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A41 144�i v Application Date: �' �4 �0 d /, n � Tax Map: Amount Paid: a d0 . 00 � 3� 0 Parcel #: _ Receipt#: s � � _33 `� � � �_ o � �� S� I�'I�IEg.��T � �� a i ��.�u��_Qn�.��.��,��.,� �E�L�.u..u�:�E� Application for Services (Septic Svstems and Wells) ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Reptacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Services Re uested � Construction Authorization ee is de endent on the e of 0 Permit Revision ❑ Repair of Ezisting Septic System No CharQe Important: IJthe information in the application for an Improvement Permit is incorrect, Jalsified, or the site is altered, then the Improvement Permit and 1heAuthorization to Construct shall become invalid 1) Services Requested by: Name: �cisor� (' ,(a�.,�'�n Address: ��_��-r_ � 5-�-, �-� 1�� . r.>t �757> Phone # (home): S�'7-�,'' JS�� (work/ et�Il : S' �,'3 - �' 'i '� � 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: ,S�_ . d y�,r Subdivision: Lot #: _� Address and/or directions to Property: T, �,� f-!. _, �nll.. i-/� ;!/t .��. , c;/ -f�(� i�J^�n� Y!_:�'.r� K� 4 r�"if�' r S r LS't'��'l1 %!(�i�t � /4�-L"-:-.� /� /�I� C{ )�.!t ..:t�.r /' f'�, ' � � t `J % 4) Proposed Use and Type of Structure: Residential ;, Business/Type: Other Number of bedrooms 3 / Number of people served (seats/employees): Basement: Yes � No (� plumbing: Yes No 5l___) Garbage disposal: Yes No S7 Water Suppl : Private Well � (Proposed� Existing _) Community Well: Public Water System: Are there on the adjoining properties? No �� Yes (please show location on site plan) Note: A comnleted annlication must also include: ➢ A plat/site plan of the properly that shows properly dimensions and ihe size and location oJall proposed structures. ➢ A signed copy ojthe `Lot P�eparation' form ver�ing that the property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): .� o��-� Date : t-�'" �`�� i ��.� �� I `J• � � j � � •�^� �./ � "aJ .� V � � . . ��.��a�� m.�.�.�. IL-3L��.]1�I�. A�mlicanfi ��a�i �Talad f�r '�( 3� e Tyge of Facili�iy: # of Oc�ants /� # of Proposed Wastewatez System: Proposed Repair: �.� x Ma� � ' �rc l � SUIbC�IVI 1011 � h�.se; S�ct,ian: � t � .�, �ppo�es�esa�.�es�mit _ 1�% ��fion • / ; . New x A.dditian . �ater �aa�p�y �l( �ooms Projected Da�y Flow 3ro� g.p.d. — a �' � .. ' � Type: c�1F- �,o , Type: _ , . - - . P�1� COIId1t10IIS: � � S/, � S� � � , Ownes or Legal Representative i e• ' - Da#e: `' '" � 15 Authorized State Ageu� ' Date: S z p .. The issuance of this pezmit by the Health Depaxtnie�t m dnes nat gnar�tee the i��,ar�a of other permits. It is the respo�iliiy of the applicant/property owner tn in siae that aIl Person Cou�y Plaaaing and Zanmg and Bu�ding Inspe�tions requnrements are me� �his �apr�veme�t 1'ermat i� sa� je.�t ta revo�ation if tise sa� pian; �pl�t�'or� t� inteudesl aase c3nanges. '�e Y��u�emeaat �ernmii is n�� a�c�t� 3iy a ci�ange in ow�nersiup of the property, Tl�s p�tmit 4aas iss�aed in c�o�li�c� �atix ttae provisab�a of the 1�Torth �Carolina, .� �Z�,s rand Rrales f�P 5�sva�e ?`re�trnera� med 1)isnosal ,S'vstems' (�.SA NCAC 1�A .1900). 