A23 59��
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nc department
of health and
human sarvicss
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co�nty: a,.1
Sample ID #: �Z.� —
For Inorga�ic Chemical �ontaminants
Name: �
Reviewer: / �
TEST RESULT5 AND USE RECOMMENDATIONS
I. 0 Your weli water meets federal drinking water standards for inorganic clre�nicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
have other water sampling results that aze not taken into account in this report.
2. 0 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 instail a water treaxment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorpanic chemical resr�lts onlv.
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Ma�iganese � Mercury NitrateMitrite Selenium Silver Ma�nesium Zinc nH
3. � 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 innrsanic cl:emical results onlv.
❑ b. Levels over 30 mg/1 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. �he 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 Cadtnium Chrom�wn
Man�anese Selenium Silver
Iron Magnesiutn
Zinc
Fnr nrore injormatioi: regrrrding your well wnter results, please cal! t/�e Nor[/e Carolinrr Division of Public Health at 919-707-5900.
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:
TERESA REAVES
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sloh.ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
9014 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID:
Sample Type:
Sample Source
ES020118-0001001
Raw
Well
Date Coilected: 01/31/18
Date Received: 02/01/18
Sampling Point: Outside tap
Temp. at Receipt:
Time Collected: 3:00 PM
Collected By: H Kelly
Weli Permit #: A23-59
GPS #:
Sampie Description:
Comment:
Inorqanic Chemical + Metals 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 100 mg/L
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 5 1.3 m /L
Fluoride 2.80 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium < 1.0 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
pH 8.0 N/A
Selenium < 0.005 0.05 mg/L
Silvar < Q.�5 0.10 mg/L
Sodium
Sulfate 230.00 250 mg/L
Total Alkalinity 62 mg/L
Total Hardness 260 mg/L
Zinc < 0.05 5.00 mq/L
Report Date: 02/13/2018
Page 1 of 1
Reported By: Deddie.r�fonco!
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A OL84
.� PERSON COUNTTY HEALTH DEPARTMENT � � • �
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERh�IIT �
� Tax Map #� ��''� Parcel # � �
Zoning Township � r►-,
Owner/Contractor �'rCn �i � � � � lQ�� v � S te �- J3 - �.5�
Location/Address �",-�r►� /2o,c�ov-, �f-a.ke S/�t# /.�3� f� S/��#' 132z. ��s�"
Po ►� � vr�v�' ►'� c�d '�' GcYoss ��. �r-ez..-� �5.� ��� S.R.# ����
Subdivision Name Lot#
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Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is alt r' tended use changed.
Well and Septic Layout by
Comments: -�
Date Installed by
— �' � �
, WE SYSTI
Individual � blic
Public Replacem
Site Approved
Well Hea roved
mg Approved
Comments:
. � r.
Date
Installed by.
roved by,
,��
� CIFICATION
equired
Air Vent
equired W � _
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�_Approved by
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Tiv�eport is based in part on information provided the homeowner or hi 1/�f representative in the application submitted for this pemut "Ihe �
environmenta! health specialist is not responsible for false or misleading infotmation contained in the appticatioa The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the apptication. Neither Pecson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
�
.
1'liR;�ON COUN'I'Y i•:NV.f.RONMLN'1'�11_, II1•:AL'lil
� • • ►
WLLL LUG
�Date:�— /1-�'..5
Owner: F�-r�- h ; � ____
Location/Darectio.�s� .'�/.
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��;i;.�:V1S1011 N�1111C:
Drilling Contractor:
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SR# � 3 �i . � �
Lot #
� WELL CONSTRUC'�'ION
Distance from Ncarest Prope:rty Line I.5 �h.�.s Listzuicc from Source of
Pollution o d �
Total.Dep.th:�� c� Ft. Yield:_� GPM Static tii/ater Level Ft.
Water Bearing Zones: Depth ^�'-��t. Ft. Ft. �t.
