A23 153Person �ounty Health Department
Sewage ,System Improvements Permit
Date:.����=L�is Permit Void After 5 Years Permit # �+ - � 1'
Owner: ' SR# ���
Location/Direcaons: �;�, '�
Subdivision Name: Lot #_'�
Lot Size: t Type of ' g:
Water Supply: Private: Pablic: Community:
Bedrooms: � Garbage Disposal
Basement Basement Fixwres
INFORMA���ZQ��R .TIF�D BY
Sanitarian: ��/ � o entative
12EPAIR: �— REEVALUATION:
Size of Septic Tank: �! ��D� gallons S� of Pamp Tank:���� �i��
Nitrification Line: ��i(3/
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: - / - /� i-
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIl,iCATE OF COMPLETION
Contractor.
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc should be pumped out every 3 to S years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitcificadon line must be inspected and appcoved by a member of the Person Counry
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on bxk.
(OVER)
�e
�
b
NOT'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1) �2�
■nnn.
■���������������■�������■
�■���■���■�������■��������■■
■�����������������■�������■
■������������■■�����������■
■������������■�����s■�����■
��■�����������■����������■
■�■���■■���■■���������������
■�������������:��������■���■
■�����������■ .����������■��■
■�■��■������■ ������������■
■���������������■�■�■������■
■����■���������������■����■
■W�v
� ..
Site Evaluation Application _
. i �
Fee Collected YES `� NO
�?c� 12-/� - �/
Date: ������
� APPLICATION FOR IMPROVEMENTS PERMIT
1. Permit requested by: owner/prospectiv ow :
. _ , , ,.. � a _ _
Address:
Home Phone 4�:
2. Name and address of current owner:
Busine"ss Phone ��:
3. Property Description: Lot size: (� b.H �
4. Tax map ��: Township: � ` �u- ,
Subdivision Name: - Lot 4�:
S. Directions to property: Sta� Road �� & Road Names, etc.
,
6. Permit requested for: New Installation: l/ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. LJater supply private? public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11, Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A- 35(F)
l
igned er or utti izeci Agent
z
�
�
H
iw
ix
�w
m
r
0
r+
m
b
�
n
�
r•
�+
�
Permit Issued `�
Permit Denied
Plat Observed �
��D� �
� > � � -.__ -_ _ _ __
.�� � - x-� - =-
:
J ' .
'�FACTORS — SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S S S
1. SLOPE (X) PS PS S PS
yT .
2. SGIL TEXTURE (12-36 in.) S . S S .
(Sandy, Ioamy, clayey, S P ' S PS
No te 2: I. clay) U u
3. SOIL STRUCTiJRE (12-36 in.) S S S S '
\ (Clayey soils) � S P i� PS
i
�r�. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.;
(Im{�ervious Strata, rock)
f. SOIL DRAIAIAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
S
�S
S
U
S
,Ps
• S
�
PS�
� S
PS
U
S
PS
�
S
PS
�
S
PS
�
U
S
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
8. OTHER (specify) S PS PS � PS
• U U U U
9. SITE CLASSIFICATZON
(See beloc�)
SOIL SERIES
S- Suitable PS - Prbvisionally Suitable -..0 - Unsuitable
F,ECOt�R fENDATIOHS / COZ4IEtiTS :
ITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
aet areas, fill areas, wells, water bodies, slope patterns, etc.) '
; � ;�er�ltc�tion Date: �-`%-4 �
,�Tnount �aid• �
�'. �cai t�: 4�2
�� .
��°�f
P�rsan Cauntv �leafth �ec�artment
�rnrironmentai Heaith Section
APP�ICATION FOR SIItVIC�S
�ax �a� #: � 3
�nr�d ?�: � � �
1) Permitrequesfiedby: (Owner/ager�prospectiveawner): �i��/1-s�7��� ���(�/�.1
Home Phane: _ �6, �. j�,, qddrsss.
Business Phone: �v
� Name and addr�s ct cumecrt owner. �'tiC�N ��ti� �-s'�
d;;c.7.
