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A23 211i3 4.56 ACRES S84' 33 � �-1 V1 —� 2 ao yG � < �IS � I �'i G j A r� � _ 1�I S �ti�`�-- � 1� ,,. IF . � �� 22 ,�ra„� -� e�°P � S�,p �r . �► ►��e � � � � S� � � �~� Q�s2,�i'� � �a►-K-QoQ % �or�e r � S'�R �l� ��9''l • �. �i�` SP� ��r , �� I .\ p,r��:��,''eC.� A�-�c%� \ . � �� .;:. `� ' / ;� � �' 0 N `, a � )' � � . 2^G CRES w N N O �n � o � z ;F �- SEE CONTOUR DATA / 420' � CCNTOUR �� . � �a�� CAROLINA POWER � 8 LIGHT COMPANY HYCO LAiCt 420' � CONTOUR s�� "=1��' ��,�� 1C"" �� `—'' �� C � ZC71��["� 1E��sm,.,.,.,.,,��.]L IHL��.It�7� SITE PLAN BOUNDARY DA' LINE BEARING L- 1 S20'59'04"W L- 2 SO4'47'S3"W ' L- 3 S76'S3'24"W L- 4 S41'24'52"W L- 5 S59'47'06"W ' L- 6 N73'22'25"E L- 7 N36'21'49"E L- 8 N46'54'S4"E L- 9 N84'17'30"E L- 10 . N76'28'S5"E L- 11 N35'02'25"E L- 12 N89'34'30"W L- 13 N71°09'19"W L- 1.4 N04'S4'50"W L- 15 N32'S5'42"W L- 16 N50'37'02"E L- 17 N05'15'22"E L- 18 N76'02'47"E L- 19 N88'22'47"E L- 20 N42'13'24"E l.- 21 N18'55'S0"E L.- 22 N11'30'20"E L- 23 N11°34'49"E �-- SE� CONTOUR DATA _,' _ Name � � � Taa Map #�?" P� cel # Zl` Sub ' � �on �� Section/Lot# �j?�O Authorized State Ageat Date Sysrem componeats rrprrsear sppinximate ronmurs aaly. ?3e coacracmrmust9ag the sysrem panr m begianiag the iasuUaa`on m iasure disrpmpergrlde is msm�ed 31 1 I ��" vJ . IS 584°4��58� ---WUL IS �2 � 18�•19 �y g SE� � 11 BOUNDARY –� IS\ DATA IS �. r% 2 L ,, ACRES IS �. N � \ SD � ` \ - `_ _ Z r � �Ni�j� �' y�� ,� R/ - -------- _- ` ' � ,% IS IS IS �� 8 ` IS S87°10'48"E rn � � � $� �IF 81 i �� ( J v�� i i i � � 420' ^ ��— CONTOUR -�� IR p�TA. G+� / O 4� '�� SEE BOUNDARY � DATA i °` I S Is , \, , ` _ jS IS IS � '�—__ 101_86 C9 15 ' - —� WASTEWATER • \�� IS Ci5 IS PUMP IINE EASEMENT � C11 6 'T . V � ACRES �; w N � o � � � 0 0 n � 0 z SEE IS I BOUNDARY ----..� r. DATA '" c�2 IS IS _ __ –.�. �o IS � S G< �� I S i �i� i� 6q I F � � � 420` �-- CONTOUR CAROLI�+A POWER x � i (:HT f'CIAAPANY F 7. 2 . 3'9 ACRES f�7 � SEE CONTOUR IF ,.�� "�� - Wv� �6 10 1 .01 , ACRES � � N72. / , '4'8J28nw 6 • BS �� \y��. s. � 9, `'�O ss � p,`Y �. �2 , 5�� Tq�6\ � 4 �-- cor w � Wv� �� IF 40 15' WASTEWATER PUMP LINE � EASEMENT r-15.36 , p i S /V6 �'j�. � 1 1 ``` 8'¢s � SEE ,�r� S �P� 2 �'''�� S BOUNDARY –� CATA , 64 IS 4 / 15 O . I 5_ � .� � 13 6 ''-0 __�, b� .� SEE TS �--- .' � BOUNDARY ;S ,IS l � CATA ` � / ' � IS�� '`� SEE : , . , CEME?ERY � IS �� i DRA:NFIELD � (APPROXIMATE) � 9 `��, 1 DATA � , �. . ,. ��3404�`��.,�-.. '{ \-/ y� • 1 \✓ 1 � 1 1 -� 1 i � �, r'r nr �'ni r� �� h � �� i'�tr ✓� -f'+e�wt �SSC-R ��e : �� = 5� r j�.e,� ► � �� .� �� ---- , - `_' �- � � �.T.T�'1C�Y" ��a-��,.,.,...��.n �m.