1'�either i'sa�on ,C�uatfy.: no��:#��-;� '= L�nvironmental �ealth Sgeci�Idst �v�rr�ts that the septic tank �yste�m w�l cmaiinue to fnaea:tion sa�sf��io�ily iri tflne fut�e�or�t�at. th�waier sup�ly wiII re�sin �table. . . . • Au�tlnoa i�atio� to Const�uct �aste�ate� S�(�y�e� fmr �a�aiing Pe�.t� � � ia a *. SeE site plan aysd additional attachments (_). �' z� OW • � -. ��/� . �� . Prog�sed Wastewa#er System: -P d'C� �� A'M�P.r Ty-pe�4 Wastewater �low 3��.p.d. New � Repair Expansion - ,� Soil �,�.�IB: , g.p.dJ ft 2 . Type ofFactility: ��1� R�S. ' � Bas t X Yes No � W vto � i � ��e�a-�e�r ��t�� .eqa�e�e�� '�� S�e: S�ec '��Hc:' .� 0 � C��fl �p Tau�c: gai �r�ase Tr�p: g� � I�rrai��d: To� �sa: J o sq f# To#a� Lengtl� 35� f� ' 14��ana�a Trenc�a I)�p�a ��f i.� �-� �. '�r.�m�,ia 4Vid�la � �# Soii iover. �_ in � 'I'r��n �e�s��na � #i d • C, ID�s�ai�aa#ion: iC �i�il�uiaon �o� Serial �istriibntiom �'ress�e �old . � . s��a�tia�: _,Dve- -�S�G�a�,v� /�-a e �,� .�a��r�, S� 7= � �� ?.o — : . - -. . A,�at��a� stat� �.gen�: �,�c Permit Expiraiion Date: Date: S/ z/ o The type of system permi.tte3 is Conventionai � Ac��ted Alterna-tive. I ac��pt the aperificafiions of the P�?• . �e�/��i�8a�sr�s€��.taye: �, �ate: S: ��—v� ' PCffi� rey.11/10/05._ � � .. . . . . � _. � �,��,sf l��lf�.��l� . c�� iavirouaaaoa�a.l �ee.l�a �ITE SSETCH Name �>0 � �q �� Tag Map # _` ` Paccel # l � l � n Sub ' is' n Section/I.ot# O� -_ , s�� o � Authotized State Agent Date System cromponents represent approxtmate rnntoun only. Tbe rnntractor must flag t system �rior to beAinntnR tbe lns[allation to insure tbat properxrade is mnintained. - ; ,� P,,� �-�� , w?.�.�,� �":r z 4 . `.� i.:-� ./l/I�I�IV`-1l- / ��^f L la� � K Y � � I �qr �•`l t \ �` 1 \ � �� , �+c - �oor `- �o: � ��; . ' ��, � .�..� � l �� r S��e: l ��= �aa r e � ��'• . < � ��. A' �v... � n�-µ� '• ,'��•; Y� , r''":�. , ��D �,`�?o �'`"�� PS 3,g� � r �I �S , «. ,�' '�D !s-� / t. _ ��% � k i. <., ry• S�i':.: 4.•S.i. _ } 4`i: S. . ,� , �'Z:. �, '� ��:: . �.\`�:*'� �. i.� • . '�.<, "��t;'�c'"` y :`. L %,`ti. i '� ` .. l �.d ' �. t,{, :'..:.;'. y .•� ly ' �,� Y. �i�� +. �4 • r.�..:;Y�`. .F�;� � ,i. :e 5�.;:::.. 'L `��' � 4 ; ti .. 'v '��^ : '- �[�� 'x ',. ..rt' �l '� . � \ ` � ; -� 7' .� # , �p � � 43D . h�� ' �'�, � �� . . . . . .. .... . .. .. . ... ... .. .. . .. . . .. �1�� . ��'�� . :�, v . . . : � � �� ° . . ... .:. . : . I�iim,,��.u-��,,,,�� ,,, ��:��;71;.. ]�C��.IL��7L��. WELL PERMIT • PI,EASE SE� A'�TAC�D PLAN �OR i�VELL SI-TE LAYOUT Ta�c Map � �� Parcel # � Applicant�So� C( Subdivision: � rt Township: Lot # Type of �Vaier Sugply: % Individual _ Community Requirements: Public Site Approved By: _-� `J l� g�3 a la� Liner: Grouting Approved By: �Installed by: _ Well Log: � � � Depth set: _ Pump Tag: T!� �J p'� � 8l� �i Grouted: Well Tag: Date: Air Vent: Hose Bib: Water Sample: _ Casing Height: � . _ Concrete Slab: Pj4/'�e�`t �e �� rif�� Well Driller: Well Approved by: ' ****See AttacLed Site Sketch**** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: ,: Dat�: d `S �1 �T�I�9 PCHD rev O1/27I04 J_.� -.I; "" .+X..i-2:� _-+.- — •. �1ti.` //' .��t3 � -y.�•��`:''•��, �Z \\��.:.�+"; —�-.- uUW�711 1iL! W • � �' V .