3) Property DeaciiptiOn: �ct size:O` ��� TouMnst� C� G�eL�C�i '' `���'✓
Direc�ons to the property. Qndudin� ro�d names and nurril��rs): .,
������
L�J
C�Cy c� ��ell:
4) Proposed Use tructure Description: answer each of the foilowing questtans:
a) Proposed , ' � .
b) � Stidc Built oduiar �. Sj�gle Wide q Double Wide ❑ '
c) Number af Bedrooms. S � Number of accupants ar people to be served:
_... el. . F�errieiR�� Yes 4 Ne Q If y�s, # of serrtsnt fn�tures:
_. • ._ ,::_..�_>_.._._
fl Garbage Disposai: Y�s 4 No � `
� Dimensions of Progased Struc�ure: Vlfidth:,L Depth: ..�
5) Wafier SupPIY Type: Private �Q o��existing �), Pubiic o, Camr�uniiy �, Sp�g-�
. Are arry wells on adjoining properiy? Yes �No q If yes, lacation
6) Ptease Indicate Desired System , i ype: (systems can ba raniced in order of your p�ferencs)
(�om�er�tional Modifled Cornrentional _Aitemative . Innovative
Other (sP�Y)�
CL�ARLY STAICE �►l.l. CORNERS AND LtNES OF THE PROPERTY,
STAKE THE CORNE3�S OF'ALL PROPOSED STRUCTURES.
Pl.Et�SE ATTACti SURVEY PLAT OfR SiTE PLAN TO THIS APPLCATION
I hereby make appiication to the Persan Caunty Heattl� Departrnent for a siie evatua�on for the an-site sewage disposai �system for
the ahove-desaibed property. I agree that the conterrts of this appiication are true and represent the maxirnum fac '�1'i#ies to be
piaced aa the property. I understand if the site is altered ar the irrtended nse changes, the Qermit shall become invalid. i understand
that as appiic�rrt. I am responsii�le foc identiiying and markir►g property lines, camers and making the siie aa�ss�ie for the
persannel of the Peisan Courrty eatth D partrnerrt to condud their evaivations. I understand that i am responsibie for notiiying the
Healthh D nt ifi m grap ' s wetlands as desigr►a#ed by the Army Co�ps af Engineess. �
�g D/
0 r or Rep ntative - Date
PCHD, rev. i0t'12199
. ,5-�2.�-0� Ma� �e� 23
Ap�iicati�n �ate. Tax Maa �:
' Amount Paid• � `� ?�
Recef at #: ;? �j n X � � ParcEl �1: ���
�� �r ����.5� J�'I�I���1�
- - -_ ������
�zcava.a-oaa��-�-� .Daa�mll �3L�.m.1L�I�n.
APPLICATION FOR SERVIC�S
iF THE IyFORMA?'{O�! IN TkE APPLlCATlOf�! FOR AN IP!lPROVENIE�IT PERE►l�lT !S INCQRRE�T F�4�SIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZ,4TI�IV TO
CONSTRUCT SHALL BECOME INVALID. �
,,�rPermit requested by: (Ownerla ent/prospective owner): • l�zn � G� y
Home Phone: ���1�=0// Address: � �
Business Phone: fQU7 -
°'�2)' Name and address of current ow�er. . r� /'• Gl �� l ll'1
' r
e ��s
3) Property Description: Lot size: Township: Subdivision:�,�,f,a(�'�J� Lot #�o
Directions to the property (Including road names and numbers): �
4) F�roposed Use and Structure Description: answer each of the foilowing questions:
a) Proposed _, Existing , Type of Structure: Width: Depth:
b) Number of Bedrooms: 3 Number of occupants or people to be served:
c) Basement: Yes_, No Will there be plumbing in the basement?
d) 6arbage Disposal: Yes _, No _
,
5) Water Supply Type: Private _(new _ or existing�, Public� CommunityJ Spring _
Are any welis on adjoining property? Y�s_ No _ If yes, please ind;cate aparcximate loca:io� an the
'site plan.
6) Daes your property contain previousiy identified jurisdictionai wetlands? Yes_ No_
PLEASE WOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY QR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATIOM.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED..
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY TaiE HEALTH DEPARTMEWT
STAFF.