�.n�� STTE PI.AN Name � D� O � Sub '' � l Taz Map #�3 Parcel #�) � ' seman/I.ot# y1i i--�� 2 r J �Authorized Stau gent ate System compoueats trptrseut appmximam rnatortrs only. 73e aontracmrmust tlag t6e sysrem pdnr m begiaaiag the ias�Jlation m insutr �nrpmpergrade is maiaryaed � °`� I S xS �' �� S . � -. �......,. �, �.. �. �, �,,. .:�� C� IS �'�P /�-e _ w � � �-\.`'�.� � I5 � .� _�� D ' � 'j S �- 1 � SrE B� U N D A R Y ----..,�.. r� DATA `r �� .L J �� 1� A� { � _... ` �;� N �" C� �J R ;Ca�. � �vA f�a4�ER T G�-�'r C;�M�'��' h�`!C;� I_ �KE. �� zs �•� �E:E C 10 _ ___ .- "" �y�}L �� I5 �� S__�__� C�5 '` IS �1 i � � � I 5 � I�� p � ••�.�„r,,8 , �i� ,► . ► �� s � , `�� ' �. _ ....... � r.� ` � � . U!Q sde�a,� \ PuM � �; �,e � .�� ser��- '�' �� '��..> i 5 ' �� ,� � � � �� , 1NA5TEWA �� S`, �.� � �'�� PUMP L J . -' � �'� � E ASEME �, C ,,,�°� � � .�, -'�� . . , 4n `Scp `�`' �l' \. ' � � ,� � �'� .� , f� 15 \ � .� � I5 SE�: � � U �f D ,A R Y �-�,'�. GAT,A , �� s � • \ 1 .� �� \ �� `-� ---_..� ... � �PSS h� %1'�°�n �� l� _ .� �zo, � .,.� , � �, �, /o � � � ,. �� .� S � � I � , 1� f�-'� �, B�U�DARY �� ,,�� ,�5 � ',- � � 1 r� 1 � `.. � �" ', � � � � "`' � � � � � � � . CE�� rE.��r I S � p,, �; ,i�. DRA � NF I E � � 9 r; c p�p��OX Z �1A��E � ;, ,��, ,.�-� DATA , q� - t cs� ' � � ''+�.�. � r � ti�,� �,' � r� � , -' � � -� %" 1 5 �� % � � f� '!"� �� n � 1..- � . r - ' �� i �� ,I ' � � � � �' � � �� J�s1.�s.� �o -,-�, ,,�,-„ <� ��.�.�. �'1� � �e.�',��. A�lic�m�: � 0 b /�OS�2 . �c �p ��3 G�^� � Z� � �,� o �� r �pr��e�ea��.��i� ��r� `��l'ad ��r ��ae � 1�0 �a�aon Type ofFac�ity: IgIZ eS New �Asiditi�n � �� aa�p�g t,t/�el� # of Ocaup�sM # of Be�rooms Proje�ted. Daiiy F1ow 36� g-p•d- � Proposed Wastewater System: ct �� Type; � Prap�sed Re�air: � �,.. • Typ�: �� . Pezmit Conditions: �PJ2 S, �2 S'�e �C �, � . . - - . Ownei or Legat Represe Authorize3 Stats Age� Dat�: � The issvanc� of ttris pemut liy �e Health Depa�nent in does not �waz ��tee the i�'�nr� of othez permits. If is ti�e respons��j of the aPP��PmP�Y owner to in sure that aIl Person Cou�.y P3aaIIiag and. Zo�g � Bui�ing Insp�tions reqnaements are me� �'�as �pa��nt Per�aaat � saa�sjea:t t� ��ati�n 9i i�e sa�e p3�; �p%��'�� tiu in#estdex� �e e�g�. �� e��i ��t is s��$ a�e�t� Iig a ci�ge in oevn��adp o�' #he ��er#3►, i� p�it ��s i�suaed in c�s�9i�c� �i� t�ae px�m�i�� f th� �Toa�t� ��, .� `��vvs Eaasd Rsales f�r �esva...�e �`re�ae�s� u�xd �stsosal �vstesras' (�.SA I�T�." � fl�A .19��). I�ei�aes ��a �i�ta�#�r.: aoa��:tFa.�.' '� �aav�nanent;� �ea1t4� Sper.ial'as# �rra�rant� t�a�t t.�a� se�tic *.�k sy�e� w�l c�m�immn�� t� f�a�on s��ia�ea�iy i� tflne fiai�re�or�#�at- t3i�-wa�r supgclp wai! r�sin �Sotafisie. . . . • ��a#�n�a�a�i�n t� ��ns#�et ��t�rat� 5�� (�s�� a�g ��.�� *. Ses site plan c�d additional att�c�cments (_�. � j� � . � . � D✓. . Prop�sed Wastewater system: �! ��C�Q'�r� Ty-p�� '�Nastewater �lmw 36 o g-p.d. New %C Repair Expxnsi � � .