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A40 388I�'� �� ` AppfiF°ation Date: '�-�-I(� Amo��.tPaid: Zoo,ob GK�15� Receipt #: ,�]2_Q23 G�00, 0 U 117D6� \�' ?,�f �� 1 � Tax Map: Li 0 . ,,�, j- � � �� Parcel#: 388' ]t�,.�.�� a-��.�: � ��.11 IH[ �:�,.11 a:ll� � � z/ �G ic tion for Services `1 x=S ��Z- Services Re uested Improvement Permit (Site Evaluation) Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the t e of s stem ermitted) Mobile Home Replacement or Building Addition Permit Revisian $150.00 (if site visit re uired) $75.00 Well Permit (i�ew/Iteplacement,Repair) P.epai: o: Existiag Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: . Name: �,1►1�{J► �1 u A w/r' ��v S Phone (home): 3 3` 3�4 z�� Address: � z 4 r- � !.1 � at �J � C M � +�► s /� �r (work/cell): ' � S�i $' 2 ► � 9 2) Name and address of current owner (if different than applicant): Name: Fhone: Address: 3) Propert-� Description: L�t Size: Subdivision: !I � C 2 Lot #: � Address and/or directions to Propert-�: ❑ 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 pubiic 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: �/ Occupants: ❑ Expansion of E�isting System If expa.�sien: ��ar: er.t mam�er of be rooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes ❑ no ONon-Residential Type of business: Maximum number of employees: Tatal Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New weli ❑ Existing JVell ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If applying for `Authorization io Construct', piease irndicate prefer��ed system type(s}: ❑ Conventional ❑ Accepted ❑ Innovative ❑ A(ternative ❑ Other ❑ Any I cert� that the information provided above is cvmplete and correct. I also understand thut j the infvrrr�ativn p� ovided is inacc te, the site is subsegu ntly altered, or the intended use changes, all pernzits and approvals shall be invalid. �� I o-,.�—� � � 'l -i le Signatu (Owner/ Legal Representative*) Date * Supporting documentation required. 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, �1C 27573 (336-597-179Q) ��, ; , �� )E-�s �.-yn �-� �:��.Il IE-3I � �.11 �Ih� Tag Map: �� Parcel: 33� Subdivision /i � Phase/Section/Lot # Applicant: �,4Ai1�fi1 � �/1� I y Address/Location: �_�� ----------�'%��.-------_____._.___��---- -- — Tmga-Qdpm�r.t Perrr�ii Permit Valid for: Five Years ✓ Non-expirin� Type of Facility: �/�f New � Addition _ Number of: Bedrooms / Occu ants / Employees / Seats: Proposed Wastewater System: Proposed Repair: � Permit Conditians: Authorized State Agent: (X) Owner or Legal Re 1h'ater Supply: �g�r-Z,C, Projected Daily Flow:� gallons/day Type�.�� Type• —/790 The issuan�e of this permit by the Health Department does not guazantee 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 pian, plat or the intended use changes. 