I hereby make application to the Person County Heaith Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
. c �/���!���=
,�-�a�0
or Legai Representative
Date
PCHD, rev. 06/27/02
�
SEE A'
Tax Map #:
ApPiican� ,
Locatlon: _
PERSON COUNTY ENVIRONMENTAL HEALTH
Parcel # / J �. 7 Township
PIN
PhaselSecUon �
��>5�.� � �
�M� ��
�: .�/�1/6�
LottF_�_
/ � V� 6,.�v r ' ' C�/'!^��
Improvement Permit ��� Ke`� '�`�' �
New V Addition Type of Structure e� ,S'.,�y� '{Lh�, i��-.cg,,,,
O
# of Occuparrts�� # of Bedrooms � Other �"
Projected Daily Flow: ��� g.p.d. P rmit Valid For Five Ye N
Proposed Wastewater System:
Proposed Repair. (��. � � r�scc,r� �be.._
. c���,,. L�
Water Supply ' �, �.,�
System
Owner or Legal Represen�ative Signature: � Date:
/� �
Authorized State Agent: �„�_���. Date: ,<o "��— �,�\�
.� ,
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. � e'pe mit holder is
responsible for cheGting with appropriate goveming bodies in meeting their requirements. This site is subjeat to revocation if
the site plan, plat, or the irrtended use changes. The Improvemerrt Pertnit shall not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Carolina Administrative Code.
Authorization To Constru�t Wastewater Svstem IRe4uired for Buildinq Permitl
WastewaterSystem Desaiption: ���fl�/1y� �G Wastewater Flow: .�0 _g,p.d. Type: ��/b
Facility Description: �Z.� New qr Repair ❑ Expansion ❑
Basement? O Yes �� Basement Fixtures? 4 Yes �f� - •
�£:.����i.�2.di1 1��?��v�/o�! �i�
Wastewater Svstem Requirements —'-" „� g/p� D�%�U�13 �%'��':'
�� E�"' �
Tankage: Septic Tank size_ (ODb gal. Pump Tank size -� gal. Grease Trap size '� gal. �"""
Trenches: Total length � ft, Trench Width ?J' ft. Total Area sq. ft.
Max. Trench Depth: � in. Aggregate Depth:1� in. Soil Cover: �P in. Trench Separation �ft. on center
Permit Expiration Date: � /,��d �
Authorized State Agent: Date: Z� D
''See attached site plan and addendum page or additional permit conditions.
�� �,��► �,��
� �����
9�� � �pw !�
/�d� _
The type of system permitted ❑ daes ❑ does not differ from spec�ed on the application. 1 accept the ���Fj,�
specifications of this permit
Owner/Legal Representative Signature: Date: -��--�
OperatiOn Permit
System Type rn accordance with Table Va)
This system has been installed in compliance witl� applicable North Carolirta General Statubes, Laws and Rules for Sewage Treatrnerrt
and Disposal, and a0 conditions of the Improvemerrt Permit and Construction Authorization, Issuance of this peRnit impl'ies no
guararKee ffiat the system installed will function propetiy for any given period of time.
Authorized State Agent
Date
PCHD, rev. 03/07I01
� �... :. U:., .v{ :: � � :: � ::2 . . .. • .
.+�.��t .� ... �.• i .. t. � •.t• � ��� �
. .. .��� �•• .
��?�":.1i:•4•C; .� !,r,T.+' � �.. "' •V .
'.�►!�•:"J%�, •� " M.. : 4.. '
. e::+. • . . . t
rlb. t .,-•1•..' !•
.a;i .•ii:n..:5% M1^�"�'�.�'�
- �.,p-.v: ; nvv ...� w nv.,.e �iNm+• ��-..r: . . . . -.7� ,�.� ��� �i� 7�, '
.�3i���.,,.,.—,v.'—.,.,^'��,.-,^�.'� �'^i;'n'�!"j �' . ,-r'1L:f.11�:�JG� :
�t,�- � �il�i 1�
y; . «;�:�� ,� � . , � � .
Tau Map ., � 3 Parc�l #/�3 rownsiup: .-
A}�plican� tc —C � � 5
Subdivision: I� c" LLv ��-t� � I.at # G� �
r __,.�:,.... n•- - . . � _ _ � T � a . . -._ �_ � _ . . . . ,
0
0
�yype of �ater SnPplp: ✓Individuai Connm�mity Pni�lic
R�irements:
Site Approved By. ��
Grouting A�pmved By: - � � � /:
WeIl Log. � �
PumP 'Fa� '
�VeII Tag: ' ' .
Air Vea� - � � � -
Hose Bi`b: � .
Casmg Heig� .
Concrete Slab: � � �
♦
�_ �. � i � :�
Line,r:
'Installed by: .
Depth se� � �
Grout�d:
Date: .
Water. Sample: '
Well-Appruved by: . Date:, .
