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A23 107-�l� U'1 �eal h�De ar ment U�� Person Count p � - ' Weil Permit � Date: �.�LB- 9z 'This Permit Void After 3 Years Owner: ' G�u fi SR# 3�� Locado irecti' s: k ' --- WELL CONSTRUCTION Distance from Nearest Properry Line Distance from Source of Polludon t� Total Depth: Ft Yeld: ` GPM Static Water L.evel Ft Water Bearing Zones: Dep FG Ft Casing: Depth: From � to �� Diarr�ter. � Inches TYPE: Steel Galvanized Steel If Steel, does owner approve:' � No Weigh� Thiclrness: Height Above Groimd: Inches Drive Shce: Yes No Were Problems Encountered in Setting th �asing? Yes No If "yes" give reason: Grout: Type: Neat d/Cement Concrete Annular Space Width Inches Water in Armular Space: Yes No Method: Pumped �Tf� Poised '� Depth: From _� � S.bL___ Fc Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, gtav� cuttings) - Ratio: to ID Plates: Yes No 4 z 4 slab Yes �— No � k � � '� c� I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � THIS WELL WAS CONSTRUCTED CORDANC WITH REG ONS SET ,� FORTH BY THE PERSON COUN7'Y NT• � ��_�� w L 16 Z Si Con Date 0 3 //o ' 's Signature Date Issued � ✓ ( � Y`C vJ - V �on� ; : Sanitarian's Signature Date Completed Sketch well location on reverse side. . .- _ , • .. ., _._..._ AQr��on County Health Departmen# Sewage System lmprovements Permit . � -J ��? � �'-r-r _ )ate:—..`� 's Permit Void Atter 5 Years Perm�� )wner: � _�z p N �- ! SR� .,L_3,.2.4 � ubdivision Nama: � 1'°t �� .ot Size: � � Type of Dwelling: '� ��••!'P Vater Supply: Private: �' Community: tedrooms: �._..— Gazbage Disposal '�. vo -�,, w��.- iasemcnt Basement Fixtures � NFORMATI0�1 D BY � , , o�y livc i2Jll1a17311: r � �/I.t-�i �EppIR; REEVALUA ON: �ize of Septic Tank: �� Kallons Size of Pump Tank: y =.S � � � . . �' �iuification Lit� � �epth of Stone: 12 inches ''� �,� � 7.z �Iax Depth oi Trenc . -~'. �b.�a� ` �I�emativC Sys Conv. Pump LPP Pump :emarfcs: vh �v.. ,. ----- �'�`� -'-��-�-�-�j:,�,.�� _��_ )ate Well Approved: Well shaild be 100 f� from any sewer system 3Y Sanitarian �a�e Scwage S sUem App �ed: �� ` Z 3Y Sanitarian � 'TIHiC�TE OF COMPLETtON � • � �r�r�� ., �ontractor. �.�_ , �j'� �^��.��.�+��.��.��.��.��+• � iewage System location. inscalladon. and ptotection must meet state and local � tegulations. Seplic tanSc should be pumped out every 3 uo 5 years and shali be maintained D by ownet in such mxnner as nac tv creue a public health hazard. Septic tanic and nitrification line must be inspected and approved by a member of the Pcrson Counry S� Heallh Departmertt belore any portion of the inslallation is coveced and put inlo use. I� �he site plans ar intended uu change thit pernut is subject w revoCation. � � � (G.S. 134 A-335F) � \ � Location of sewage di.tiposal sewage system sketched on back. � {OV��) �� . �.: r ( � �1��•� C�1 � -i r ��' I �-L� ��. � , , � � g^ � • t�3 �ti �,� .. N � A � � fi x x '° m M A � � y � R�� s � � � � � � � � m W �o � � c �' � .. � � �y O � � o � � a ..., � �- � �. '° � � � � a 0 � � m c � �R 9 � °' � � � � M a � .�y O � � m- � ro N �y � A� � �i �� w �, � t!L RF �� fp. �. P� y� � t�+ ApplicationDate: �'��-'�U Amount Paid: 0 0. 0 U Receipt#: D � G Tax Map: v� 3 Parcel #: f 6 i . �� 7� �� S f ��.� �� _ _ = '-�-.z �C��7��Y 7C.'�rnwuu o�n.]rncn�-lr��.�n.11 ]HCQ-aRllit]E-n Application for Services (Septic Systems and Wells) 1) Services Requested by:� d�� l1 Name: ��c•v �vt Address: �o� Wes r►.u�s� CE. /V(el�ne tJG Z73oZ Phone # (home): �}��1-s��'�7 �� (work/cell): 3 �6-L! 3-�i7 2C� CC-LL 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: a� �C �or n�'e Lot #: Address andlor directions to Prope�' G� � C�e � t- .Se ��.. MrGeC �I�II il.�� +o �a�Ge notr�te %a.1 .�'ta�., i1�n"v� -�o Ctt�t� Cr�e.ek us oU,;� cv� �t�f' �' �1IIGi� GWUS�+� 4) Proposed Use an Type of Structure: Residential Business/Type: Other Number of bedrooms �_^ / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) WaterSupply: (�ee�u�e.+-cevti% We�� Private Well � (Proposed i/ Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted annlication must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated I am submitting this application to request services from the Person County Aealth Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Lega1 Representative): � i ��{�� (-' Date : �� ' � U 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� j �� .