'The lmprovemeni is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws a�rd Rules for Se►vaF� Treabnent and Disnnsal Svstems'(15A NCAG l8A .19U0). Neither Person County nor the Environmental Health Specialist wurrants that :he septic system will c�ntinue to fanciioQ satisfactorily in the future, or #hat the water supply wiil remair poia5le. Authorization to Cons#ruct Wast�water System See site plun arid addiPionul attacltrnefzts �_). x Proposec� Wastewater System: �� A (*)Type �� Desi n Ftow �_ gal./day Nev� 1� Repair _ Ex ansion � Soil LTf�R: . gal./day/ft2 Type of Facilir�: Basemenc _ Yes a/l�io (*) Sys[em Types III6, Illbg, IY, and i; require periodic sysrem inspections by the Ferson County Health Department. W�stewater System Rps��riremen*s Tank Size: Septic Tar�k � gal. Urainfield: Totai Area 6 b sq. ft. Trench Width _� ft. Pump Tank /D6t� gal 'fotal Length �_ ft. Min.Soil Cover �' in. Grease Trap gal. Max. Trench Depth l� in. Min.Trench Separation ft. Dist�ribvtion: Distribution Bex ! Seriai Distrihution__ / Pressure Manifold _�/ Specifications: _ G/�� ;l� � Ai�thoriz.,d State �igcnt: T'he system permitted is: Conventional ai�d specifications of � {X) Owner or Legai /Accepted � / Alternative Issue �ate: l�f� Pe!�mit Expiration Date: / Innovative . I accept the coliditions Bate: �'� � 07 _� � Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC' 27573/ph: 336-597-1790 (rev 5/12) IZ-�1-�� ,tg . R.v:.,� officQr , pT piot to �ahich thtis to+y +.qu4+r++�ents Jb* � �„� "� �jf �IDGE ACRES LLC 3g0-340 'OUSHEE LA SALL� AVENUE 50' R,/W N82 58'19"W 26�.6�' C3 C2 � .-�., i � � �`Mqqq � O CE��R�`1NE GF BR ANc� � D.B. 390-340 S8'' ,v�2 5a+� s"w 2se. so� %TOTq�) ' o �I � � V� � � � .� o . � � � F � � .�. O � , O O `a •'� 4 y fi s I 0.. u �; � Q � � ^ � � C� m � ep 4 � � �� I � A�q � � M� � 3 ; � � � h�r 9 4'a � a i l� ��—�pJJW� � � � � I `, ..�L� � � J c�i C �� ag Z �� i �=•-i . , �r� � a o � I !�Qd F L�'„ a q =�o � � q VJ O b o� ! `J' n � � r Q: z� V'' ' � S a�� ; . f� �b d f�.� �� _ `0p� I " ' o�c nq. • � �[ Q ° 4 �+ � u r i � i ' � ti 4 � � �tl� � 'O q � h : i d �+` ' � � b .V . W �l � a �=d a 4� � � r� •y ��e ,Q i �� a� lC h z�, �,'��z ��.s� ��.� �� ~ �^ � � �� I -�+..sa.-d-n.�o,.�. ,,.,�,. �aa.��.Il IE-1C�.a�.Il�GI{a Sloped To Sl�ed Watez IS" Coves • � ... Ixilet Fmm Sepfic Tanle +1" SCH 40 PVC Pipe ' NEMA 4% Simpiex Contsol Panel +4" X 4" Pressare Treat!ed 12" Sepasatiox F.lectrical Ccnauit = 0 �. . � . • • �.. � • ` Accesa Cover• � • • - • ' �� ' •I � � � •' �. �• r • � Y J •.: or�F�awth . n��s�. -' ; � Po:tlamd Ce�e�ent Graut Phon Ho1a' ♦ . �� Cl,eck Valve " HigH. Watex ILiarm Lev�el :•� ' ��° SlpaYd{IOri� :>• iiigk Lev�el- Pump Ox -�� .. �� tt fiVapozLock •.: �Drawdrnyn Hole .r � � CQr � • •Law Level -Purnp Ofi' -�---^' �:. t ' t � ' Piecasi Concret4 Taak .•; (MaterialStxength}35( •� • •, � •�;,: . . . • • . _ T�x M�� L � P�rcel # ` ' Suhcllivisio i �� Ph:��s�e Sect�ion'Lnt # ' ' Ih�et SealBotk End� Of Tke Con�it -` 24° Minixtnun —i .. ., . , Threaded G �te Valae Zip Ca Ties 4° Cosusete -. :'. •_ .•.'� Concre{e Riser �° Separation ' • ,' � %�;.t/s+' - r�.----pextlasul Cox�crete G:out ". " . e� Mas4ic • - • r. � .;.• - : • . �p�y , . � Openixig Filted V9ith ,ine .. = Portland Cemex�t Crmut Outlet To Distrbutiox 2" SCH40PVC Pipe 'e Float Wites .� � .a f i Floats ; � �ILemovab1e '.:' . F1oat Tzee ' � , : �. r� , ' �_� `�` �_ .' .+. �odc� ��.a�v�n�e T�v.� � �_ � . Pnmp Hust ge Rated To Deliver � �0 Gallons Pes Hinute. Agaiest ! Feet Uf Tota.l Dyna�i� Head TDH). ��`�. � I�I�I�.�� s. �w�-� s = � � gT��i' Q��,�,�g,� ,� g 8� lE�.-�.