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A24 310 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant .Sliwr.ant ��1,' �� Address u — �/tf.� County ��Ya�,j1 Collected By �S Date Collected �� 0'� Time Collected �: cb Source: C�'ell � Spring O Other Location: ❑ House Tap ell Tap . ❑ Other ONo Charge �arge ��*��*��*��,��**��*��*��*��**��***��*�**��*�� ***��***�*��*�*��*��**��**��**�*�***�*�*��*��***� Results Present Absen Total Coliform ❑ FecaUE. Coli ❑ �Y Reported By �;s��e'�► M 1 0 bactreport �vP� (�;,aV � 'I . 0 � g� �:; • • ' , LI . C . /�lc�.�.o.q y ` 0 / Z �5 vf � � = � ��. � ZR o �' , � � � �� - �j �`� �� w . . 20'� ¢1� Sv. �'r- ,� � � � � � ./C' � /� . c9 �� . --s-,� �O � 5.�� "-S�t� 420 co��-ov�e -'�r_�s� � ..�,,... ' sd. t�� a T�.• /� o �t! �j.�IE'3 O,t/ � G.c..� Co�c.v�-,�. �W `o , � G` t. ''��NS � �� NORTH CARaLINA �.esa.v Ct�v;� i �( _ B�'41G Diif Y��11'�2N ,S�vS T�,9� T�fS P1AT OR :,�A° HEj� O.t�.�� d A. �rcp�;,Tc ��q��,� j� THF S��T- ��iS KMUWLEDGc ,1M� BE�-#��::.�� iN �� ;P:;�?AR�� F;��" AN ACTUA�. 5�f'� MAp� BY Ni!r� AN�J COI�PI� .�.�� .�1BE�Z is .!-- .(��; �- X R�EGI. Tl�tf �i�0. - ��s3 n 1i . C. Mv.v.oa y , 0 �.eoP�� aF T.Fs sF �vic..r�.vs c ci,u�v,•vc►.�.�.�M . i o�v�v� ,��',�a,v G ov.vr'�/ .c�o.CTN C4.Co.��.vo S c.o.c..�, / '_ f'o' � �o� Aao� � �,� _ � P ,�-�_ � . � (� �e�'� a w � a � ¢ � F .—� Improvements Permit (Established/Recorded Lot) Improvements Permit (Unrecorded Lot) �`��'s� .� �il - �f�� - � ��z , ��l X. � 'OR SERVICES �quested: _ Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) Replace Existing Well 1. Permit requested by: � �wner/prospective owner/agent: 1 � � Address: �4'�� h �%�u rhG'n Home Phone #: � �3 — 3 (o �} Business Phone #: a8(o - r7'i� Name and address of current owner: 5�19- 79y'% � ��'n5 ybfS �c � C'hu r ��u.hflrn . N. C. : Lot size: Tax Map#: Parcel#: _ Townshin: Directions to property: State Road #& Road ames, etc. �wv �"7 Rlah�' 6n Ce�'o �d • :e on m �-, eu m�» -� �-�- � 0 0 Number of occupants or people to be served: . Dimens� ns or Proposed Structure � � � / �( �Z' �idth: � � W — �"j�/, � � lenth � 1 S � D �'�,�%�b � 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? /�l�w t�ause New G��e�bo Water supply type: ivate �d'�public ❑ community ❑ spring ❑ -e any wells on adjoining property?Yes C7'� No ❑ so, identify location: p}oct�s �� Lo-f' /a ca :. �1�- 1 o.G`.�- .,.R l..-E- _/or„�'.�n a-�- la� 10. Type of structure/facility: Proposed: C�Existing: ❑ Type of dwelling: House: C�Mobile Home: ❑ Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes No ❑ Basement? Yes C.� No ❑ If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pei'son COunty Health Department for a site 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. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the da�e of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. �ignea uwner or Hutnorizea r�ge«� f { � ' Permit Issued ❑ � Signature ` - Date ' �/� �� " � Permit Denied � Plat Observed ❑ B !