� - � ' � ."h�teiL'' }: ��` '. +� .'' _ . �.'�' —t" � f�� - I�►;?:V'..�.. � ��-�:'-.• =` ' � . ° � �ii :,.�,� r'n,Ef �nl e�� /'i �l,� �L ., ... : --• .:�. � a �- � � ..- - -.r :. �:�-:, :=-�� ' �-��.: - - - . ---= r:�:�:=�:��:::'��;-:-::- - �,� . . _ . : .. _.:�... _ iiE�:.::�-3;�..a:--::..:r:��.�:�.-�e��:. D� On� �.� �- pfl . .: <- owner_ � li5 4 n G f tt y�^ Grout Log ;_ n u t P� # i�L j �P►Z'- I.ocation: � _ -� Subdivisi�.: C . Lot # Z- • WeII Consttadion Distance From nearesi PmPerty Liae (Minimum 10 fcet) 1(�_ Distance firom S�ic System (M'mi�m 6o fe�t) ��_ Total Depth: f b� ft Yeld: l GPM - Static Water I,eveL• Z S� g Water Bearing Z� Depth Z ft ft ft ft � - Depth: From� to � �� tt Diam�et�: _�;n � - T'ype: Galv'aniaed Sbeel 1�b�— Weigh� 7Lickness: S ( Height above C'marnd: _� in - Drive Shoe: Yes No Airy problems encountened wh�e settmg casing9 If "yes" give reason: - _,Xes � No Groat: - • . - Nea� SandlCem�t Concrete Grav.eUC�t _ -•. i�iular Space �V'�th - mches Water in Aimular Space. Yes � No Met�od of Grou� P� �- Pou�ed Deptfi ' to Ft r�a�terials IIse�L• � _ No_ Bags Pordand ceu�ent " Weight o� 1 Bag Po�mds . I�ner: If mndiue (sand, gravel, cut�ngs) -Ralio to ID plat� Yes _, No 4 x 4 slab _ Yes _ No � - ... � Dat,e Installed: Grout Dn7liag Log Installed by - Location Drawing I�om To li'orma�ioa . ✓��y�t�� . . �s4 • � � ' �� . � � - _ l �� C�Ifj► j� �C abOVe' II�U�OQ 1S COIICC� 8IId �18t �I1S WCll �Pd.S � III �CC �Vi�11Y�[11�0IIS S_P-.� f03'�1 by the Pecson C.amfy Heat& Departm�t - - Si�re of Can�fixcfa�r _ � /�� - ID # � 7 Daie . 7 - Z �" � � - . Patmp In�t Pnmp Inst�llation Contractor_ .� �� i 1 �n State Regishatioa Number: 3Z 6% 0 $ Shatic Wat� I�.weL• Z $ / � �utp Make & ModeL- _ .� �(,, ��-e�{- ' P�r,p Siz� and Ratin�. �(?� hp l� gpm [ hereby certify #hat t�is pump was insfalled and t3�e well head co�lebad acx�+dmg ta tibe Persan Couniy Well Rnies in effect � ti�is date and ffiat a oapy af t�is r�ecotd has bee,n p��ovided to-ti�e weD owner. , Pump ia� �ature �'" : � - D� Z � �%C� � r+ev 01/27/04 a �� r V_•- b � � / � �� .��_� ��.� ��.��. . Applicant: Location: a �� - Cia�� 0 / ax M�p �,rc Sub � iviston Fh,ase Sec .ion� ot # # of Bed�raoms �. . • ' � �Z ��,JJ . ��'�'�� [� � Syst�m Type (In Accordance Wiih Table Va): �:11�1� THIS SYSTE�VI td�►S �E��& ITISTALLE� II� C04�lP�1�►NC� VUtiH �►PPL4C�.BLE . NORTH � ��1ROLIR�A GE�IER.�►L STAzi1TES, RtJ�.ES FOR SEUVAGE iR�ATfli(E�(T AI�ID DISPOSAL, AND • ALL COt�lt3lTlONS OF � Ti-dE lNiPROVEI�lE�4T PERI�II? .�►ND CaNSTRUCTION AllTHOR td. - � � � ,�—C/ `' Z l � � . Authorized State gent aie � 1 nstalled. By: ,�� ,✓� S �ate: � �l Z l � � . . � 9 ��' 0 ;, 7��i ' �� 10 `-1-o PfL S 5 'Iz'i rCi"I�, ?'2V. v7/ZQ/�'1. I ��G �� NS��T�O� ��iE��.��7' �YP� 9@ � � Tax IViap ��1 Parca9 #� Sysitern Type (Tal�ie Va) Ov�erlApp�icant Subdivision Address/Location SecfF'hase Lot # � Se��ac. Taral� lni�aa0/�at� N6�a �a��on n� In� a c��te � State�ID/date �e St�e�tl-, Trenct� �dth� '3 ft. Ca aci L c1-u�o al. � �� Trench De th ��' in. ✓` Tes and Filter � � �✓' T,rencii Len f�c� ft. BafFfe ✓ � Trencf� G�ade � ,/� � Sealant Trenct� S acin Riser ifi a plicabie �.