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Application Date: .� :�J�' C�'� �,OQ �� ,j�-6,� �a� � � � ����� Tax Map:
Amount Paid::,� GtiC� �C)0 ` �-r�� � � �� �:3 Parcel #: _
Receipt#: •5 3.��,'� G� ..5 .�,5 �?�� I � i �'��`��;��'�s- �
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1 ��- � • sc�-n�,-aa-.�a-a�..���n a��.�.n��,..
�� � �-`''t� � Application for Services
(Sentic Svstems and Wells)
Improvement Permit (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)
$225.00/$125.00
Services Re uested
Construction Authorization
(Fee is denendent on the tvpe of
Permit Revision
$75.00
Repair of Egisting Septic System
No Char�e
Important: If the i�zformation in the application for an Improve`nent Permit is incorrect, falsified, or the site is altered, then the
Imnrovement Permit mid the Autliorization to Construct shall becon:e invalid.
1) Services - ues ed b,�
Name: C�i O�� '�� .
Address: � `.: I `� ' � �� % t •s-c
�` �.F' �.l • r . �i���
Phone # (home�:�.��'�' ��%r ����
�o c/cell): J� �' � ' ��,� �'
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2)Name aJ �address of current wner (if different than applicant):
Name: �•�'��'-ic-v5� �t4f3' S"r3 �
Address: _ _
3) Property Description:
4) Proposed Use and Type of Structure:
Residential �� Bu,s�iness/Type: . Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _)
Garbage disposal: Yes No
� Water Supply:
Private Well �(Proposed Existing _�
Community Well: Public Water Syste�} :
Are there on the adjoining properties? No '�/ Yes
(please show location on site plan)
Note: A completed application must atso include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of tlte `Lot Preparation' form ver�i�zg tlzat tlie property is ready to be evaluatec�
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.
5 '-� � r ^j�
� � I �J
�^� � `^�'�'� Date i =' ? ' �
Signature (Owner/Legal Representative): �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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��t ��lad ��r � �'ive � �% �Saa�s�n
Type of Fac�ity: i3 ,e . � �ew � Addition . '��� �'aa�g��gr �2 i
# of Oc�upants/L141C # of e3rooms � 1'roje te3 Daiiy F1aw 3� g� d,
Propose3 Wastewaier System: i . ' � �/ . -� Type: ��9
Pron�se3 Repair: ' ` ` — `1` Typ�: �'Q. .
Pezmit Conditions: t� l i9�J �i �� 0� s'i 9� SA.� c� •�' ��ii n-e2r�eaQ D�4rt S. ' .
i+ A A � i _ '_'_T .. _ . i _ A � � �. ' .
OcvneT or Lega1 Represe
Aut�orize3 Sta� Ageu�
�a.t�:
Tl�e issuanG. o$ tlris p�it liy -t$e Health Dep�ztment m does no� g�ee the i���rr� of o#her persnils. I� is t�e responsia�ility of the
a�pl�ca�prOPertY owner m� sure tiaat atl Person County P� and Zon�g an� Buzi�mg Iaspe�tions re� are me� �iaas
�aenp����i �'�s�at i� s�sjext #� revva��n if ttae sa� �SI�; `pT��'�� t� 'vmtesade� �ase e��g�. i�e �ra��estae�t ��t i� s��#
a�e�#� l�g� a c�ge in o�er"s3�ng o� #lae p�ropes�#�►, 'T�aas p�it v��.s issuged 'a� ���li�x� �i� tDa� �ax�mvisim� mf th� I�T�� �C�rol��, .�
`L�►vs apad Rrales f�P Sesva..�e �`restanesst �d �is�sosal �vste�vas' (15�i NC "�� 1�-S .1���). I�Teii�aes �r.x�0n ��u�t�,�.. mqr��:t��.'` '�
�aav�s��ent� �eai� Spe�i�i'sss# �v�rranis tiaat taae s��tic *.� sy�sra vv�! c�n�n�e tm fa�e�ao� s��#'a�ioazHy iu #9ne faatza�e`or�t�a���
t9a�-��ter sup�iy wa71 remain �aot�ie. . , ,
� �ua�fin��a�i�as � ���straaet ��s#��at� S�s� (.��� �a�r ��a�g ���� �
�'. Ses site plan �d additio�al att�c3cments (_). � . � . � -.
���s� w�� sy�:�ri�P �� �� r� _ ' � � �ry��a ���.� �m� � 6.0 .�.a. .
