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A24 121The is��Healt� artment P CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT �To. Date `"� � Owner: �-�P .�� 6l � e�- �G✓�p Location: _—,��— � � n . _ �� 7 > '.L f' X"}. -�i ✓P w,'� � .� �, l Z F1 �Z p, Contractor: � '��T�n�.��es �r� � � Water Supplp: Private �`'�� Public i ..�� I ,- � ��° J . �-f- � l , - � -�-,T-�- 1 �T' C>�1/7�/ '?' ��:i.�j ��n� :s'1�,�/I�%/� / Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal, washing machine, other sutomati Size oi tank: �d� �� • / V � < < % � � Other disposal f cilit : _ c appliances Nitriflcati,o_n line: '/ � 3� �Y) C��D �Y // �i7n,Y9-•�- i Water supply and sewage disposal facilities location, installati and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT H LTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE I ALLATiON IS COV- ERED AND PUT INTO USE. � , n� I� / i, t C\ Date approved: Well:_.1�,� Sewage Disposal:_ BY: '� � --� .�� (Owner or M��presentative) � Certificate of Completion Date Approved: � � By: Sanitarian (OVER) Location of w 1 and sewage disposal facilities sketched on back. ��r��', � % �� y � L } �w •w DATE ISSUED: � - OWNER: ADDRESE� DRILLING CONTRAC WELL PERMIT Caswell-Chatham-Lee-Person Counties �DATE DRILLED: S �'y-�� COUNTY: ��'�'R �Qu ROAD/STREET:�,P�E l3,3[ .,ut_ PERMIT VOID AFTER ONE YE R�— : ��! NAME ADDRESS WELL CONSTRUCTION Distance from Nearest Property Line /p {-�. Distance from Source of Pollution �QO �.f_ Total Depth:_[�_Ft. Yie1d:�GPM Static Water Level: a� 0 Ft. Water Bearing Zones: Depth:1,�� Ft. Ft. Ft. Ft. Casing: Depth: From D to N Z Ft. Diameter: � 3'y Inches TYPE: Steel Galvanized Stee1 � If Steel, does owner approve: Yes No Weight: Thickness: � Height Above Ground: Inches Drive Shoe: Yes: �/ No: Were Problems Encountered in Setting the Casing? Yes_ No ✓ If "yes" give reason: Grout: Type: Neat '� Sand/Cement: ,� Concrete Annular Space Width 3 Inches Water in Annular Space: Yes No ✓ Method: Pumped Pressure Poured ✓ Depth: From 0 to �� Ft. Materials Used: No. Bags Portland Cement � Weight of 1 bag �lbs. If mixture (sand, gravel, cuttings) - Ratio: � to � ZD Plates: Yes ✓No � Chlorination: Yes No ✓ 4 x 4 slab Yes No_j� De th From to Formation Descri tion f7 I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY CASWELL-CHATHAM-LEE-PERSON DIST. HF mH nF.PT. � �� . �� 7 Signature o�' Con�ractor ' Date FOR HEALTH DEPARTMENT USE ONLY REASON FOR NO INSPECTION• _ � -d Sanitarian' ignature ^ Date Sketch well location on reverse side. Use establishe reference points. .. .. •. . . • . F��'y',,.' �� .I�� ^ . �--� ^` . • �_ >' 7'' . --__- --- � � � �:��.�� -f ]�" v��aa-�,.,,,�,n.��.Il: ��a.m.Il�a � _ ._.. .... .... Tax Map #: � � �� . Parcel #: � 2 � Zoning: Township: ' SUbdivislon: � Section: Lot: Applicant: � �i �c�Q�� . Location: �� pC� 1 � 1 4peration Perm it System Type (In Accordance With Tabie Va): THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, ' AND ALL CS2NpIT10NS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION � _ ..._ _ : _ . _ _ . ;� .� ,��.�.,, P`� [`' ��13 --- — -- � Date 1 _.. _ ` � 1��..�� `�`S°� �� I � � 2-�_�3 � s��s� , _ - �'�'` '��t�� `� � / . - ��p�. — ., _-- � ca".�'`y _ _ _ +Q�p�-+�. ��e. - -+ - -- c,�,k. �.'��' rc.�..� A � G�%% ��7/G2'i%G� � . � �� e. � �� -i-� 2� � �� n2pa'2 � Yy�'� 4a,� < 5��i"� I�*� � r � '�_ 1 a-.� �� Jt.,,,- ,�n � PERSON COUNTY HEALTIi DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT 9-Zg�ll unlCnown �i .�.Z_� _121 Date of Inspection System Installation Date Type Tax Map Parcel # �0 j a I � Property Address Instructions: Check yes or no for appropriate items and explain in space provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs py�ping ? Inches of solids: � Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose tanrlk : Elapsed time readings ? Counter readings ? Drawdown rate: I� YES / NO ❑ � ❑ I� ❑ � ❑ fJ ❑ � �� ❑ i ❑ ►� ❑ � ❑ I�i ❑ � ❑ !J °�%a DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?� Surface water effectively diverted ? Diversions/swales properly maintained ? ❑ Vegetative cover maintained ? Protected from traffic/unauthorized uses ? Distribution devices in good condition 7 Field free of settled or low areas ? / / / / / / / / � �I ■ � . ■ ■ ■ ■ PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & �/ accessible ? ❑ / ❑ Nf A Pressure head properly adjusted ? ❑ /❑ nl�(} COMPLIANCE: Compliant ❑ Non-compliant [J� Needs Maintenance ['� REMARKS .