� S�� : • 2 S g.}�. dJ $ 2 � Type ofFact�i�.y: �r��C. ' � Baseffient �C Yes_No �7��_��r �.e��a�� '��: �e�tac'T�:'�dAO �� T�, ��c7g�1.- �r�e�a�P- ^ � ��al: 'T�� -�,.�: Ol�� q ig �o� L�a�t�$a 3�� ' ' � �� I��a �_ � �� d�a � � S�i� ��ver: �_ � � �e��a S��o� � � ��aa�on: �i�a�1'baa�ao� �� Ses�ai ��a�aa�� iC �res�e l��o � /� . �u��#imans: � t r 4�'( %; a�,� r�'9� � CQ�' ��A�2''�-��v'P� �, h' 2C�'. .; n �ta.� Ag��: � Permit Ex�iration Date: Date: 'The tyne oi system p�i�e3 :s Convea-acnai � Ac;.�te3 �1t�x�aiive. I a�cVL�t t.he sperisica�ions oi the ��-1�' ��i ��Q��z�e• (..� �t', � • �� --- �at�: �� 1 /"o rC�.,,� re��. l Il i0145.- . ; .. � � `�-�--�,��• �� L_...-•. Y /^Y � � � � 1L � 7� �w-� �r � �,� �:, � �.�.I1 I�3Y � .�,.IL-�ll�. Sloped To Shed Watez NEA�fA 4X Simplex Control Panel 7 I� 4" X�l" Pressure Treated Post � 12" Separation Electrical Con�it — I 6" Covez • � Acce» Cover. . •• , • , ;• ' 1 � � . _ � . i •�' o ' � = ; .'�`. '" . ; �,, Openin� Filled With Anti Siphon Hole ` P land C t Gmut T�x M�� — P�i`cel # �� , � �ihclivision Ph�� = 'S < ction'tot # Duct Seal Hoth Ends Of The Conr.b�it �- 24" Mininnun --1 "'' --- - 'I'��d Gate Valve Union / ^� I-1 Zip Coxd Tie� 1 Inlet From Septu Tank oxt emen �Drn,,n H,ll� I 4" SCH 40 PVC Pipe � Check .�.Nylo Valva �Pe � Higkt Watex Alarni Level ' (6" Separatinn� . High Level- Pump On � �f fiVaporLock i �� " �, Hole a �! . . � �Draridown �Up Hill) � � . , . Low Level -Pump Ofi ` � . Pvmp �• , Pzecast Concrete Tank 4" Concrete � ' � ;.; (�riaterizl Strength>3500 PSI) Block •'.`,.'.' : ; .' •-_`_'. . •:'••, ; . , y ' Concs+e4e Risex 6" Sepaxation • '• ' � :�..tJ::+' - � '�,�...-�—Portla:ud Conczete Gxout Mastic • - ' � Opening Filled With Supply �' portlaxudCementC'mout Lix�e • • 4utlet To D'vtnbution 2" SCHAOPVC Pipe Float Wires � , •r F7oats +.. �Rexnovable �•�. F1oat Trna , , r � .. �. �, �.��:� �. �o�i �a�,Lo� �tntrrn �� r � ,/ r Q�, i l�tr 0 '� ��cc-�f ��33-oa�� . c�� - s'�-� u � � �� `��.�� ' 1��.�� --- = �-j- � � �� /I�n��n,.1n�� 1 � 1E�-9-��..,,-��.li 1t�L�.�.D.,�Il�. Owner: l�I``�l�wKl'ci►r Tax Map: �a3 Parcel #: 2(1 Date: 7 0 �.ime Tap '�a� (Sc�) Tap �o� Line ��ngt�a �oe�v / ��ot # �iaaraeier(�) ( m) :. (ft) 1 z �0 s•� D , pQ 2 z �o ?, �D . d�8' 3 � z �o ?� �dt� • d't 4 3 0 0. to � .� 5 6 7 8 9 10 ��O ft of line x 65 gal. per 100 ft= 2 3�i� "—� ; 100 =�� gal 75% x Z3 ga1= � 7S gal per dose � gal per minute (gpm) _�'low �8at� Frflction �e�d I.oss: ft per 100 ft of supply line x ft of supply.line = 100 = ft ft x 1.2 = ft of fricrion head 5`� Manifold Siae: " Forc� Main �ize: " PVC , �otaI Dynamic �ead = ft of Elevation head + ft of Pressure head + ft of �(-�i ✓l�rs Fricdon Head = TDH ✓ ��`1� Pump �eqiaarement: GPM C� � ft of Head„ CR�� S. Drawdown: f%5 gal per dose ;�fgal per inch =�_ inch drawdown per dose zS �nteea'� �� 'or�taon . �� :.. .., .. rycr�ev�e �� , �� ■■i��rs . . , , ,. i► �ir i► i� , . ' ' ' ' r . :.