��,.,. ,.,,,. ��¢�.11 IH]C�.�.11•�. Owner: S Tax Map: �� Parcel #: 3�i Date: '7� z�- �� I.ine T'ap Tap (Sch) Tap �low Line Lengt�a �iovv /��ot # i?iame�er(iia) ( m) �:. (ft) 1 � � �(o ?- I �v-d � .02/ 2 '/z �( o �� . I 3 2 �l n 7- I 4 '(z �( � • 1 5 S 7 8 -�- Z V'PH �{- o -2 9 10 � � ft of line x 65 al. per lOQ ft=z�0��'�'� ; 100 =��0 � gal 75% x 2�� ga1= � gal per dose '�_ gal per minute (gpm) = I�'low Rate �+'riction �ead ' Loss: �?� ft per 100 ft of supply line x'✓� � ft of supply. line =100 =�' R� ft f'`� ft x 1.2 = 3 ft of friction head �. Manifold Size: �_" I�'orce Main Size: Z " PVC Total Dynamic �eari =�ft of Elevadon head + Z ft of Pressure head + 3 ft of Friction Head = �TTDH I'ump Itequi�eanent: �� GPM @� ft of Head i)a�awdown: �al per dose ; 21 gal per inch = �� inch drawdown per dose C�atea�ai 3D� �or�matioa �ti:.. ... rvcr�a,vatYe sa�AorvcTm ��+ar . r�w ' - - � � - �. � : � ,. �[t�)��0�00 iiii � ii � iiiiii �+ iii � iii iii+: iii � �r��ia�i��i��i�ii�ii��:�t+iii��+ : :� : �: �iianifoid Siz / � Ta s ��i%ld Max �To. Taps off one side g;� (,'tedace b �a ;or ta in �oth _._. �,,,.--- �e� � �u 16 y � {n dQ.l. 2 i 12 . . . . _ , � I1ozv er TaP Si�e iLlcu¢rial FTa.v GP?rl te. �� Scf:ed 8Q �.� �,'� Sc3ied 10 %-_' ;, " .:iched 80 !� ! •• �� Sciteri sp :%.5 -. I" I �; I � � ��> \ I��da�-��,Il 1��.IL�I� Applicant: Location: � Tax Map 40 Parcel # 388 Subdivision OaK��ao Acc�s # of Bedrooms �{ l:td �Q« --� �� n..l �Ju��w/' " ��r-a�i�� nit System Type (From Table Va): �L Product (IIIg): Znf Type V& VI Expiration Date: Type V& VI Renewal Date: �►� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disgosal, and all cons3ations of the Imprcvemeat Permit a�d Construction Au�horiza�icn. �' �� 2-�� Authorized Agent) (Dat ) 5 y� 2-�-�� (L' ensed Contractor) r o�� y' (Date) � ��`� _ , t � •I:�� (y� '. �) • �Y . �J . Scale _ �,�__ ?CHD, : ev. 1 �;14/12 0 . � S�lt� lin�'r �-- pfE'�3i1t'�'. �'►`6,^r,i?:'S�i� (1CJ�", n,5�'R��fC� (.�S � Z- 1—i� P�essur� �t��td',=�1- su�o�Y l�n� inSEallc.d Z-�-l� Line Len ' 2 � 3 � �f -Zo ' s � Total 35 ' Tax Map: , t�_ Parcel #: 3$8 s em ec is Type II� - ys em ype: Notes• Pump System Checklist Contracted Certified Operator (Type IV Systems): � � � .. -. iZ7n .Tr . , • . 1 7r. • . i G ,. � . . �' ConnectGIS Feature Report � �� CT�'►I S tVEB HC75TINv I`�T�.'� �+L'� �i.� �P^�c��+ i"�/a��l� ;rI �n �� . � '�' I � 25099 ,,� �� , i,.� `� � �- ��^�aoo�1, � ��o �� {� t> r� F,T Z 'r ��-/��- • P / . .,.f �; t� t_�� l} �- �� -- xil' 2509� SE��'tC i k*1 I oc�� , �u�l� T�1 a � (OCOe%%.�f � R � Page 1 of 1 : A�o - 3,5� Person Printed December Ol, 2016 See Below for Disclaimer �:, �; � 2svsa� ; ;, 2';.i�.� ft ., ``_ � y ��o�s � Contr�r �� Gv �'�7-1�g0 � •� �� ,.� l r Io � �� 25��5 � �\ � � - -� - ---- . ��e�D...- . _ __ . . , . 't' :; r". Q � G !;:j.',.� f� ., ; j!,; �r '"%,.'' /i'',:' jf; ;,�,� ; '�%i`, ��:.'c%%�• ��i �%�,;i'�;; :�Per�gn r f;. ,i�,. ',�,`+;,.'' � `. � �`% 83, / ' % 'i . / .'. ;//.:�'i�''ij,' -'�' ��1 ��'"�-� �R, '�, �� t:l;i._ t� �•�' r� �rif:; .`r ' l' �,_� / � � . � £� j �,�,/. .� �r ''/`�.:� ;/``. :fy f� �; ;i�':/�.•� fl.; ��' i`;.� / .`�:�'/ �/ � _j' / l i r'': �' �S ��:' �/f�� // �: y�' `T� �;! � / / ,.