. ***�See Attacited Sfte Sketc�**'�''r
W�lls must be 10 feet from praperty lines. -
Wells mns# be 100 feet from sc�tic syst�ms. �
V�Te�ls must be at least 25 feet from any bn�ding faanda#ion.
s �� � .�� .� . .�� •
PG"� rev Ol/27104
%
3j
�
���.�f I������
, ���;��
IE�-�.��� ����]l. �C�.m.��. Owner. 1 l...IGt r.�
Tax Map: Z Parcei #: � S 3 Date: '"
I,ine '�ap Tap (5c$�) Tap k'!o� ijane �eaagt.�a I'low / f�i
# Diaaneie in) � ( ua) ,. {ft) �
1 1 O 1•1 �'O � . DQ
2 � i . .
3 � Z, �
4 � �
5
6 - �
7 . .
8 ' �'g'. ZO
9 , .
10 � .
.� � ft of line x 65 �gai. per,100 ft= ? 100 =� gal
75% z� gai = f��. gai Per dose $• gal Per minnte {gpm) = F7ow I�te
Friction Head
I.oss: �•'7 g ft per 100 ft of supply line x �'6 ft of supply. line =100 =• O ft
_� ft z 12 = •?� ft of friction head .
Manifold Size: _�" I�'osce Niam Size: �" PVC
Total Dynamac �eadl =1'�ft of Elevarivn head +_�ft of Pressure head + j ft of
Friction Head =_�`��TDH Noi�+G: �ti/. tt�.� ft�'i Ma�-�
�+unp RequiremenL• .Zg .� GPM C�3 ��• ft of Hea �,
Drawdown: I S�o gal per dose ; 21 gal per inch =?�� mc� drawdown per dvse
-� a: r ..,.u, : ����. ��. �, � �
. . _..,,,.. .,, . �._ ,.,,. ,, .,. �
�
=fi�����t0 � ,.� �
v , . . . �.i.11i" '. i , • �: �
, . I�[i)�����0
�) Q) �) 1�1 i���*i����i�����ii�*i��*����i�*
�.. .. .. �*��+��������w��������������+�
� � � � : _, ..:��:: ,:
��.�
ywllaa�e
Z" 'min �
�in�
� 9me�
" i`iow rs TaU
Siza 1LS�ial r'Tow G��I
:.c •• Sc}3ed 80 �.S
;. ,• ' Sc}�eri �0 �.1
� j " Sr;3:ed 80 101
�•, �• Sc9►eri s0 IZ.�
. :��`�,5� I��I�:.���
, . . . . ��� �°��
]��-���mm � ���.]L IE3[��.Il�
�I'A"E. S�TCH
I�Tame N I���-�► ,�� � I Z ��.� i�1� 1�. u�,� � s Tag Map #�—���.Parcel #:1�
Subdivisio - � � Section/Lot#
��� L
1lutho ' d t gent � Da e �
.Systeaaa coar��r�ra�ra�r repr�sent uppr�oas^i�sr�te�cont�urs anly. Tiae co�tiructprmuatfTcig �he syst`errapr�ior to
lregi�traing the is�s�tlZcxdzon t� i�rs�re tddat j��v�ierg�-cade is maarataa�d
r—
/f� . r�� ��fi�!����f�� ��������� ,��� ��i����� -
.j
�; i ys � � .:: FV ., .. . . =4pi""' . . O ; . s j . ..Y . 5 . �,f y ., � � - � .
; Lt 3 S�ili :� .� �, � Si � ' k �� awfs s�,� � ° .; �Sj��� �:
;?ii 3� �: . t ,e ��c�s' R'����< .�`�' ' S�dg� ', *,�'�� s�� '� �?F s � ��
'.' i � � z Lt K ��/� � � y� � �.: �` { j
� � p `" $ � � .S4 �, s � £ t S'� 5b's F.. ;! �� z� s � � F� ,. ._� 2
� s �
fi . �,�� ., q,� � r,. � � ,�( ; ,� .. z �5 ��-s ��3 , f ¢
�� >£� �` 3.� r � � E ..7 � 5 S ' c . S �i�. � ,�: S �.c . ..,k�; : 9 � .:
z ' � �s �
;� E � , �� £; .. �� �ss� i ' � `�'� s ` r , � . '� E� . d �� '
' ;> .
