A24 131� � � Person
�
��ount H a �h De aR�n�
Y p
-f� � Well Permit
Date���� T�S P�it Void After 3 Years o{� f'
Owr�r. �� b�• � n✓v� SR# � 3 22
LocationNirecdons:
.
SubdivisionName: �- Lot#�_
Drilling Contractor.
WELL CONSTRUCi'ION
piscance from Nearest property Iane Distance from Source of
Polludon
Total Depth: c. Ye1d: �� GPM Static Water Level F�
Wntet Bearing Zones: Dept��t.�_ Ft. FG ��t.
Casing: Depth: From cJ to G.. FG Diameter. �''( Inches
TYPE: Steel Galvanized Scee1�
If Steel, does owner appro��� No
Weight: Thiclrnes • Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
It. "yes„ give reason:
Grout Type: Neat ����t �ches Concrete
Annular Space Width
Watet fn Armular Space: Yes No
Method: Pumped_�. Pres�rg,,,__ Poured `�
Depth From to G..V FG
Iviaterials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
ID Platese (Ye s�av� cuttinIgsO - Ratio: to _
4 x 4 slab Yes_T— No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH R ULATIONS SET
�R BY THE P SON UNTY PAR .
� �- � lt .z�% 5 z5 Q3
�{ ✓ Sign of ontrac Date
lI `
O ' � �7//.1'/Sz
C �n „�-,( anitarians Signanue Date Issned
�T
� �� . . Sanitarians Signanue Date Completed
Ske well location on reverse side.
�
a
�
� �
�-tlZ� F-��-'�-7 l32Z
' ' - - " _ I'� A b 'T A �/�
���..���son County Health Departmen�"-'
Sew ge System Improvements Permit
Date:�� `� This Permit Void After 5 Years Pem►it #_ ;, j�
Owner: - `� � j � - •r j- o r � R } �-� SR# 1 '.;,,Z: � �
Location/Direcdons: �- - .
Subdivision Name: �:.•7:'-�.�; � -`"i � r l � l=.
Lot Size: - /. �� �+ �;-�' Type of Dwelling:
Water Supply: Private: �' Public:
Bedrooms: �'x. Garbage Disposal N a
Basement Basement Fixtures
INFORMATI�N CER�Tk7ED RY _ , �.•�!
I.ot # . : 4-' }
Community: t ��
_ f�
aamranan� .�,�t;���t�(„�Y�./ F�r(,.C"{ OWIICf Of fE�IC1P111811VC
REPAIR: ��REEVALUATION:
Size of Septic Tank: ��� �allons Size of Pump ank:_
Nitrification Line: . ,.L.�L.•� • �� / T
neprt, of swne: 12 incnes a� rnw e, � .,
Max Depth of Trenches: 'irt r '
Altemaave System: Conv. Pump LPP�ump
Remazks: j..'�i.r.,..q.i: . i' .1; ;, �� �` t .�: l.:,r,:,; �';ti:l , . : y
,
� �: ,�.�� �up� � i ._ •, . �-� ,� ,
� �+y t • � . . ! ; . /.t:"/�.- /
_ _ _ �7'.r. fl1Lt _ .,.r?1.�: L:� � � �.:�: _ _!'�' i_' �� _ +L.�,. f �/_��_r �
I �
Date Well Approved: Well should be 100 ft finm any sewer system
BY Sanitarian
Date S a S s App �
BY Sanitarian
, CERT�IICATE OF COMPLETION ,,,�
Contractor.�j�_:[ �..Ji s' �
---��—�1cv,� s=��l-q=3------------- �
Sewage System location, installadon, and protection must meet state and local �
reguladons. Sepdc tanlc should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and �
nitri�cadon line must be inspected and approved by a member of the Person Counry �
Heaith Department 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. i
(G.S. 130 I��.���,.
� �.
�ltr
Location of sewage disposal sewage system sketched on back. ��•
_ ... `Q
(OVER) • --- -- �y
�i
Report To:
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:
CONNIE NYHOLM
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://siph.ncaublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
520 N. PLANTATION RD.
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES110311-0009001 Date Collected: 11/02/11
Date Received: 11/03/11
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 11:00 AM
Collected By: J. Smith
Well Permit #:
GPS #:
Inorganic Chemical 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 52 mg/L
Chloride 12.00 500 mg/L
Chromium < 0.01 0.10 mg/L
Copper 0.08 1.3 mg/L
Fluoride 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 22 mg/L
Manganese < 0.03 0.05 mg/L
pH 7.1 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 36.00 mg/L
Sulfate 26.00 250 mg/L
Total Alkalinity 236 mg/L
Total Hardness 220 mg/L
Zinc 0.08 5.00 mg/L
Report Date: 11/16/2011
Page 1 of 1
Reported By: 'lied6lc 7?%Keol
��ii l�� �- ''e%' �
� NOV 2 3 2011