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A24 163� Dat�:-/D ='"" ' Owner: Location/Directions: �uL�':vision Nvnc: Drilling Contractor: PERSON COUNTY ENVIRONM�NTAL EI�ALTH W�I.L LOG SR# '� llistance from Nearest Property Luic r,�s Distance from Source of . Pollution o d ws • Total,Dep.th: �� Ft. Yield:_ �� GPM Static Water I.evel .�� F�, Water Bearing Zones: Depth �_Ft.- qTF� Ft. �t. Casing: Depth: From_ D, to� � Y Ft. Diameter: G� Inches TYP�: Steel � Galvanized Steel .�- If Steel, does owner approve: Yes No � Weight: /3 Thickness: ,� 8-S�eight Above Ground: /� Inches Drive Shoe: Yes ��No Were Problems Encountercd in Setting the Casing? Ycs No Ii "yes" give reason: Grout: Type: Neat Sand/Cement � � Concrete - Annular. Space Width 3 Inchcs Water in .Annular Space: Yes No �-- Method: Pumpe � Pressure Poured .`-- Depth: From to d�a rt. . Materials Used: No. Bags Portland Cement�_ Weight of .1 bag�lbs. If mixture (sand, gravel, cuttinas) - Ratio: � to� ) �ID Plates: Yes v No � � � � � � 4 x 4 slab Yes � No � I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS �SET FORTH �y•THE PERSON COUNTy HEALTH DEPARTMENT: �� . ,,��;5.� Signature of Concractor Date � . i • •- Site �valuation Application ` Fee Collected YES � NO � �' 6 � ,°� A�.�� 3 .- ��1.� Date: I � APPLICATION FOR IMPROVEMENTS PIItHIT ��9.?�` ae 1. Permit requested by: owner/prospectivP owner: „ ,agent: Address: f�� /4Lov`tlt /Y�L1 �!'. /Cox�,�c Home Phone ��: SG'7 -$ 3 a� Busine 2. Name and address of current owrier: R�-- � lo►�►Zo �elLtZ�' i �,C. �73�'3 Phone fr` : �q `, oX 3`l� . SemoeQ. 3. Property Description: Lot size: 3 a �+�r�s 4. Tax map ��: Township: Subdivision Name: Lot ��: S. Directions to property: State Road �� & Road Names, etc. 7a�Fe ra q d � l3 36 o u�-�- -F�o C�� -t� �..:, Clase �� 1 r�; �t a .�. � r,.� cc n /.. •.,, ._,ti rl.� n.� cp L1� <,1'l e► /.� /I Uv n LL l. l: � 6. Permit requested for: New Installation: � Repair: Additional Renovation re-using present system: z w � m ,C e yoa � yv u.. �� 7. Number of occupants or people to be served: � 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? � o iv �e. - 10. Water supply private? � public? community? spring? Other source? (Specify): Are there any wells on adjoining property? e5 If so, identify location: T-1 h � ( e�--l- O Z -�� e r i S•� �..� � 11, Type of structure or facility: Proposed: �_ Existing: Type of dwelling: House: Mobile Home: �G Business: Type of business: Number of Employees: Number of bedrooms: _� Garbage Disposal? Yes No ✓ Basement? Yes Iv'o �/ If so, number of basement fixtures: 12. Clearly stake all. corners of the property and the corners of all proposed structures. I hereby 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) "�.) .i? lt�R.r�C : . Signe�c Owner or Authorized Agent H w �. � w 0 � r 0 rt � b � H � �• rt � ��- ' Permit Issued Permit Denied ' Plat`Observed ��, 1�.�oY�� _��r n� �. �LUrnh� ,,, �- �j U ��-�lt�'1 �� `!�, _ ( �� j y � ��},,o,� ��--�-- .S R� �33 � i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4 1. SLOPE (X) . SGII. TEXTURE (i2-36 in. ) (SandS, Ioamy, clayey, Note 2:1 clay) . SOIL STRUCTiTRE (12-36 i.n. ) (Clayey soils) 4 . SOIL DEPTH (i.n. ) 5. RESTRICTIVE HORIZONS (in.) (Im�ervious Strata, rock) . SOIL DRAItIAGE/GROUNDWATER (�acternal & Internal) . SOIL PERMF.I�BILITY (Percolation Rate) $ . OTHER (specify) S S � O_ �� US S PS �Y,__ _� PS � ►�' U S S � S �`� P S U U $ $ � � 3(�" ps U S S PS � o�, PS U S PS � � `I�,u."