� .,._ .... �,'...... 9�� 'i' s-�� I _ �� ,.. ��c��omoo ;i:ii�si�:�i:iiiiii�iiii�iii.� ��N��Nl+��i��+1 a v: �rianiiold u%ld lYi�x �izE (='tEdnce ir li4" t37�5 �� d 3» 9 (n � 4a+ Taps off one side ior :ap in �oth '/�" taT�S 1" �lo�v p�i TsP �i�e 1}Tcu¢riai Flo:c G�Y! :' ' Sc�:ed 30 �.� 1. Sctied '0 '._ ; " :icl:erl 80 1 � 1 :• ' Sciied ?0 ?' - .1 0� �� • .. ' .'\` ; . /, . _ . \ - . �' �. �% i I '� � \ i � ' ! y _ ' - � v � , _ --� -- - _ — �-' ' ; _ '� �� – j,. ,I _�i i = ; – 1 , _--- _ ,� '�' i �' � �R/VEK, , � I� _ Ay , � , � , . , , _ '�j� . __ -- _ � �'�. � \ � nS ' . °�'. _ _ •'\ [ Z- Izl�� , IF,; •� ,.\ ! ---- - _ _ , ,� � �,\ \ -_...-----._._._. : ; , :� - -.. \.� ,\ . _ ' ___-----� . 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Barnette Well Drilling 336-598-9275 p.1 liESIDENT�AL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Naiwai Resources- llivision of Nater Quality WELL CONTRACTOR CERTIFICATIOi� #� G d l�� 1. WELL CONTRACTOR: � �� Well Coniractor {Individual) ame �mette Well Drillina inc Wefl Contractor Company Name - 6'I 1 Barnette Tinaen Rd Street Address R xb N 2 574 City or i ovm State Zip Code 3� 36 � 599-OQ'15 Area code Phone nvmber 2 YYELL INFORNEATiOPl: VUELL CONS7RUC710N PERMIT#_,�iti,� 1�ot3 � arr OTNER ASSOCIATED PERMIT�(if app�icabfe) �i[l�t� SITE WELL Ib �t{if appfieabie) 3. YVELt USE (CheckApplicable Box): Residential Water Supply (� DATE DRILLEa �'�y I f TIME COMPLETED �!� AM ❑ PM Q 4. WELL LOCATION: CiTY: CAto/�+ ,_COUNTY rtla. n �.�� ft/ c..7� i (Street Name, Numbers, Corr.munity, Sabdivision, Lot No.. Parcel, Zip Code) TOPOGRAPHIC / LAJJDISEITIIVG (check, appro�riate box) �Slope �Vadey iyriat pRidge pOther LATITUaE 36 `_• " DMS OR 3X.xxX)OUocXX DO IONGINDt 75 �' "�M5 OR 7X.XxxX�Wcx pfl Latitude/longitude source: [�;PS []ropographic map (location of weU must 6e shcwn on a USGS topo map andattar,hed to this f+omi if nof usirrg GPSJ 5. WELL OW�IER�� OS� Owmer Name / / �t!/t 11'! �p T' f Sb�eet Address �.,,1� r��- �f � • ?��Y ra�,T�^ � Siate Z�p Cod � ��.�t_1 ,�� ' ?L� � Area code Phone number 6. WELL DETAfLS: a TOTAL DEPTFl: V � b. OOES VYELL REPtACE EXISTTNG WELL? YES p NO @� c. WATER LEV�L Below Tap of Casi:ig: � �. (Use '+` if At�ove Top pf Casing) d. TOA OF CASING IS -�, FT, ,qbqve Land Surface' 'Top of casing termiAated aVor 6elow land suriace may require a varian�e in accordance with 15A NCAC 2C .01 �8. e. YiELD (gpm): ____�, METHOD QF TESi BIOWII ZO!'Ci f. DISINFECTiON: TYE�e T�"'� Amount � C q - g. WAT�R 20NES (depth): : Tap Bottom ifZ = Top�� 9ottomr�% Top B�ttom Top Bottom Top Bottom Top 8oriom Thicknessl 7. CASING: Depth Diameter Wetght 1LM�atgrial Top� Bottom� Ft. � � � �,� 11 !'