New � Re�air Fx}�ansicn p� .- sQ� �T�B: • � g.}�.d.! ft 2 .
Type ofFac�7ity: 3��`�/�5 ' Basement�Yes '� No .
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'.�� ��: ��nkac '��: � b� �p '�� '.I �% (3'0 � �a�� '��p: '�- � . -
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��bu�on: �i��aa�aon �o� Ser�i �n�dai�aa�a��a ��xes�� �fo�d���l•c �f.ih �*"�
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Perm�it E�ira�ion
Date-
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The tyae of system pe�ite3 is Canven�cnai Ac;.�teri A.lternaiive. I a����t the �e�cat,ions of the
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CLEARWATER S/D
PERMIT CONDITIONS
Information for the Installer:
nsurin� a healthy environment
1. System shall be installed per approved engineered plans.
2. Contractor must be certified by the drip and pretreatment manufacturer in order to
install system.
3. Contractor shall have a set of approved engineer's plans on the job site througlYot�t
installation.
4.
5.
6.
7.
8.
9.
10
Pre-installation meeting mandatory (Design engineer and drip/pretreatment
manufacturer rep. must be present).
Contractor must re-flag drip lines on contour after clearing and have layout
approved by health dept.
When clearing drainfield area disturb soil as little as possible.
No site work should be done under wet conditions.
Contractor, design engineer, drip and pretreatment manufacturer rep., and
certified operator must be present at system start-up.
Before operation permit can be released a registered professional en�iueer or
certified designer and drip/pretreatinent manufacturer rep. inust certify in writin�;
that the systein was installed in accordance with the approved plans and
specifications.
All tanks must be accessible from grade.
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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1LvICIl.�IlI��IL�Il7YILct:Im¢�11.11 1L Jl<L�.11�11�
CLEARWATER S/D
PERMIT CONDITIONS
Information for the owner:
nsuring a healthy environment
1. Before the operation permit can be released a copy of the signed certified operator
(ORC)contract must be given to the health dept. (a contract far operation ai�d
maintenance with an American Certified ORC shall remain in effect for as long as
the system is to remain in use.) The ORC must be both a Grade II licensed
wastewater treatment facility operator and a licensed subsurface operator.
2. Grass must be established over the drainfield area and cut when needed.
3. Caution must be used concerning volume of water entering system and what is
put down the drain(ex. Grease, personal hygiene products, cigarette butts)
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
���, s f ���.� ��
- � � � ����
���a��������.� ���.���
Tax Map: �� Parcel: �3
Subdivision: CL�RQ.w�R-
Applicant's Name: QO'C� �o.SE
Mailing Address:
Phone Numbers:
WELL PERMIT
(New x Repair_)
Lot: �o
Location of Property: �a.�•�btMt�. 1�L0 ���Y�slri.n.L�.�-0 �� Ll,�,�.vA�L. �-a•
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
9.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: Q�RR�tU�. �lp►- St�►cc�
�Tew Well:
EHS/Date
Location: 'f�AS $ 15 �
Grouting:
Well Log:
Well Tag:
Pump Tag: _�_
Air Vent: �_
Hose Bib:
Casing Height: �
Concrete Slab.
Date: `} 1�
Certificate of Completion
OL,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date: _
Method/Materials:
Well Driller: License #: 3.3`l�0~�1
Pump Installer: License #:
Approved by: Date: /
Additional Comments:
Date Sample Collected: l l S Date Results Mailed: -����
EHS: �
Person County Environmental Health
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 11/26/13 -
WELL CONSTRUCTION RECORD
'[his form can bc uscd for single or multiple wclls
l_ Well Contractor Information:
�'�� n�� e �K � ��i'`
Wcll Con�actor Name
33 76--,�}
NC Wcll CoatractorCcrtifiwtion Nwnber
Barnette Well Drilling, Inc.
