;1v' CO��=' Pucc! ldeno5;,apon i�a (E'IN) �b. L.adtude and longitude in degreesfminuteslseconds or daeimal degrees: (ifivdl ficld. one latltong �s wf�eicnt) 36 —1,s�, � c. � ,� 7i� r; ,�� S` w CjQN�('RUCTION E'TAILS Q�tVFi LfS1 BF1N� ABANDQ]+1�U Atmch ve!! cpr,siructiou retvrdfsJ iJarePlablt. Fnr mrd�iple ixjrc�ion nr rwri-xarer rupply n�cTLr ONLY N•.U� �be smtte cau�n+rGorc'obandonmrn; ynn oun sr8nrit a�sjorm_ fia We117Dt1:_,�`%'G 6b. Total wcli dept�: � L� {ft) 6r. Borcholc diarncter_ � �;n,� 6d. Wa[cr level bdoR gronnd sorCace: �� (ft) 7f. For caeh materiat selected above, provide amount of materials nsed: 3��9� f6� c,�wr��er�� R� �- e l s H%lc%: r� �f�l� 7g. Prwide a hrief ducription of ihe abaadoumeni proceQure_ �; u �� n� �, i Y 8. CertiScatiau: � c�.�. �� , r�'�C.� �' -5 =r� SiyutureofCatificdWcllConlraeDoror\VellOwne pate By signing this form, T hereLy cereify tha; tlee ;a�ellFs} x•as (KereJ aba�doned in accorda�7ce tivith ISA NCAC 02C _0100 or 2C .010p iYe!l CarstrJch'on 5landards and that a cop�� ojthis recad has bee�r provided to the weJ! ms�ner, 4. Site diagram ar addi6onal wcll details: Yoa ma}� use tFee back of this page to provide additional w�ell sitc details or weil abandonment details. You may also attach additional pages if necessary_ ST iBMi'f'f'AL 1NSTR�JC7'I�NS l0a For All Wells: Submit this form wi:hin 30 days of completion of well abandonment to the following: Airision ol'Water Resoarces, InFornw6on Processing Unit, 16l7 itilsil Service Ccnter, �isleigh, NC 27G99-I627 lBt�. For Iniection R'dls: [n addition to sending the fotm to die address in 1 Qa above, also submit one copy of this form within 30 days of completion of u�eU abaadonmeatta the follo�c�in� Airision o[ri'aterIiesnartcs, U¢dergrouud Injection Coatrol Program, 163d Nlail S�rvice Cedter, Raleigh,lYC 27699-1G36 6e. Outereasiugleugt6 (ifkno�vnj: /+�� f�� lila For Water Sannlv dc lnfecSon Welir_ In addidon to sendin� the form to the addrezs(�s) abovt, also submit one copy of this farm withia 3Q days of completion of well abandonment to tha county 6ealth departmau of the counti� 6t Inner casingJtubing length (if I�o�vo� �iq (ft) ��e abandoned. 6� Sereen len�t6 (if l�own): JFrl7 (ft} Focm GLV-30 NoxtF� Carolia� DapannxntofEaa•unnmentand Natmal Resources—D'n•ision of Water Reso�ca Revised August 2013