� . / '! /� �i � � � � / ' � ' / , :% /;' /,.' :' / :� ! i �:�' % � � •'' /� ��, ` �/. � /' � �� . i �/ i '�� I. %:': �t�'.�,�.'�/:'+, f/,./; ''ff.^� � , a i/ � � � i � /i -,. � �, i; � , ./ �,�� i� '� �,�'�,%�' 1 : 80 Feef . �, S R� . � i� , � ,' '/ i.� /. , .r •i':':��:`/ �_ rn � � � i . 'i �;. .,�;, -,�.�:� JTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who havf centiy upgreded to the Windows 8 operating system or a new version of lnternet Explorec We were able to resolve this issue by directing users to the Intemet F�cplorei �mpatibiliry View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-USlnternet-explorer/products/ie-9/features/compatibility-vieH this does not solve the problem feei free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has beer epared for the inventory of real property found within Person County, and is compiied from recorded deeds, piats, and other public records. Users of GIS system arE itified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectG!! sume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. httn•//vic nPrcnnnnnntv nPt/(-nnnP�t(,'TT4 vFi/l�nwnlnadFile.ashx?i= aac man�Or,�1a91 fl 9hr. 1 �/1 /�fll ( ��.sf ��.�� - � � �� ira�au-�aan-ffao�radam.�. ��cem��a WE�L PERMIT (New Repair _ ) Tax Map: �"( v Parce�: 3� � Su�iivisi�i: QM,�n o(qR rec L�t: �_ Applicant's Name: � �`^' � "�S Mailing Address: Phone Numbers: Location of Property: _ sf �S o� � f-� �n(�. Permit Co�ditions: 1.) See attached site plan for proposed well location. 2.) All applicable Sta�e uftd County regula��ons governin� construction anc� sEtbacks apply. 3.) Permits expire 5 years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: � `-. �Tew Wzll: � � EHS/D t Location: Grouting: Well Log: Well Tag: Pump Tag: Air �Jent: Hose Bib: Casing Height: Concrete Slab: ae S - I 21� Z�S'�6`� ✓ ✓ ✓ V ✓ Date: � 2 �^< <p Certificate �f Comp!�tio� � Q�L,iner: EHS/Date Well Driller: S o Pump Installer: • ' Approved by: � �� Additinncl �L'omments: Depth: Grout: DAbandonment: Date: Method/Materials: License #: 31 D License #: Date: _ �Z $-1 Date Sample Collected: 3'-�-Q ^� 7 Date Results Mailed: EHS: Person County Environmental Health 325 S. Morgan Si.,Suite C � Phone: 330-597-1750 Fax: 336-597-7808 Roxboro, NC 27573 11/26J13 1. WELL CONTRACTOR: .I�LSIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources — Division of Water Quality WELL CONTRACTOR CERTIFICATION # 3104 Van Elliott Weli Contractot (Individual) Name SOUTHERN WELL DRILLING Well Contactor Company Name STREET ADDRESS 1530 Beaver Dam Road Creedmoor NC 27522 Ciry or Town State Zip Code 9c i 9 �_ 603-7165 Area code- Phcne number 2. WELL INFQRMATfON: S(TE W ELL lD it(if appl'wable) �- G o��c�l� 3� STATE WELL PERMIT#(dappiicable) DWQ w OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box): Residential Water Supply Q DA7E DRILLED , " � � '� �, TIME COMPLETED AM O PM Q 3. WELL LOCAT ON: CITY: RO C pfY� COUNTY �'Qr'S 6�'1 q � �.