co�ny N�
Z Wdl Construcdoo Pcrmit tt: // Z�
List a!l applicqble wt!( construdion permiu (r.e. Cororty, State, 4ariaxe, etc)
3. WeII Use (check well use):
Water Sapply Well:
❑Agricultural ❑MunicipaUPublic-
❑Geothertnal (HeatinglCooling Supply) �"dential Water Supply (single)
❑IndustriaUCommercial ❑Residential Water Supply (shared)
Non-Water Supply Well:
lajecGon `Veil:
QAquiftx Recharge ❑Gcntindwater Remediatiaf
I7Aquifer Stotage and Recavexy OSalinity Barrier
OAquiferTest �Stormwater Drainage
❑E�erimental Technology OSubsidence Control
�Geothetmal (Closed C.obp) �"[Yacex
�Geothermat (IieakinglCooling Retum) OOthe` (explain under f�2I Remarlcs)
4. Date Well(s) Complcted: ���ell ID# /! Z�
Sa VVeti I.ocatian:
��� ds �
FaciGty(Qwnee Name Facitity ID# (if appliable)
�/�f�l�. Gt'Q,�'f�� L %�
Plrysi l Address, Ciry, and Zip
�� ��.S2��rv �- 2 d 3
County Parccl tdwoificadou No. (PIN}
56. Y.afitude aud Longifudc in dcgrces/miautes/seeonds:or decimal degceeS:
(''i'wetl 6cld, one Iallong is safficicnt)
�'6 - ��► -j"i N 7� --� � -S�w
6: Is (arc) thc wtll(s): � anart or OTemporary
7. is tfiis a repair to an siisting:well: OYts or �
Ijthia i.t a repatr fill out brown weU cons�incXion informatlavi drrd.etp(ain tkc aature ofll�r
rcpar� under.�'1l rcmarks secrion or on {he buck of (hts form.
8: Namber of wells constructcd: �
For mukipfe injection or norr-water su�ily we!!s ONLYwith the same tonsUrscliox, you am
submil one form.
9. Total wd1 depti below 13nd surCaee: ! p� (ft)
For multiple we/!s list a!! depths if drfJerent (eranplt-3Q200' wid ZQIDIi�
I0. Static water level6elow top vf casing: �� (ft)
If xn(er leve! rs abave cnsinA rse "+"
11. Borehole diameter � (in.)
12.WeRconstructionmctl►od: KE/R. �L7�"dLRS�
(i.e. au�er. �otary, eabtq dicect push, etc.)
For [ntemal Uu ONLY:
�2. Ctrtifiufioa:
�o�.�� - P.�� 8 -- � ` �t
Sigaauua o£Catifiai WeI1 Coatractor Dau
By signing.ihrs fornr, ! hereby certiJy thnt (he well(sj xK+s (xrre) conrrrxcred fn aaeordance
wit/� ISA NCAC 02C.0I00 or /SA NCAC QIG .8200 Wep Coru�nrcdtin S[andards and thir! a
copyaftiys reao�har been pmvkled a rhe Nell owner.
23. 5ite disgrlm or sddition9l weil detsils:
You may use'the back of.this paoc Lo provide,additional well site ddaits qr well
conshvc[ion detriLs. Yon may stsd auach additional pages if ne�sary.
SUSMI'�'fAL INSfUCfIOlYS
24a For All Wdls Submit this form within 30 days of compldion of well
c�nstiuetion to thc following:
Divisioa of Watcr Qnality, Wormation Processing Unit,
1617 Mait Setvice Center, Raleigh, NC 27699-1617
24h. For Iniection Welis: In addition to sending the fortn to the address in 24a
abov� aLso submiE a copy of this fornt within.30 days af oompletion bf well
canstruction to the following:
Division of Water Qualitp, Undergroaad[njectiou Conh»1 Pmgram,
FOR WATER SUPPLY WELLS ONLY• 1636 Mail Servicc Center, Rale�h, NC 27699-1636
13a. Yield (gpm) �� Method aftes� B��Wn20 minute 24� For iYater Suon�V & Iniettion Welts: Tn addition to sending tlie form to
the addtess(es) abovq also submit one copy of this fonn within 30 days of
i36. Disinfectiou type: HTH Amoun� 7�2 C+V i� �mpletion of wc�1 cotutnletion to the county healfh dcpaztmcnt of the counly
whae constrttctod.
Form G W-1 North Carolina Departmwt of Favitonment ud Natiaal Reso�uoes - Division of Wafu QiiaGty Revised Jao. 2013
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Applicant: �. �fl se.. S
Locaron: � „
l�a►�ol�-
1C��eration ]Pe�°�it
System Type (From Table Va): �Q
Type V& VI Expira.tion Date: —17 - f
Tag Map � Parcel # v� 3
Subdivision C�-2�tr�l�
Ph�se/Section/Lot # _�_
# of Sedrooms 3
Product (IIIg): ��c�o �}� �
Type V 8c VI Renewal Dat .
This system has been installed ia compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and aHI eond'atians af the Improveme�nt Permit and Construction
A i�thnt'lZa�1011.