�'�- rop_�,� aoaom� Ft. 6 �/ !� �Y ��,/. : Top Sottom Fl. : 8. GROUT: pepth �Vlaterial = rop �O Bottom Zo Ft. Sand/Cemeni : Top Bpttom FL : Top 8ottom Fl. 9. SCREEN: Depth Dearneter Top Bottom Ft in, %p Bottom Ft. fn. Top 8ottom Ft. in. Method Poured Slot Size Materia[ in. in. �. 10. SANDlGRAVEL PACK: Depth Si2e Matarial 7op 8ottom Ft Top Sottom Ft. Top Bottom Fl. 11. DRILLING LOG Top eottom �_/�— ,�_� [ � �t��_ / / r / / 1 / / / / � 72. REMARKS: Formation Oes/cripSon O b f ! a^ + ,. I DO HEREBY CERTIFY THAT THiS WELL WP,S CONSTF2UCTEb IN ACCORDAt�C� WITH 75A NCAC 2C, WELL CONSTRUGTIO#� STfWDAROS, AND THAT A COPY OF TFiIS RECORD HAS BEEN PROVID�D TQ THE WELL OWNER, � � �_� �_�j Sl RE QF ERTIFtED ELL CONTRACTOR DATE --��i 1�r, � L'%►i� �-. rwN rED NAME F PE SON CONS Rl1CTfNG THE WEIL Submit w[thin 30 days of completion to: Division of Water Quaiity - fnformation Processln�, Form GW-ta 96i714tfaiE Serv[ce Center, Raleigh, NC 27699-9fi1, Phone :(9f9) 807-63a0 Rev. v09 ��.ss ��..�� I��aa-��„-„-„ ��.�.Il IF3I��.I1�I� Applicant: �.�,��p Location: � � ,u_ �aD ,. Oueration Permit Tax Map �� Parcel # ��/ Subdivision ,_('��s�",�r.,lF,� Phase/Section/Lot # � # of Bedrooms � �3 System Type (From Table Va): Product (IIIg): y�d� � This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. / m �, �,,� � � � �r orized Agent) (Date) �;r ��_S � � �l • I.��.�) � S 1 �Z Z(O .�; (Licensed Contractor) `i (Dat �'�'� ' " �C� � � \ � � �Y'°l(�.�,' f'. --c��5/W� �r.�d�to.0 � Kx��— � 2 �� f'F' SiT� '%"'% 7�2¢jN �if.Gp '�!�.�� a ^�� + �S�PpQ� L��l� o� Lor i� Scale: �'tS ��c�f't ¢°'` �eoss,�� "��J� i�g�� ct�30�/ d ��G� ��Ks �% C�y►vP,��Y Q►-�ss,� . i y� �P��t � ��P �� , �,. � �6 S�' ,�'1 �� 3" , �' �i ��.:� Line Length G�D ' Z -�o' /flb � /zo ' Total o r� �� r2�z�� .,�, Tax Map: ��?Parcel #: 7�! Septic Tank System Checklist (Type II-I� System Type: �� Notes: Nitrification Lines Trench Width: ?j- ft. Trench Depth: ft. — Total Length: �� ft. Minimum spacing: � ft. Rock denth/aualitv Grade (< .25" in 10' Cover (6" minimum Setbacks � From wells Property lines Foundations/basements SurfaceWater Other: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: InitiaUDate �. !7 Z � ��?o ;IZ/ 0 � NOTIFIED BLTILDING INSPECTIONS: Copy of OP �mail Date: -�7,�cr �l� � Z `� T (Revised 12/09 BH) r� .� ' � . . . + � N� (�+�lin�i � �Divii�On of Pablic geei� . � . . , . . � . � ��nal and �i�i�.�0��3'�.8pid�ni+�logy .Scc�on. .. . . . .. . . . . . IlVORGAI�IIC.CSEN�CA� �I,�ySIS.�itEPOR�' � , � � .Prlvxte �re�t�►thr iatorm�tf.