_
R�?` > > �. 's
t tcM �� .:" � . �.�.�:is � ..',r.,€_ ,Y., ,.� ..�.s�2�t .....'_ ✓ x�x��.. .r.:: s` ��.., ; -�� >i � .�. f��,.,. . vx���%���t�sx. . . .«.4,i. : . .
4 [�,
�� � � �i �. � � �..f�t...�"'��
_._.�, 1..��1.1 ��' � 6,`'� 4�'n'/"1 �'�t¢"' � AI
i
,. .,,
,._
�... � -..- ,� �" �#' �' ,, �
-. ---
_�. � �
/� i-:+!.,��•,, �r.. ,cr- < { , ,�,,�,��!.
`����'A`� �. <^ - �'��'��.�'�'�
, "�,r �p�p ^%= � F P �,��� P �
�t �`',p '���,"� ��l
u�,�- ,.. ;' � f �i,,.. ,.
���£ 5� "____ `r .
' I,ur ` a fl / c.1 !'.s /',,•:� /,.,J "� �" ;?� ;3:�"Ems�`�'d �,,�
x� 3 S f
�" ^' , � ��1°�<
a �s : � F�� %{,�� i''��� �.,�r�*}� � �'� �J%� f�1 �'r /�
„a``> � yr
,
,.. ,.� ; � � �,l' , �r,���.c � � �-�
�. � - . ,
� � ������ �
t � u r ,��,�% ,,_�� � .,�.�.��' r � _ �
�, ,� a
� �;�'f' �: a��F�`" ��/�-,
$ � � n ����,� ,/r i � 0,8� {` .�i'C� t'��',:�+ ��f����!�'i
�� �•f � �
.> ;.;i�. � _� ��,tv,l*�,$"'
� �,�
i� �� �� !P ^ � � `s�� ��
`'y� �'s' �� tL� �� �*p.f.
���fl[���/9 i ...l.Ys.� ..�.Y�`�i��j011�ii.�'.,�iXY�
(;; ;' ( P;'
_,
1:
£� ��1�3 �3 � x ..
1 I � t
Jl 1���3� �.� 1 1 i ��.
�z �
����`
� ` ;
rh
� a `.
t� B
�ls �. �
s
',�a� �R��w.� � �. �E^k`�,,,� '.
i �
� � .��� ��� ,�������� �� .������� �.
� : :
�� �'`� � :' ��,`,, � ,�,6,� �„��' `
���
� j: ' � �
"J �, ';�
�� � 4�c G�ap A 2 P�600 � 1�
�� 1 y � � ���� �� �lJIJ1YlYllUZ`Jl1VUU
/ \l. � V
� � � ���� �� ' ° 04 � (n
IG��aa-�������..11 IE-3L��.]1�]�. � ofl <- o 0 0 �
Applicant: ►
Location: �� �, Q -�i /2� -� f� a„ --�
�` ;Ct.l�u J2ic�at R� 7 !o+ w. �C.� ' 01 roc4.i S!-rn�.%Y oJ- r+h•r.r.s,.�
- �ration er it
System Type (In Accordance With Table Va): �J
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITii APPLICABLE iV0 H
CAROLINA GENER�4L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIOiVS OF ' THE IMPROVEMENT PERMIT AND CONSTRUCTiON
AUTHORIZATiON. � �
� � )11J1it,( 0 /���Z�/ -/VL' �� �n�� ��/�/ /i�� .
Authorized State Agent � Date
I nstalled By: � �n�� ��s Date: 7- � g-�s �
� .
�_ � y� �/ �. ��t � � .
, ,
,9¢�y''�G ,�'� `'S rs2p�-`t or2o.
/ �'. '�-�" `
f ���.� v`� a td q g .
r/� Sp'
� . , . . .
9�'� �o � e�•.
. �
C✓ , .'o� .. � .
� � io�i._ I�p�G
�
r��-
, ��Z� ►,o . �
0
� 'c� � �
�� � s
.�� ,
`7'�1y��Q,,a_, �
U�
�_1 � ' .