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Authorizsd Agent)
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Scale
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Tax Map: �3 Parcel #: �-�
Septic �'ank System Checklist (Type II-I� System Type: � Q
Notes: � �Pr2 a S �- � �t � 1 ��
� Nitrification Lines
Trench Width: � ft.
Tren:,h Dept�i: in.
Total Length: ft.
Minimtun spaciub: ft.
Rock dent�/aualitv
Grade (< .25" in 1
Cover f6" minimu
Setbacks
Froiri wells
Properiy lines
Foundations/basements
SurfaceWa�er
Other: �
Pump Systeffi Checkli�t
InitiaUDate
Cantracted Certified Operator (Type IV Systems): ►'�YUh.��Q��-F- Sa�� ���-�rAC� yt���2� lor2�(�( �
Tuesday, October 28, 2014
Mr. Adam Sarver, REHS
Person County Environmental Health
325 South Morgan Street
Roxboro, North Carolina 27573
Re: Certification of Installation / Clearwater, Lot #6
Norweco Pretreat / American Manufacturing Perc-Rite Drip System
Mr. Sarver,
This letter is to certify that the waste water drip disposal system installed on lot 6 of Clearwater, Person
County, NC was installed in accordance with both the manufacture►'s and the designer's specifications
by Retrac Lewis of Jimmy Lewis & Sons Grading & Septic Tank Services, Inc.
All system functions have been tested and are operating within the designed parameters. As
requested, a copy of the drip calculations is attached as Exhibit A. The final "as-built" drawings are to be
mailed to your office by Ms. Lynn Mann.
Should you have any questions, please feel free to call me at your convenience. We appreciate the
opportunity to serve the citizens of Person County.
Sincerely,
�y.e.� �tJ./Sv--�
Randall G. Nelson
Lynn Mann, PG
Certified American Perc-Rite Drip System Designer
210 Hawthorne Drive
Brevard, NC 28712
828-273-4453
Person County Environmental Health Department
Attn: Adam Sarver
325 S. Morgan St.
Suite C
Roxboro, NC 27573
336-597-1790
Date: November 16, 201�
Re: Lot 6 Clearwater
As-Built Schematic, System Start-Up & Final Inspection
Adam,
The system was installed with a total of 18991inear feet of drip tubing in two zones,
which exceeds the minimum design requirements of 18001inear feet. Please see the
attached as-built schetnatic for the actual run and lateral lengths. The pressures measured
during the dose and flush are adequate for system performance according to American
Manufacturing guidelines. The minimum flush rate required for Zone 1 with 9721f is �(4
Lat x 1.59) + 5.2 gpm dose = 11.56 gpm, the measured flush rate is 13.0 gpm. The
minimum flush rate required for Zone 2 with 9271f is (4 Lat x 1.59) + 5.0 gpm dose =
11.36 gpm, the measured flush rate is 12.5 gprn, so Uoth zones exceed the minimum
required to maintain 2' per second scouring of the lines during flushing.
Overall the system appears to be installed and functioning as intended, as reported by the
installer, Retrac Lewis, and the supplier, Randall Nelson of Carolina Aerobic Systems.
The system doses and pressures as installecl are at or very near the original de�ign
parameters, with extra linear footage of drip tubing installed as allowed by the field
conditions encountered during constiuction. The locations of the system components are
derived from a drawing provided by Adam Sarver.
I have enclosed one copy of the as-built schematic drawing and certification letter for
your records. If you have any questions please don't hesitate to call.
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Lynn A. Mann
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SYSfEM SfART-UP PRESSURES � ZONE 1- PROPOSED PERC-RiTE TOP-FEED
ZONE 1 ZONE 2 SUPPLY MANIFOLD,1' SCH 40 PVC.
DOSE DOSE � ZONE i- REfURN MAMFOLD, 1' SCH 40 PVC.
Supply- 60 Supply- 52 � ZONE 2- PROPOSED PERC-RI'fE TOP-FEED
Return- 47 Return- 50 SUppLY MANIFOLD, 1" SCH 40 PVC.
5.2 GPM 5.0 GPId � ZONE 2- RETURN MANIFOLD,
FLUSH �H 1" SCH 40 PVC.
Supply- 28 Supply- 23 � k^ pVC LATERAL SUPPLY LINES.
Return- 1 Return- 2
�� 13.0 GPM 12.5 GPM � , �- �� '� I � `d'�: � �
/ �
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ZONE
!�; 4" PVC GRAV[TY SEWER LINF.
�;�A NORWECO SINGULAIR BIO-f4NETIC 500
GPD WASfEWATER TREATMENT SYSTEM
03 1,400 GAL PUMP TANK.