�.GJ �� \r..r � �J � � � JL 1L. 1��.'11�IL7L�c�mm �nmm �71'Il.��.� Jl J1�.�L�'�.lYb W�+ I,I, PERMIT (New � I2epair� Taz Map: Parcel: /D � Subdivision: Lot: Applicant's Name: � Mailing Address: D eS ' n /�% Phone Numbers: - 5 - -/- e l� �i Permit Conditions: ' " 1} Seg attached site plan for proposed well location. 2) All applicable State and County regulations gove�ning consiYuction and setbacks apply.� 3) Permits expire S years, from the date of issue. � Other Conditions/Comments: J��e. sure .� �oca� v,,� �,o�o✓�e✓�u %i no 1 �'e P�rmit issued � I�ate: 8'- � -(D C�R'I'�'�CATE OF CO11dIPLE'I'IOl�T 1Vew Well Inspection: E /Date Location: '�s Grouting: -� � 1 D Well Log: Well Tag: � Pwnp Tag: v Air Vent: ' g � � Hose Bib: Casing Height: Concrete Slab: Well Driller: �Q{,��i�Q, Pump Installer: � ,,,, Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonmeat: EHS/Date Completed: Method/Material(s): Well Approved by� License #: License#: Date: �� fb �f n,( f,'�� Date Sample Collected: 1 �� J� � Date Results Mailed: '� Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Phone:336-597-1790 Fax:336-597-7808 8/1/08 �--��?,'�' .I�` J�t1l�.� �l�l ``' ��— � � �U1�°1C� 7�,��u-�,r„ ,,,,-„ ,��.��.11 7H[��.11� SI'I'E S�TC�i Name r � �.1a � L_ Subdivi ' Da K o � utho�ized State Agent Tag Map # /� Z3 Patcel #%7 Secti.on/Lot# �— �?'10 Date System cumponents re. present u�proximate �contours only. The contractor must flag the system prior to beginning the i�istallation to insure that prolbergmde is maintained ` `t� ' ' �+� �►c� /ao `��1�', , �J ��aiK��u� a« s�-�'ba�l�S �` C IC �� L i 25 �� a�'1 c ' � �n� b�'��' ��ri ��n � U� T6CGt�vh G�,p �o�er-{� � � � �� S �- � I I � � � - �'`" �;: ��`�$� _ 8� � � I� � �r_ �. �� ..< _ _ � �$�90 C: qN ` � ��r �v � � �"_ - � _ '�'f " ,�A , � .. �z �� , �. � �" ,.. R � � P�€�;... �. .. _ � ' �,. � .� ��a.. � � � �� x . � � , �� { �� , �F � e o� ' ,si� �: � � �>. �' � � �� .�� .�� . < � � �5 ` . � 7V7 �2 �a .+ �i � e � � s� � �� n' � �� . o. � � .� � , .�_�o� � � , �e '�r �� ,a� �,,,, T� ,�` . �s� � L� . ��' r � ;� � � n� � � Y�v � �� ` . � �� S�. ,` ��. � �� ;�. .� = a � � : ,�,�� ,� WP�'��kcr RESIDENTIAL wELL corrsTRuc�riorr �coRn North Carolina Departrnent of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # J � �"!�`i'' 1. WELL CONTRAC ` �a il � .t,�.�� Well Contractor (Ind� idual) Name B�mette Well Drillin4 inc. Well Contractor Company Name 611_�amette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# � OTHER ASSOCIATED PERMIT#(if appticaWe) 0 SITE WELL ID #('rf applicable) 3. WELL USE (Check App�icable Box): Residential Water Supply [� DATE DRILLED l�' a Z'"� 0 TIME COMPlETED ZC�O AM p PM �/ 4. VYELL L AT10N: cmr dk� � cou►v-nr sv ( A/� C �Y1Gt� �a,��,o.�f� (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOP PHIC / LAND SETTING: (check appropriate box) lope pValley OFtat ❑Ridge OOther LATITUOE 36 "= " DMS OR 3X.XXXX�UCXX DD LONGITUDE 75 •_• " DMS OR 7X.XXXXXXXXX DD LatitudeAongitude source: �PS �i'opographic map (locaSon of.well musf be shown on a USGS topo map andattached to this form if not using GPS) 5. VYELL O ER ��c,�iard %h��► �ia�/ Owner Name l, �( l/V��`nz/�► �b �t r C'-� _ StrF,�t Address /vlrlo�,�.G �/. � 27�Z iry or Tovm State Zip Code �, sz3- ��y-� Area code Phone number 6. WELL DETAII.S: a TOTAL DEPTH: � � '� • b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO � c. WATER LEVEL Below Top of Casing: 2] FT. (Use '+' if Above Top of Casing) d. TOP OF CAStNG IS � FT. Above Land Surface' 'Top of casing tertninated aVo� below land surfaoe may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): � METHOD OF TEST BIOWII ZOIII r. DISINFECTION: ry� HTH amou�c 1/2 Cup g. W TER ZONES (depth): : Top �� Bottom 3'2 Top Bottom ; Top_� Bottom 2 3S Top eottom Top Bottom Top Bottom Thtcknessl 7. CASING: Depth Diameter Weight Material Top_�_ Bottom�� Ft. � !l4 �-2r �Z. Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Materiai Method Top �O eottom � Ft. Sand/Cement Poured : Top Bottom Ft. : Top Bottom Ft 9. SCREEN: Depth Diameter Slot Size Matsrlai Top Bottom Ft, in. in. Top Bottom Ft. in. in. Top Bottom Ft. in. in. 10. SAND/GRAVEL PACK: Depth Size Top Bottom Ft. Top Bottom Ft. Top Bottom FL � 11. DRILLING LOG Top Bottom �i�� i��a / / � � / � / / / 12. REMARKS: Material Formation Description T�pso,rJ L � '�'` � b1�i � r � I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROV ED TO THE LL OWNER. ,G r � p �l"�c� SI ATURE OF C TIFIED W L CONTRACTOR DATE � �! 