� � Rocic De th and Quai' -- Tank Outlet Seai Dams/Ste down� etc. Pemnaneni iUlarker Pressure Laierais � � Puma Tanls � h� q Hale Spac9ng � .�^ Waterproof ISealant Riser Water Tight � �ue�e� Checfc ValvelGate Valve �11arm visable and audi�le Electrical Com onen�s ' Rate m A roved Pump Niode! Bioc�c Unde� Pum � Pum Removal Ro e/Ct�ain . ��Dis�aba.t�iion: Sys�an � Serial Dis#ribution Pressure fVlani o Low Pressure Pi e A r. Pi e i�iateriai and Grad� Sleeve Ret�ui�d� �etb�� From� Welts ' From Propesty lines Surface Waters Public Vllater Suppi Verticai Cuts (>2 ft. 11Uater Lines Ve�iicle �Traffic EasementslRight of �aer Easemer�is Recorde �� .:., _,,;,� resener�t pct�d rev. 31'f 3/��t � Application Date: Amount Paid: _ Receipt#: _ Tax Map: �_ Parcel #: /c�(� • 6 \ ��?.5,� �� i�'_ �a�n u�ca aa =�-�+• �cs ga �..en Il 1�� ae�+.ea.Il d�a Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 (if> 600 end) (Fee is dependent on the type of ent or Buildine Add $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Itepair) $3 00.00/$200.00/$75.00 1) Services Requested by: Name: S C-� ,� Address: � r . $75.00 0 Repair of Existing Septic System No Chazee Phone # (home): �� 2 C� (work/cell): 2)Name and address of current owner (if different than apglicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: 4) Proposed Use and Type of Structure: �`� Residential Business/Type: Other ��UYn Number of bedrooms / Number of people served (seats/employees): , � Basement: Yes No (with plumbing: Yes No _� � 6 x �� ' Garbage disposal: Yes No 5) Water Supply: Private Well (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed application must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and [ocation of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently attered, or if the intended use changes, all permits aud approvats shall become invalid. Signature (Owner/Legal Representative): � Date :� Z j� / ll 10/OS Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� ) . �� ...�� J � �.J � � � �]h1�17r°�(.'D1171.]I�1C]Lc�1m�.c�A.� ��:<�D..�� uilding Additions/ Mobile Home 12eplacememts Tax Map #:� Approval Requested for: Applicant Address: Phone #'s: Parcel#: � Mobile Home Replacement � Building Addition Pernut Located: k Yes No Installation Date: 2 0$� Design flow: �(gpd) Current Contract with Certified Operator on file (if required): �_ Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required � Cornments: ��N�� 55�dti � J04�'(i r `,� 3a � S�Q ��Ic�Q � ddition/Replacement Approved � v�-✓ �{ zc O En onmental Health Specialist Date Application Date: �' l�`((� �� S� ��T Tax Map: � . Amount Paid: b, pp C ' ._... ,* • �- � � ��,�� Parcel#: Receipt #: 5 b'L � 1E::.rzao-nn-�savxaac�anU:an.]L 1HIao�.lLd�ln ❑ Improvement Permit (Site Evaluation) , $200.00/$300.00 (if> 600 gpd) l�Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Wzll Permit (1`Tew�Replacement/Repair) $3 00.00/$200.00/$75.00 lication for Services Services Re uested 0 Construction Authorization Fee is de endent on the pe of system permitted) ❑ Permit Revision $�s.ou ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 �) Applicant I ormation: , Name: .i� . d- '.