� 1.5�� PVC Sch 40 FORCEMAIN (FMl) tn
iR,�i�-.,,.ii� Unit,
� 15 GPM HYDRAULIC UMT tor American
Manufacturing PERC-RTTE DRIP SYSTEM.
� APPROX. 30 L.F. 1.5� Sch 40 PVC GRAVITY
HACKI►A3H RETURN LINE.
��� vOR1YEC0 & AMER[CAIv PERC-RITE GONTPO�.
PANELS.
9Q PROPOSED ZONE SUPPLY L[NE (SL). Approx.
315 L.F. to Zone 2, Additional 60 L.F. to
Zone 1, 1.0" Sch 40 PVC to Supply
Mani(olds.
Q ELECTRICAL CONDUIT and W]RE to
Remote Zone Velves.
� REMOTE ZONE VALVES.
REPAIR SYSTEM DESIGN:
SUBSURFACE Di21P WITH
AEROBIC PREfREATMENT
3 BDR: 380 GPD
� LTAR: 0.10
---� TRENCH SPACING 2'
1800 LF REQUIRED
I1890 LF SHOHN FOR REFA_R
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August 5, 2014
Steven M. Barnhardt
417 Stonewyck Drive
Burlington, NC 27215
Re: Lot #6 Clearwater Subdivision; Health Department file: Tax Map #A23, Parcel #203
Dear Mr. Barnhardt:
On August 4, 2014 I made a site visit to the properly referenced above to meet with your builder
(Cecil Barker) and well contractor (Keith Barnette) in reference to siting a new well. A new well
location was established during the visit and marked by the well contractor with a blue wire flag.
During this process, however, a two car garage apartment was in the process of being completed on
site. According to North Carolina laws and rules for sewage treatment and disposal systems 15A
NCAC 18A .1949 (a): "The minimum volume of sewage from each dwelling unit shall be 240
gallons per day and each-additional bedroom above two bedrooms shall-increase-the-volum�of -
sewage by 120 gallons per day." This being said, the existing garage apartment structure is
considered one dwelling unit with a minimum wastewater design flow of 240 gallons per day. Any
future dwelling unit(s) will also have a minimum design flow of 240 gallons per day or more
depending on the proposed number of bedrooms.
Currently there is a valid wastewater system permit on file for a three bedroom (360 gal/day) home.
(However, the garage apartment unit will require 2/3 of the permitted drainfield area.) Therefore,
any future dwelling(s) cannot be permitted unless the size of the current septic system is expanded
upon.
Please contact me or my supervisor (Harold Kelly) if you have any questions or concerns in regards
to this matter.
Sincerely,
Derrick A. Smith, LSS, REHSI
Environmental Health Specialist
CC: Planning & Zoning
Building Inspections
Health Director
C��b'L"`�. ��2��
Harold Kelly, LSS, REHS
Environmental Health Supervisor
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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nc department
of health and
human services
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For fnorganic Ghemical Contaminants
County: •� Name: �. � T-'
Sample ID #: Z3—Zp Reviewer: �Lt��
TEST RESULTS AND USE RECOMMENDATIONS
1. [�Your well water meets federal drinking water standards for inorganic c/iemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical resu[ts onlv. 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 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 instal) a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorQanic c/:emical results onlv.
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Manganese � Mercury � 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/I. 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 innrQanic cJiemical results onlv.
❑ b. Levels over 30 mg/I 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 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 inorQanic chemica[ 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 Cadmiu►n Chromium Fluoride Iron Ma nesium
Man anese Selenium Silver H Zinc
For n:ore infornration regarding your well water results, please ca!! tlie Nort/e Caro[ina Division of Pub[ic Health at 919-707-5900.