�� -('ahK wA5 �c�" �cr_essi�O�2 T�K i5 ex�rer✓t�e�y �e�� n� we w�r2 unab�� -ta reach .fl�e �f�� or Q�A�Vv� T"i0G{fS � o -�esf • ��c ., ��T� nc deparfinent of health and human services .� � � � � ,� � i� � � q � �i s:,�- e 5` � s � �s � '� � � � t1 -,��.Y'v � .� ..P�:r„t,� r^t � sl-"� � i �`.�. � (, 4a n �}, sW.,� �?, y� � t?� ° q u� + � �: Tj nrs h: �+ Y•:�� ' �! � �1 � � �3�°;e �� X� 2P 'e � u�. ti .« va' :..> . �.� � .. .3 i., �':.a,� x � .. �a k. �. �� m :� i8 m7 � � �::s u �;�,--� � ;? `�� Y i � .� � < �yp . �` .n � ., :3 ; i ; � :? �a .rr - :t� xs �;'� r o��, r F �,r�a�,Y '�. as. .v . ; �; �.,.a , � � � � � . � k �' � �` » � � ��" �' � �. � �� ,� � � _� � � ; � _. ,zc �� 'S,.Fs a �� . ,. �u �,�.� .� _ .� ��,:i` For lnorganic Chemical �ontaminants County: --r2,s Name: �'�F p Sample ID#: �}-2t�,� y/ � Reviewer: l_ TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic c/te`nicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may I�ave 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 install a water treatment system to remove the circled substance(s). However, it may be used for wasliing, cleaning, bathing and showering based on the inorQanic c/:emical results onlv. Arsenic Manear Barium I Cadmium I Chromium Nitrate/Nitrite I Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc pH 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 iiiorQanic clremical results onlv. ❑ b. Levels over 30 mg/( 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 I S 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 chemical 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. Cadmium Chromium Fluoride Iron Selenium Silver pH Zinc For n:ore iirformalioit regarding your we!! water results, please cal! 1/re Nort/e Carolina 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: JEFF NOBLETT P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http�/lsiph. ncpu bl ichealth.com Phone: 919-733-7308 Fax: 919-775-8611 70 TEAL DR ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH ^ � � StarLiMS ID: ESO40716-0079001 Date Collected: 04/06/16 Time Collected: 3:30 PM Date Received: 04/07/16 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A24-121 Sample Source: Well Temp. at Receipt: 4•0 GPS #: Sample Description: Comment: 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 67 mg/L Chloride 23 00 250 mg/L Chromium < 0 01 0.10 mg/L Copper < 0 05 1.3 mg/L Fluoride �.3,2 4.00 mg/L Iron 0.30 Lead < . 05 0.015 mg/L Mercury < u uuuo u.v�c ��y�� Nitrate < 1 00 10.00 mg/L Nitrite ^ < 0 1 1.00 mg/L pH .._. 8 2 N/A Selenium < 0 005 0.05 mg/L Silver < 0 05 0.10 mg/L Sodium 24 00 mg/L Sulfate T ^ 30 00 250 mg/L Total Alkalinity ^ 238 mg/L Total Hardness 270 mg/L Zinc ^ 016 5.00 mq/L Report Date: 04/26/2016 Page 1 of 1 Reported By: Deddie.�lanco! North Carolina State Laboratory Public Health Environmental Sciences Microbiology 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: ESO40716-0096001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JEFF NOBLETT 70 TEAL DR SEMORA, NC 27343 Collected: 04/06/2016 15:30 Received: 04/07/2016 08:31 Sample Source: Well Sampling Point: Outside tap P.O. Box 28047 4312 District Drive Raleigh, NC 27617-8047 htta://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Angela Heybroek Well Permit Number: A24-121 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Owens o4/08/2016 E. coli, Colilert Absent Darneice Owens 04/08/2016 Report Date: 04/11/2016 Explanations of Coliform Analysis: Reported By: Susan Beasley / � � 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. Report To: North Caralina State Laboratory Public Health Environmental Sciences PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Microbiolagy Certificate of Analysis ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ESO40716-0096001 I �� I�� I� ��I I��I I�� I� ��I ��I�� I ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JEFF NOBLETT 70 TEAL DR SEMORA, NC 27343 C ollected: 04/06/2016 15:30 Received: 04/07/2016 08:31 Sample Source: Well Sampling Point: Outside tap P.O. Box 28047 4312 District Orive Raleigh, NC 27671-8047 http://slph. ncpubl ichealth. com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Angela Heybroek Well Permit Number: A24-121 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Owens oaioa/2o�s E Coli, Colilert Absent Darneice Owens 04I08/2ot6 Report Date: 04/11/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev ..(�'� f.scz+�6'�� 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.