�� li� . (SUeet Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Gode) TOPOGRAPHIC / LANp SETTING: ❑Slope pValley ❑Flat ❑Ridge ❑Other (check appropriate box) May be in degees, lIiTITUDE 3_ minutes, secondc or LONGITUDE in a decimal fortnal Latitude/longitude source: pGPS OTopographic map (Iocalion ot weM must be shown on a USGS fopo map and attached to this lorm �7not using GPS) 4. WELL OWNER � OWNER'S NAME S�3'L1 h�1 �� h j STREET ADORESS � � City or Town State Zip Code L_} Area code - Phone number 5. WELL DETAILS: � d6 a. 70TAL DEPTH: b. DOES WELL REPLACE EXISTING WELIT YES ❑ NO'�] c. WATER LEVEI Befow Top of Casing: a� FT. (Use'+' H Above T of Casing) d. TOP OF CAStNG IS �� FT. Above Land Surface• 'Top of casing terminated aUor below land surtace may require a variance in accordance with 15A NCAC 2C .0118. � e. YIEl.D (gpm): ��Z METHOD OF TEST � f t. DISINFECTION:Type Amount g. WATER ZONES (depth): From�d T� From To From To From To From To From To 6. CASING: Thicknessl pepth Dia eter Weight t al From � To �� Ft.� � Ftom To Ft From To F� 7. GROUT: Oepth ateHal , From i5 To :L v �t. From To Ft. f rom To Ft. 8. SCREEN: Depth Diameter From To Ft. in. From To Ft. in. From To Ft in. Meth pd�� Sbt Si2e Material in. in. in. 9. SANDlGRAVEL PACK: Depth Size Mater'wl From To FL From To Ft. From To Ft. 10. DRILLING LOG From To 11. REMARKS: Formation Descripfion I DO HEREBY CERTIFY THAT THIS W ELL WAS CONSiRUCTED IN ACCORDANCE WfiH 15A NCAC 2C, W ElL CONSTRUCTION STAN OS, AND 7HAT A COPY OF TIi1S RECORD HAS�OVIDED TO W L OWNER. �� SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE /�i�,� l�-� lo� PRINTED NAME OF PERSg14 CONSTRUCTING THE W ELL Submit the original to the Division of Water Quality within 30 days. Attn: lniormaUon Mg�, 1617 Mall Service Center— Ralelgh, NC 27699-1617 Phone No. (919) 733-7015 ext 568. Form GW-1a Rev. 7/OS \� 7 �. � � � ,� �,...-., ,�+ _ �� `�..� � � �� :',,��rii�caaevnr�nit7►:�;,,�n�at�,�.� ��"'��r��iti:.�ir� Date: �/ ��/� Name: ��'"i t✓�K Address: 0 4 e �( . �r ,,,fl C 5 ? Re: Bacteriological Test Results Dear Well Owner: Tax Map: `�D Parcel: �� Your well water was sampled on �/ Z� /�, and tested for both total and fecal col:form 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, coo ing, washing dishes, bathing and showering, based on ihe bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soi;. Fecal coliform bacteria arz 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 rot b� safe for use. Young child: en, 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 or fecal coliform bacteria should be properlv disinfected and retested prior to resuming 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. Sinc rely, `\��Ye✓ Environmental Health Specialist Person County Health Department (rev. 4/20/16) Perso� County Environmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579•1790, Far 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 Name of System: SAMMY HAWKINS 103 LASALLE AVE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 ROXBORO, NC 27573 ROXBORO, NC 27574 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES033017-0103001 Collected: 03/29/2017 10:50 A. Sarver IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 03/30/2017 08:29 Angela Heybroek ES Microbiology ID: GPS Number: Sample Description: Comment: Sample Source: New Well Well Permit Number: Sampling Point: well head A40-388 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 03/31/2017 E. coli, Colilert Absent 03/31/2017 Report Date: 04/03/2017 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. �� ne d¢parhnent of 6eaR6 and humen serviees ��, , e . ,� � ; , E ,�• , �^ � ,� ,--•- ` � , � L ;- �.