Casing: Depth: From 2_to�'_Ft. Diameter:_c�_Inches
TYP�.; Stccl � Galvani2ed Stec:l
If Steel, does owner approve: Xes I'io
� Weight: /,� Thickness:�g'��,Hcighe Abovc Ground: ��. Inches
I?rivc Shoc: Ycs �- " No -
i
Were Problems Encountcrcd in Sctting the Casing? Yes No .� �
T /' �
at 'ycs" give; reason:
Grout: Type: Ncat Sand/Ccmcn[ � Concrete � �
Annular Space Width -3 Inchcs
� Water in Annular Spacc: Ycs No �--
Method: Pwnped_ Prc:ssure Paurecir ✓
Dept�: Fr�rr� ,� to �-o rt.
MateriaLs Used: N��. Bags Portland Cement_�_ Weight of 1 bag�,�,lbs.
If mixture (sand, gr�ivcl, cuttinas) - Ratio: � to f
� ID Plates: Yes ✓ No � � � _ .
� 4 x 4 slab Xcs�_ No
.
I HEREBY CERTIF1' THAT 1'HE ABOVE INFORMATION 7S CORRECT AND THAT
THIS WE�.L WAS CONSTRUCTEI.� IN ACCORDA.NCE WIT�-i REGULATIONS �SET
FORTH B'Y�THE PEi�SON COUN'T'X i-IE.�LTH DEPARTMENT. -
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Si�;naturc c�F C'c>ricrac:tor Datc ,
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Date: i! /�/ �7
Name: �Q.�..:�Gi �;, t ��2�G,A '��,,p�;f�.r>Tax Map:�� Parcel:�
Address: �� ic.� � C(�� �Lj�j,� � .
5�-�. �'� ?���r-
Re: Bacteriological Test Results
Dear Well Owner:
Your well water was sampled on �� / 27 / � 7, and tested for both total and fecal coliform bacteria.
Your water sample test results are noted below:
;( 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 only.
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. 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
gi �undwater may be entering the well. If coliform bacteria a�e present in your water sample, the water
may,, not be safe for use. Young children, the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physicians should be not�ed of the test results.
A well that tests positive or total or ecal coliform bacteria should be properl 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 o�ce
hours are 8:30 to 5:00, Monday through Friday.
Sincerely,
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Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant I�CA�����
Address b 1. G' �1.�,� L( County •.
�`D -
Collected By
Date Coliected �L ' Time Collected Z I.`�
Source: ell ❑ Spring ❑ Other
Location: ❑ ouse Tap ❑ Weil Tap ❑ Other
o No Charge harge '
..............................................................................�
**�**********************************�********�*****************************
Total Coliform
Fecal/E. Coli
Results
Present
❑
❑
Reported B
Date Reported ���""� ' � /
Report Called o YES o NO
Calied To
Absent
r
Site, E`saluation Application
. /
/
Fee Co•llected YES
P� 16�.iq�6 `�
�.e �1��
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0
Date. � — � 3 - l,�
APPLICATION FOR IMPROVEMENTS PERHIT
1. Permit requested by: owner/�rospective owner:
, agent:
�„P,,,�Lt �. �.'Ra�-°�-
Address: ���,1 �dt,.�.✓� I�o�C�Son R�, Rexboro � N•C. �'I S
Home Phone ��: q►o-S97- S3NR Business Phone ��: S��''te
2. Name and address of current owrier: �A+'N e
3. Property Description: Lot size: ��, $� Z
4. Tax map ��: Aa3-�� Township: C��^`��+�y tiQ►n
Subdivision Name: Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
6� �-%q }-e � aq� I ?L2.
6. Permit requested for: New Installation: t/ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: 3
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. Water supply private? public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring? �
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: 3 Garbage Disposal? Yes ro ►�
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 Yiereby 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-335(F)
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Signed Owner or Authorized Agent
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Permit Issued
. . .
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTIJRE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
S. RESTRICTNE HORIZONS (in.)
(Impervious Strata� rock)
6. SOZL DRAIDIAAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
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g. OTHER (speci£y) PS PS PS PS '
U U U U
9. SITE CLASSIFICATZON
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitabie U- Unsuitable
R ECO�NDATZONS / COMMF.I�ITS :
S:�_TE CLASSiFICATZON DLAGFtAH (Znclude: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas, Wells, Water bodies, slope patterns, etc.)