�n �m� recommend�tlone County: �-t�irf�� . � . � . _ Namo, . I� Samplo Id Number; �� D J i.ocation; � . . � Reviower . I�IJ2. � Your well waterwas testod for 15 m �`�Y�� PORT � . etals, �lus nitrates, mtr�tes,�andpH: .T�e resul�s wcro evaluated using the. federal �drinking waltr standa�d8: The pHis a measurc:of tho�acidity of the.water. Drinkin water ma . � contain aubstances that can occur naturally in water or can be introduced�into tho water �+bm man-ma Y . sources. (Thesa recommendadons aro based on inorganic. chomical analysis onl , de � _._X ) TEST RESULI'� AND US��COii�. �� ' Your well water meets federal `�". �-� 1VAATIONS � b , g water standards. Your wata can b e used for drinking, � cooldng, washin� cl �ung� �d showering, � � The following sp6stanc,o(s) exceeded fedetal ��g� �o� w drinldng watet standards, �yow water can be used for taste odor ��' �1��' b�ng, and showering, but aesxhetic problcros such as bad , , ateining of porcelain, eto, may occ�, you may want to install a�household water <�reatment system��o addres8 aesth�tia problems. � . �- Arsenic The following substanc�(S� �� fede� � � � well water not be used for g�'at�' ��d�s: We recommend that your drin�dn� or cookin� u�]�S you install a watec treatm�t syatem to remove the circled substance(s), gowever, it may be used for washing� cleaning, bathing, and showerin , ., _ g Re-sampling is recommended in months, � Re-sample for lead and /or copper, rake a�rs� �aw, S minute, and I S minute saaiple inside tha house (preferably thc lcitchen) and �f passible a first draw, S minute and a 15 minute sample at the well head to determine thc sourc� o f�� lead and/or copper, Contact your local health d artment re-samplirig�assistanca. � for Routine well wator sam �T�R CONSIDERA,TIONS . p for the above substances �s recommended evety tv�,o to three years. Sarnple your w.ell water when th�ro is a�oa;oy�,n problem or contamination in your area, after repairs or replacement of your well, or after a flooding oyont, Con�ct your 1oca1 health dapartment for sampling instructione, Contact your IocAI Le�lt� depArtroent !or mone InfermAtloa or g� te htt ; eoi,atataae.�enUoli/6at�ctrheet htm 1 North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH BOB ROSE P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph. n coub lichealth. com Phone: 919-733-7834 Fax: 919-733-8695 325 S MORGAN STREET CLEARWATER LOT 14 ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES082411-0031001 Date Collected: 08/23/11 Date Received: 08/24/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.5 Sample Description: Comment: Time Collected: 2:45 PM Collected By: J. Smith Well Permit #: A23-211 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 95 mg/L Chloride 32.00 250 mg/L � Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 1.