�es PS U � S US m 3'Qi P.. US S S PS PS U U S PS U S PS U S PS U $ PS U S PS U S PS U S �s U S PS U S PS �T S PS U S PS U $ PS U S PS U S PS U S PS U S PS U 9. SITE CLASSIFICATION �S (See below) SOIL SERIES S- Suitable PS - Provisionally Suitable tJ - Unsuitable R F_COt�QiEI IDATZONS / COMMF.rITS : S:�_TE CLASSIFICATION JLAGFtAM (Znclude: Soil areas, property lines. roads, streams, gullies. Wet areas, fill areas, �aells, water bodies, slape patterns, e[c.) � � � � U � cd a G�� PERSON COUNTY HEALTH DEPAIZTMENT WELL SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT Tax Map # �� Parcel # / (o � , Zoning Township a �. Owner/Contractor te 3 -� — gT Location/Address � i2-�t 1�32 S%Zt� 133� ,/�1'�+ o� __�� Subdivision Name Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is alt r' e d us hanged. Well and Septic Layout by Comments: Date 1cl- '. v� Installed by �� ..., Individual � �emi-Public Public Replace ent Site Approved Well Head Approved Grouting Approved Comments: Date Installed by Approveci by SYSTEM SPECIFICATIONS Required Slab _V Air Vent ,/ Required Well LQ� _� Well Tag � Approved by Tlus report is based in part on information provided the homeowner or his/her representative in the application submitted for this pemvt 'Ihe� environmental health specialist is not responsible for false or misleading infoRnation contained in the application The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this teport that may have resulted from false or misleading statements provided to him in the application Neither Person County nor the envuonmental healtli specialist wazrants that the septic tank systetn will continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipro\pemtit.sam O1/95 rev.1.0 ORIGINAL 0 0 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �� G�'��.�L�.-�L� Address � n� tV � �� 1'lr'�� ounty Collected By -1.�-Z�-� Date Collected �/i ��.�_Time Collected `Z- �� Source: [�IVell ❑ Spring ❑ Other Location: House Tap ❑ Well Tap ❑ Other ❑ No Charge harge ' ..............................................................................� ****�************************************************�********************** Total Coliform Fecal/E. Coli Results Present � ■ Reported By Date Reported �r `� � / Report Called YES ❑ NO Called To , � D�� `� �� Absent ■ � r � Il � *.� � �� l./ `1.1� �.J 1. �l � � ��a�nsonn.nvca��a��.� ��,Il��a Date: �p /��/� Name: G �"►.l �'_ � � l_ Tax Map:�Z� Parcel: /� Address: Z� N1,C�,►.�—Ea R•'1c l( l�D. `��n�l,osz.d.�pjL z�73�3 Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on C' //lo //�a , 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 bacteriofogical results only. ✓ Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria aze naturally found in tl:e soil. Fecal coliform ha�teria are associated with animnal and/or human waste. The, presence of either totai 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 groundwater may be entering the well. If coliform bacteria are 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 notified of the test results. A well that tests posativ�or total or fecal coli%rm bacteria should be properlv 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 office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� 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 Report To: H. KELLY North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis pER�ON Cd ENVi�tONMENTAL HgAL�H 325 S MORGAN STREET ROXBORO, NC 27573 EIN: 566000331 EH StarLiMS ID: ES060216-0008001 