� ��,,. Address: `-/ � ,, ,,,. fiv�F �r et7 `/�S ,n/C. .?7S�/ � 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3s� - 36 ��-v S't, t/ (work/cell): 336 •� 04 ��7 �3 � af�er 4:�0 Phone: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: ❑ 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 thar, 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) roposed Use and Ty�pe of Structure: , esidentia! ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of E�isting System If expansion: Current number of bedrooms: O Repau• to hlalfunctioning System Will there be a basement? ❑ yzs ❑ no Vb'ith plumbing fixtures? ❑Nan-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum numUer of seats: S�v �� P ❑ yes ❑ no 5) Water Supply: ❑ New well M'Existing �Vell ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6 , erred s stem e s: C7 Conventional ❑ Accepted ❑ Innovati re ❑ Alternative ❑ Ot�'�er ❑ Any � I cert�� that the information provided above is complete and correct. I ulso understanci that if the information provided is inaccurate, o�th�ite is subsequently altered, or the intended use changes, all permits and approvals shall be im�alid. Signature (Owner/ Legai Representative*) * Supporting documentation required. i�'►/,n(�•�� 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) .� 'f , � . � � � ��` � � �� `, � �" ��.�.��.�;��.��.Il ]�C��.�.�. Suiiding Additions/ Mobile Home Replacements Tax Map #:��_ Parcel#:Jy� Address: 3�N i�r�n �r►,� {��, �-.�I.�. �'IIS �IG 27 5� � , -� "� Approval Requested for: Applica� Address; Phone #' Mobile Home Replacement � Building Addition . Permit Located: ✓ Yes Installation Date: ��Q,S,� 53(f, - �D�i- 2713 �� Design flow: �1� v (gpd) Current Contract with Certified Operator on file (if required): � Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: �- I Z'/ (� (date) (Applicant's signature if site visit is not required) � S� � S� � s�e�� ddition/Iteplacement Approv�d � Enviro ental Health pecialist �- /3 �l Date � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 u �� s�- I�I�II�..��fiT �: .. � � �� ]E��Ssoaa�a.m�m�mIl" ]E"IC��1l�7ka S1TE PLAN ' Name /►�iIGi1QQ� `TiDhf. TaxMap#�_Parcel#_�_ Subdivision � Section/Lot# I Authorized State Agent Da� ,Tystem components represent npprazima�e contours only. The conrractor must Jlag the system prior to beginning the inslallo�ion ta insure that proper grade is maintained. Note: An Accepted syslem may be used in p(ace oja conventional syslem without permit authorizalion or modification. � ,,a,,�, ..{� cnhS�c� �le�c,�� P . �� g��s� QP • . , ..,, . , ��1 � inn � h►m usv� �wt t,�.�l � Acv�-1 atr �� y�� ~ � �� l� ��;��:�.�:,,� �E-�[�.:.�:�.�<�� Date: Z / 22 /�� . ,_ ,, , .„ � �b rr. . t! .. � - Re: Bacteriological Test Results Dear Well Owner: Tax Map:�_ Parcel:� Your well water was sampled on �/3�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: V 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 bacterio[ogical results on[y. Tota( 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 `nay 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 or 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. Sincerely, ► ' �� En ironmental Health Specialist Person County