-,, 5•--�''� b 1 ,s � � ,��, ( I . � �, : f � fI`� , r l �"' !`i �"t , t!; , € � t � f �;� � L.i l! i f� 5\ J I 4 � 6� i i�,' i � f � i,i '.. i i,� �!-.� ! p ,, p l �; � I � � � � °e" r�►� ;!� %�, f - �„r,� ; �`.",1 ,., , r �; j� ; .-. , �.� {I_+ t t�/' .,.,..:� �, `�,t `t Ls �� f p s E r �.,,, `,j F E' y,; I�� r�i e t�, _ c�� L. For Inorganic Chemica0 Confaminants � TEST RESULTS AND U5E RECOMIV�NDATIONS 1. � Your wel! water meets feder�l drin.king water sta�dards fo� inorgani� cnenuca�s. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the iKar�onic chemical resalls onlv. You may have other water sampling resuits that are not taken into account in this report. i. �The following substance(s) exceeded federa[ drinking water standards or the North Carolina 2L calculated health levels. The North Cazoiina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the cucled substance(s). However, it may be used for washing, cieaning, bathing and showering based on the inoreanicchemical r�cullso�lv. Arsenic � Barium � Cadmium � Chromium Copper Fluoride Lead Iron ivi gane Mercury � N�trate/Nitrrte Seleniwn Silver Ma�nesium Zinc nu 3. a, Sodium lev�ls exceed tha U.S. Environmental Pratection Agency's-(USEFA) Health Advisory level for sodium of 20 m. 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 hased oa the ino��anic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. 0 Re-sampling is recommended in months. 5. Q Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a I S 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 inorPanic chemicalresulls �nlv, hut aesthetic pr�blems such as bad taste, odor, staining of porcelain, etc. may occur. You may want te install a household water treatment system to address aesthetic problems. Barium Cadmium Chromium Fluoride Iron Man�anese Selenium Silver pH Zinc For more informatian regarding your well water results, piease call the IVorth Carolina Division of Public Health at 919-107-5900. �� North Carolina State Laboratory of Public Health 3�12 D�st?ct�Drve �� Environmental Sciences Raleigh, NC 27611-8047 � htta://sloh.ncpublichealth.com � �,w� , Inorganic Chemistry Phone: 919-733-7308 'c�«,M,,,�w 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 103 LASALLE AVE ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES033017-0058001 Date Collected: 03/29/17 Time Collected: 10:50 AM Date Received: 03/30/17 Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: A40-388 Sample Source: New Well Temp. at Receipt: 0.5 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 Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:04/10/2017 < 0.1 < 0.001 57 < 5.00 < 0.01 < 0.05 0.41 0.27 < 0.005 3 0.360 f 0.0006 < 1.00 < 0.1 8.1 < 0.005 < 0.05 21.00 44.00 155 160 < 0.05 Page 1 of 1 2.00 mg/L 0.005 mg/L mg/L 250 mg/L 0.10 mg/L 1.3 mg/L 4.00 mg/L 0.30 mg/L 0.015 mg/L mg/L 0.05 mg/L 0.002 mg/L 10.00 mg/L 1.00 mg/L N/A 0.05 mg/L 0.10 mg/l mg/l 250 mg/t mg/l mg/l 5.00 mg/l Reported By: Deddie .r'�foncol