1 f�� '� `�l R � +� PRINTED NAME F PERSON CONS�RUCTING THE.WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Senrice Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09 �� r �. a J \`�� ► • � � �.../ �� ]Y71."CV'71.7L�t�]�71.Il'�iA.�ilClLi�%a�A.� �aG��tl.11'�� Date: � ( �; - ( D Tax Map: Address: 23 Parcel: �0 7 (�S Cav�e L'rPvK Re: Bacteriological Water Sample Dear �1�, Menae�,�,�i� Your well water was sampled on �/�/�, and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The results of your water sample are as follows: No coliform bacteria were found in � your well water and therefore your water can safely be used for drinking, cooking, washing dishes, bathing and showering. ✓ 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 and fecal coliform bacteria are associated with animal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well has not been properly disinfected prior to being used, or that contaminated groundwater is entering the well. The well should be properlv disinfected using the enclosed chlorination procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, the Health Department should be notified so that the well can be re-sampled. If the well water continues to test positive for coliform bacteria, then there may be a problem with the water source or with well �construction. A well contractor or the Health Department can assist you in identifying the problem and finding a solution. If coliform bacteria arepresent in your water sample, then the water may not be safe to use. Young children, the elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the results. Water can be disinfected by boiling for one minute. If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from 8:30 am to 5:00 pm. Sincerely, _ �'�. Environmental Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790 Revised (11/13/08) North Carolina State Laboratory Public Health 06 N. W?m�ngton St. Environmental Sciences Raleigh, ►vc 27s„-so4� http://slph.ncpublichealth.com M i c ro b i o I o Phone: 919-733-7834 gy Fax: 919-733-8695 Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET �JXBORO, NC 27573 EIN:566000331 EH StarLiMS Sample ID: ES101910-0045001 � �� ES Microbiology ID: 21656 GPS Number: Sample Description: Comment: Name of System: RICHARD MENDENHALL 165 CANE CREEK �EI'v7�RA, N� 27343 Collected: 10/18/2010 11:30 Received: 10/19/2010 09:06 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A23-107 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present valerie Yager �0/20/2010 E. coli, Colilert Absent Valerie Yager 10/20/2010 Report Date: 10/27/2010 Explanations of Coliform Analysis: Reported By: Susan Beasley 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. � North Carolina State Laboratory of Public Heaith Environmental Sciences Inorganic Chemistry Certificate of Analysis P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http:!lslph. ncpublichealth. com Phone: 919-733-7834 Fax: 919-733-8695 Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH RICHARD MENDENHALL 325 S MORGAN STREET 165 CANE CREEK ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES101910-0021001 Date Collected: 10/18/10 Date Received: 10119I10 Sample Type: Sampling Point: Well h�ad Sample Source: New Weli Temp. at Receipt: 9.0 Sample Description: Comment: Time Collected: 11:30 AM Collected By: J. Smith Well Permit#: A23=107 GPS #: 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 Cadmium < 0.001 0.005 mg/L Calcium 71 mg/L Chloride 14_00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.27 2.00 mg/L Iron 0.14 0.30 mg/L Lead < 0.005 ' 0.015 mg/L Magnesium 16 mg/L Manganese 0.03 0.05 mg/L Mercury <0.0005 0.002 mg/L Nitrate < �1.00 � 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7_4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 20.00 mg/L Sulfate 27_00 250 mg/L Total Alkalinity 246 mg/L Total Hardness 240 mg/L Zinc <.�.05 5.00 mg/L Report Date: 11/01/2010 Page 1 oP 1 Reported By: De�le'%i%acol