:�:`i" ��
- rs � I xr� �
�'T- u-��-�5 � _ 5-�3-os
�'+s-�c� 1�ZS• �ocA
S"T3 1y� 1� i -8S
PCHD, rev. 07/29/04
�;
�
���TiG �'��1K IRlS������.� C�BEC�CL9ST (i'ype 6f -1
Tax Map #�0�3 Parce! # System Type (Tabie Va)
Owner/Applicant Subdivision I�� /��. on
Address/Location Sec/Phase L t # (o
Septic Tank nitial ate (Vit�� �cat�on ines ni�a aie
State iD/date 5't y-ri-o�s �- '�' Trench �dth � � ft. -���g-�s
Ca aci �-t - ioo� . al. � � Trench De th �$ -ay in. �
Tee and Fiiter Trench Len th ft.
� Baffle � Trench Grade � �
Sealant � Trench S acin
Riser if a licabie � � Rock De th and Qual'
• Tank Out(et Seal Dams/Ste downs etc.
Permanent Marker Pressure Laterals �
. Pump Tank Hole Spacing
tate ate � BS �-�3roS �-� o e ize
Ca aci '�s-i��� at. Pi e.Sleeve
Wate roof /Sealant Tum-u slP.rotectors
Riser Required� Setbacks
Water Ti ht ri,�. v �a. From Welis "►�,�- c�14
- Pump From Property lines
Checic Valve/Gate Valve ✓CS StructureslBasements
Ant�-s� on o e �,_�q_bs itc es raina e a s �
Fioats/Switches cs Surface Waters ✓
Alarm visabie and audible ✓ ,o►Z�l� Public Water Su lies � rv n �
Electricai Com onents �,/��. - Vertical Cuts >2 ft. ✓ 7- q-o5'
� Rate m ,i k Water Lines ✓
A roved Pum Model �i Vehicle Traffic
Block Under Pum e Ad'acent S stems
� Pum Removal Ro e/Chain �-�9-o-s Easements/Ri hf of Wa s�/
. ��Distribution. System Other
� Serial Distribution Easements Recorded
� ressure ani o �_,�..� e �e erator ontra
Low Pressure Pi e Tri-Partate A reement
A r. Pi e Material and Grade �
� Valves
Commen$s . .
pcf�d rev. 3/13101
RESIDENTIAL wELL corrsTRucTioN REcoxn
North Carolina Deparhnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # . %"
1. WELL CONTRACTOR•
�an i��aG�n
Well ConUactor (Indivi al�
Bamette Well Drillina Inc.
Well Contractor Company Name
611 Barnette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3c 36 � 599-0015
Area code Phone number
2. WEL� INFORMATION:
WEL� CONSTRUCTION PERMIT#�M �SD c' W"
OTHER ASSOCIATED pERMIT#(if applicable)�(_ l��_
SITE WELL ID #{rf applicable)
3. WELL USE (Check Applicable Box): Residential Water Suppiy �
DATE DRILLED �� � I�
TIME COMPLETED � V AM ❑ PM [�
4. WELL LOCATION:
CITY: ��P� COUNTY �S� �
c/lk Qid� �
(Str�set Name, N bers, Commun' , Subdivision, Lot No., Parcel, Zip Code)
T�OPOGRAPHIC / LAND SETTING: (check appropriate box)
L��lope ❑Valley OFlat ❑Ridge ❑Other
LATITUDE 36 ° ' " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 ° ' " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: OGPS �Topographic map
(location of.wel! must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WE OWNER
. �a�� ���
Ovmer Name
�..�I�� �
_
Street dres
S�I�iIiJ I��1 �rC�
City or Town State Zip Code
c 33� � ZZ5' -81? � ,
Area code Phone number
6. WELL DETAILS: c' �(�
a. TOTAL DEPTH:� D O T�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOII
c. WATER LEVEL Below Top of Casing: ZS FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS y FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �! L METHOD OF TEST BIOWII ZOfTI
f. DISINFECTION: Type F'iTF"� Arnount 1/2 Cuq
g. WATER ZONES (depth):
Top 3Lo Bottom �6 i�
� Top Bottom
: Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thicknessl
7. CASING: Depth Diameter Welght Material
Top�_Bottom 6 Z Ft. ���� �R- 21 �_
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Materiai Method
� Top_t'Z Bottom L J Ft. Sand/Cemeni Poured
: Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
O /
�/ �+i
����
/
/
/
,
,
/
�
/
�
/
i
12. REMARKS:
Formation Qescription
4
��
.� �
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
PROVIDED TO THE ELL OWNER.
/ `!�`�
SI RE OF ERTIFIED WELL CONTRACTOR DATE
!�K � �/ a. w C� ( q�l �n
PRINTED NAME OF P SON CONSTRU TING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/O9