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 16 mg/L Manganese 0.04 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 7-7 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 33.00 mg/L Sulfate 53.00 250 mg/L Total Alkalinity 263 mg/L Total Hardness 300 mg/L Zinc < 0.05 5.00 mg/L Report Date: 09/09/2011 Page 1 of 1 Reported By: �e�le %%lareol North Carolina State Laboratory of Public Health O6 N. W�m� gton St. Environmental Sciences Raleigh, NC 27611-8047 htta://sloh. ncaublichealth. com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH BOB ROSE 325 S MORGAN STREET CLEARWATER LOT 14 ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES082411-0031001 Date Collected: 08/23/11 Date Received: 08/24/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.5 Sample Description: Comment: Time Collected: 2:45 PM Collected By: J. Smith Well Permit #: A23-211 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 95 mg/L Chloride 32.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 1.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 16 mg/L Manganese 0.04 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 7.7 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 33.00 mg/L Sulfate 53.00 250 mg/L Total Alkalinity 263 mg/L Total Hardness 300 mg/L Zinc < 0.05 5.00 mg/L Report Date: 09/09/2011 S�� '_ 20"�1 ! �� I �- . i � Page 1 of 1 Reported By: �e�te �okcol North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH BOB ROSE 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES082411-0097001 � �� ES Microbiology ID: 29852 GPS Number: Sample Description: Comment: P.o. eoX Zaoa� 306 N. Wilmington St. Raleigh, NC 27611-8047 http�//slph ncaublicheaith com Phone: 919-733-7834 Fax: 919-733-8695 CLEARWATER, LOT 14 Collected: 08/23/2011 14:45 Received: 08/24/2011 08:54 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A23-211 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Lyons 08/25/2011 E. COIi, Colilert AbSent Darneice Lyons 08/25/2011 Report Date: 08/26/2011 Explanations of Coliform Analysis: Reported By: Susan Beasley ��. ,..__ _ ._ _ _ � ...:___, ::_�--: - ; � AUG � 4 20i1 ' � ; !, _ ; -= -- ------=..=J 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. �.��, ; .�� .� �� -= � = �� .�.��.� ��«�� W�LL P�T�IiVII� (�Tew�Repair� }� 23 TaY 1VIap: �arcel: Zl ( Subdivision: ��1. � Lot: % Applicant's olame: � b �o � 1blailing Address: Phone Numbers: �ocatnon oi Property_ Permit Conditions: 1) See attached site plan for proposed well Zocation. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire S years ft�om the date of issue. �ther Conditions/Comments: Permit issued b�: 6�� `-� ��+� IDate: ZS D C�RT�FICA�'E O� COIdIPLETIOI�T New Well Inspection: E S/Date Location: / �/�( Grouting: � �� 7C--�Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: �/' Concrete Slab: Well Driller• I�.IVv�!