Health Department (rev. 4/20/ l6) Person County 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 iVlicrobiology 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: ES020117-0093001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: DUSTY STONE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 374 HORTON FARM RD HURDLE MILLS, NC 27541 Collected: 01 /31 /2017 11:00 Received: 02/01/2017 08:25 Sample Source: Well Sampling Point: Well head J Smith Susan Beasley Well Permit Number: A41-144 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 02/02/2017 E. coli, Colilert Absent 02/02/2017 Report Date: 02/02/2017 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. �� ,,,�� nc department of health and human services County: Sample ID #: € o rN / � t � f ' C. � , �,...,.. � �y ' i F - � I ^�, y p/ '� yi�'Sy�- ' 4 �i",� � � � '�� f; �, L�r �� J � i # � � `•� �r t f � �� y ; �.� t , F ; , # ��__.. � 2 i � y I-^ � r �.� f--�, � e �—� F�. �`�� F t <.„` �� --•;� �'��)j (`'"1 �' ,P1�� 'p..�! �� " i !•j p� �� ;.f �...'4 �... �..'- ° � �. � _„i '�_.J' �.._l � �'`>_ .�,.J `�.% �•' r 6 ; � � ! `...1 i � `.� t. @ �: : e 4_i For Inorganic Chemical Contaminants Name: s� Reviewer: — � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorganic chemical resu[ts on[v. You may have other water sampling results that are not taken into account in this report. 2. �he following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina 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 circled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inor�anic chemical results onlv. Arsenic Barium Cadmium � Chromium � Copper � Fluoride � Lead � Iron — � 1G�r,aanell Mercurv I Nitrate/Nitrite I Selenium I Silver I Magnesium � �inc � pri 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. 0 Re-sampling is recommended in months. 5. 0 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 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 inor�anic chemical results 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 Man�anese Selenium Silver pH For more information regarding your well water results, please call the North Carolina Division of Public Hea[th at 919-707-5900. e North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH DUSTY STONE 325 S MORGAN STREET 374 HORTON FARM RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES020117-0036001 Date Collected: 01/31/17 Time Collected: 11:00 AM Date Received: 02/01/17 Collected By: J Smith Sample Type: Raw Sampling Point: Well head Well Permit #: A41-144 Sample Source: Well Temp. at Receipt: 1.5 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 m /L Barium < 0.1 2.00 mg/L Cadmium Calcium < 0.001 44 6.20 0.005 romium < 0.01 0.10 Copper < 0.05 1.3 Fluoride < 0.20 4.00 Selenium si�ver Sodiurr Sulfate � < 0.005 0.015 10 0.580 < o.000s < �.00 < 0.1 7.6 < 0.005 < 0.05 9.20 < 5_00 L N/A 'Total Hardness 150 mg/L Zinc < 0.50 5.00 mg/L Report Date:02/09/2017 Reported By: .�Cennet�i Greene Page 1 of 1 ��231a � /�.� -� �� .e, �. � �,,� Ca-�— d-v V�Qn W�1� � Sr ��, �'" s � �-� �� f 1� � �J� S� e SP�• ��a�,d ��- /�/ a,�e � +�� r � ,�''�e � � 5 03 � ��lC,� �-o �e-��- �o p y o�' ?T