Sampie i ype: Sample Source: Well Sampte DescriFtion: Commen±: Courier # 02-33-15 Data Col�ected: 05/31;16 Da:e Received: J6;02;16 Sarr�pling �oint: Ou:side tap Temp. at Receipt: Name of System: GWEN TERRELL P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htt�://sl�h. nc�ublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 4629 �dCGHEES �dILL RD SEMORA, NC 27343 Tirre Collected: 4:00 PWI Ccliected Sy: H K��Y VVell Parmit #: A24 163 GPS #: CA Well Monitoring (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Aluminum < 0.05 3.5 mg/L Antimony < 0.002 0.001 mg/L Arsenic < 0.005 0.01 r►ig/L 8aii�� <`J. i 0. i I'ilglL Berylliurn < 0.002 0.�04 n�g/L Boron < 0.1 0.7 ___ mg/L Cadmium < 0.001 0.002 mg/L Calcium- -- 9g - - ---------- m��------ -------- - ------------------------------------ -- --- - Chlcride 18.00 25� mg/L Chromium < 0.001 � 0.01 mg/L Cobaft < 0.001 0.001 mg/L Copper 0.01 1.0 mg/L--------- -- --- -------------------------------- - Iron ------------------------------� 0.10 0.30 mg!L Lead < 0.0�5 0.01 � mglL . --- — _Ma�nesium---------------- ----- 42 ------------- -----m��---- - Manganese < O.Ot 0.05 _ mg/L Mercury < 0.0005 0.001 ___ mg/L Molybdenum _ < 0.010 0.018 _ _ __ mg/L Nickel <0.01 0.1 ------ mg/L _ pH --------- -- — 7.4 — -- N/A ------- Potassium ---- ----- -- 2.06 ------- -------- m�� ---- Selenium < 1 0.02 __ mg/L _ ___ Sodium 34.3 >. 20.0 mg/L Stro�tiur.+ �5 2.1 m�- --- ----- -- --- -------- Sulfate 90.�0 250 m�ii. ___ _ _ ------------------------- ------------------------------------_--- --------- Thallium < 0.0001 O.00�02 -_-___- - mg!L _ ------ -- - - ---- --- ----- ----- Total Al�alinity m�__ _____ - -- --- - -------- - -- --- - - - -- ---- Total Dissolved Solids • 560 500 • mg/L _ ____ - ---- --- ----- -- - - _ _ ---- Totaf Hardness a __ __.._�� _—_____-.--- Total Suspended Solids ---_-_ - ------ ---------- ---- -_- --___--m�� ---_-- -- -- ----- - Vanadium 0.�076 _ __ O.00U3 m,c�.lL___ _ _ _ ---- - -- --- - _ _ - - -- - - --- - - _ _ _ - -- Zinc . 1.00 mg/L — -- -- Page 1 of 2 Report'To: H. KELL� North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Nam� of Sys:em: P.O. Box 28047 4372 District Drive Raleigh, NC 27611-8047 htt� �//slo h. nco u bl ich ea Ith.com Phone: 919-733-7308 Fax: 919-715-8611 ALFONSO 8� GWENDOLYN TERRELL 4629 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES061516-0016001 Date Collected: 06/14/16 Time Collected: 2:30 PM Date Recei�ed: 06/15/16 Collected By: H Kelly Sample Type: R2w Sampling Point: Outside tap Well Permit #: A?4-1f3 Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: Hexavalent Chromium (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Hexavalent Chromium 0.32 0.07 ug/L Report Date: 06/23/2016 CANAb = i.oai Asn Management Act Page 1 of 1 Reported By: De66ie.�loncol North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 httq://slph. ncpublichealth. com Phone: 919-733-7308 Fax: 919-715-8611 ALFONSO & GWENDOLYN TERRELL 4629 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES061516-0016001 Date Collected: 06/14/16 Date Received: 06/15/16 Sample Type: Raw Sampling Point: Outside tap Sample Source: Well Temp. at Receipt: Sample Description: Comment: Time Collected: 2:30 PM Collected By: H Kelly Well Permit #: A24-163 GPS #: Hexavalent Chromium (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Hexavalent Chromium 0.32 0.07 ug/L Report Date:06/23/2016 CAMA = Coal Ash Management Act Page 1 of 1 Reported By: Deddie .�tanco!'