�1�i-^� Pump Installer: '� dVell Approved by: M� V�� Date Sample Collected: -Z�" Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 I�iner Inspection: EHS/Date Installer: Depth: Grout: �efll Abandonment: EHS/Date Completed: Method/Material(s): _ Lacense #: License#: Date• � I I � I Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 ,� to Application Date: ,�' �%��' �� ,� � � � ��.� •�' � Tax Map: Amount Paid::��,( L�C� �L��} . r t;�;� =�� Fry �p,z`r'c� Parcel �: Receipt#: .5 �.�' ��`.i G� .S"' ,�<'S �: � � � "� � :� L'�`� �,c��-- ) <<a� �q�'� i r �,��,3�� :�� +��y �,�, � �C�O��C� 1 � ' \ ��ca-arii.s-�c,a.a.ax�..c�aa-�aaJi. .��L.c�.en.�.��a C��-''*`' j Ap�plica�on for Servic;s fSentic Svstems and Wellsl Services Improvement Permit (Site Evaluation) �200.00/$300.00 (if > 600 gpd) 1VBobile. Home Replacement or Building �iddition $150.00 (if site visit required) Weil Permit (New/Replacement) $225.00/$125.00 Construction Authorization (Fee is dependent on the type of sy: Permit Revision $75.00 �tepair of Ezisting Septic System No Char�e Important: If the information in the application for an Improvement �'ermit is incnrrect, falsi�ed, or the site is altered, ihen the Imnrovement Permit a�zd the Autl:nrization to Construct sliall become invalid 1) 5ervic�s ques�ed b�' :� Name: �� r� �^, ��, �C...�N „��" , . � Address: `--� �::: � � ' v � c:� :A:'� z��s--�. "��-� �-' �-a; ��, �.� �. ii�� ,s� �� •�C. . z�� _�- �:� J �`.�,' Phone # (home . �k/cell): �� _ �,�� •�,> ,� �' -�, 'L 3 S �a y �'�-�.� 2jl�Taane a�rd•7addrQss of curr�nt owner {if different tinan applieant): Name: � �.`�.��.�r-a�� 's'� q� Address: `'' � � `� `-` . �� i � 3) Property 7)escription: Lot Size: �� $abdivis�n: �� -- Address and�or directions to Property: �' �"E�� ,� ;°�q �. �:� � ��'d'-' S 3' ; ��e' d �t 3"'�i � �""' � '� '�"" ' vf"'�. y f"C'y. � !'.4� �a, .r-p-,f�� • 4) Proposed Use and �ype of �tructure: ' 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 5} 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) 1Vote: A c�m�leted a��lication must also include: ➢ A plczt/site plcan o,f t�ie property ihczt show� prope�ty dirnensions and the size and location of all proposed structures. � ➢ A signed cvpy of tlie `�ot .�'s�eparation' fo�m veri�ying tliai i�ie p�aperiy is �eady ta be evaluatQrl. � a�a submit�nng �his a�pincaiiom to �-es�uesi servic�s �ro�a ihe �'ers�n County I��altln �epaa�nent. T�e �a�orm�#ion �rovidea� ss �e�ur��e. � uncderstand �hat �f a�ay site :s �ite�¢d or t�e �atendea� use ��aanges, a�l permits shall become �nvalid. - ,� � �''; �- --� _ _�, �-; ..:..� Sig�ai�ap� (Owner/Legal Representative): 'h =,...-•�� ` �� ' <<.'� �� "' �i i �-" �` 06i07 Person County Environmental Health, 3?5 S. Morgan St., Suite C, Roxboro, rtC 27573 (�36-�97-1790)