��ZS , S'
Report To: H. KELLY
North Carolina State Laboratory of Public Health
Environmental Sciences
inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
STEVE BARNIMEDT
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sloh. nc�ublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
CLEARWATER LANE LOT 6
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573
EIN: 566000331 EH
StarLiMS ID: ES061115-0042001 Date Collected: 06/10/15
Date Received: 06/11/15
Sample Type: Raw Sampling Point: Outside tap
Sample Source: New Well Temp. at Receipt: 6.0
Sample Description:
Comment:
Time Collected: 10:45 AM
Collected By: H Kelly
Well Permit #: A23-203
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 41 mg/L
Chloride 30.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.24 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 22 mg/L
Manganese 0.09 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 7.5 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 26.00 mg/L
Sulfate 15.00 250 mg/L
Total Alkalinity 157 mg/L
Total Hardness 190 mg/L
Zinc 0.38 5.00 mg/L
Report Date: 06/18/2015
Page 1 of 1
Reported By: Arno/d Holl
North Carolina State Laboratory Public Health
Environmental Sciences
�ilicrobiology
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: ES061115-0109001
� ������� ������ ��� ����� ����� ����� ����� U��� ���� ������ ����� u��� ����� ���u ����� ���u (��� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
STEVE BARNIMEDT
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sl�h.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
CLEARWATER LANE LOT 6
ROXBORO, NC 27573
Col lected: 06/10/2015 10:45
Received: 06/11/2015 08:29
Sample Source: New Well
Sampling Point: Outside tap
H Kelly
Angela Heybroek
Well Permit Number:
A23-203
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Denise Richardson 06/12/2015
E. coli, Colilert
Report Date: 06/12/2015
Absent
Explanations of Coliform Analysis:
Denise Richardson 06/12I2015
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.
�-� 2�3 - z �`�
DAVID BRANTLEY & SONS
WASTEWATER TREATMENT INSPECTION REPORT
SYSTEM OWNER: OPERATOR: Admin
Barnhardt, Steve CERTIFICATION:
ADDRESS PIN#
596 Clearwater Lane TAX REC:
Semora,NC 27343 '
SYSTEM OPERATOR:
DAVID BRANTLEY & SONS '
DATE OF THIS INSPECTION:
DATE OF LAST INSPECTION:
FACILITY:
Type size and sewage flow in accordance with permit
TANKAGE:
Risers accessible, surface water diverted?
Risers structurally sound, watertight?
Sanitary.tee in good condition? Effluent filters cleaned?
Sludge depth/appearance , level acceptable?
Grease Trap:
EFFLUENT DOSING SYSTEM:
Sludge depth/appearance , effluent appears clear?
Required pumps present, operating, and cycling properly?
High-water alarm present and operating properly?
Vent/floats/pipe/valves/disconnects in good working condition?
Control panel/electrical components in good condition?
GROUND ABSORPTION FIELDS:
No evidence of effluent surfacing/reaching surface waters?
Minimal ponding in subsurface trenches?
Surface water diverted around fields, no depressions?
Line cover/vegetation adequate/maintained as needed?
Protected from traffic, destructive uses?
Distribution devices accessible?
Distribution devices in good condition, working properly?
Repair area properly reserved, maintained?
Turn-ups/cleanouts/valves intact and accessible?
No effluent standing in lower laterals?
Laterals free of excess solids, flushed as needed?
Diversion Ditch/Berm in good condition?
COMMENTS:
MALFUNCTIONING
NEEDS MAINTENANCE
STRUCTURELY NON COMPLIANT
COMPLIANT
11 /5/2015
Y N
No power when
Flow 599
rrived. Pulled samples.
; �ceAnalytical D
� � 1555'Np2CE�dDACtXr1
r
7
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Projec4 �CZr' 1'`ti'�` )�`�.r" C�.
Pace Project No.: 9227d746
Sample: EFFLUENT
Parameters
Total Suspended Solids
Carbonaceous BOD, 5 day
Fecal Coliforms
Total Nilrogen
Nitrogen, Ammonia
Nitrogen, Kjeidahl, Tolal
Nilrogen, NO2 plus NO3
Sample: INFLUENT
Parameters
BOD, 5 day
Nitrogen, Kjeldahl, Total
Nitrogen, NO2 pius NO3
Date: 11/20l2015 01:18 PM
ANALYTICAL RESULTS
Lab ID: 92274746001 Coliected: 11/04/15 12:15
Results Units Fteport Limit OF Qualifiers
6.0 mg/L 2.5 1
ND mglL 2•0 1
4.0 CFU/100 mL 1•a 1 19
0.53 mylL 0.12 1
ND mgll �.10 1
ND mglL 0.50 1
0.53 mglL 0.020 1
LabID: 9227d746002
Results Unils
23.7 mglL
27.2 mg/L
ND mgiL
Collected: 11l04/15 12:15
Report Limil OF Qualifiers
2.0 1 62
2.5 5
0.020 1
REPORT OF LABORATORY ANALYSIS
This report shail nol bs reproduced, except in tull,
vrithout Uie vnitten consent of Pace Maty6cal Services, Ine..
Pace Analyticai Services, lnc.
6701 Conference Drive
Rateigh, NC 27607
(919)834-4984
Page 4 of 7