� � � � � � ' � • 1. SLOPE (%) S S S S S D�J ! D U U U 2. SOILTEXNRE(12-36IN.) S �i' ��a�/! S S S (SANDY, LOMfY, CLAYEY, N07E 2:1 CLAS� P�. T PS PS PS U U U 3. SOIL STRUCNRE (12•361N.) , S /�/�j sj � S S S (CLAYEY SOII.S) • " "'� PS PS PS U U U U 4. SOIL DEPTH (IN.) ' S Ln D. � , S � S_ S �� . 'r�� PS PS PS ' u /�-20�l�. ' u v u S. RESTRIC'I7VEHORIZONS(Al.) S S S S (IMPERVIOUSSTRATA,ROCK) Np�E pS PS PS U U U U 6. SOIL DRAINAG&GROUNDWATER S f��L05 � S S S (EX7ERNAL & INTERNAL) PS PS PS gj-� �n. U U U 7. SOIL PERh1EABILl7Y S S S S (PERCOLOATION RATE) PS PS PS PS U U U 8. AVAILABLE SPACE S S S S PS PS PS U U U U 9. SII'E CLASSIFICAT[ON(SEE BELOW) ', �'-t, ,`,� v7�"' SOIL SERiES S•SUITABLE PSPROVISIONALLY SU['fABLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WMIPR0IDOCSWPPSEC.SM FINANCE.PC PERSON COUNTY i .� ��o�-^ �q,` ' r �4 �: / � " C �''�., �``� PERSON COUhTY HEALTH DEPARTMENT : 325 South Morgan Str�et Roxbono. Nonh Carolina 27573 (910) 597-22.D� � ��. ►�►�e t� To S��hom It May Concern: � rlr�(% V B�sed upon .. our evaluation of your lot on �� I-� yC� or /�Uv�� ca�H --d cJC�-e� Pi-� Vi� leo� j c��'�o� �k ��-j. -��` , we finn that your lo is. unsuitable r all types o ground absorption sewage treatment and disposal systems,,mound systems and low pressure pipe:systems. If you woul.d li}ce �to inqu_ire about a discharge syst�n, you need to contact the North Carolina Department of Natural Resources & Co�nunity Development, Division of EYivironmental Management, P_ 0. Box 27687, Raleigh, hTorth Carolina 27611. Telephone ;: (919)-.571-4700. • Sincerely, �. � � � Ehvironmental Health rvisor C��-b��;�y`'t,t � �� -s' �hvironmental Health S�ecialist 0 6]2 r 673 (MlLTON I1625001 �674 v4'�rG� 6�5 2�30�� 676; 1990000 FEET nt� c - � �� ` � ;,%�.�� `� _ �b `1 \��.-� �' .� J � ^�� - J��'�\a � "=�� `J/ �ti "n � ��J4� ._ �rJrf- �� '\tl �( � '/ �i<90 ` _� ,\\�� _�' _Q-� � �+ ` � . � �(`,`' . � / � �V �` � .�-`./,, -.�� . � � , \`\ `� �\. y ' ` G �`-�� r / � � � r�\�� \ Q\ �� 1% � / // , �) � , `� � � =`,� �v.11\,1� �',�al//// O ,� C-'-- � .��99 �7�^ .� .'�/J/�.1 � �J - � 'V �\ � ��' p�i � � � /% � � �� . . � �" \\ �( . � �� '� . / .. , /�`l� � � , �' � . oca� _ ,y�..� ) � ` -�/ ��.� � - �i` �`� �) L�._: � II i . / - / - 0 1 � (/i�� O /� " ' I c I•.n�� \/ �\ �� \\ � 'If.,, h� ��I � v � � io ll � �� /'\ . o �a j = � t\` �� _�=E=�F � � �/' LJ�� % ' 1 , \\�� ' ,, l � ---., . - , �� ; ��^,(� � , �- - .eM•aa 1 ��\\ N� :O -� J � \ ��-�J .�-��'\ �� h/U' � � O �I" `� y .. _ � � , �;� _ ^ � , . , 5 � _ �!` �� \� � g C= . `�a �� / -'� � ��J � O �Q� � J �� 1�� % ,,.� �W Ci : �.--��. a ��-�C �� / i(��JJ '.�-__yL ��%,�u �.�1� �c� �� \ �✓�� nc' �u. _�«J� /��- a_ �� i . -�J_ so� o � r� � -=-� � V v � , �%�� r � ' � ! -� �4111 � \ �_` '`P 450 �_�� ,� _-_� ) '�- , �1•n �: l - �L� , o� � --�,� :� �' '� � �� -�. ,Z. � � ,,- �� I�� -:�, � o� _-� ... � � .�; �� c-. � � � �� ,�`J� ,�, ;, , �_,, � _�»�� -� rr� io -�� nsO —��✓ � ((�-- ��_} ,� �� , "�,,, '� /� � � ' � � --,, \� '��-�, _ � ��, � r�if /'�s�d��i /ti � ` �� ` o � �� - . � CTc�r- < �� " `� � '` �'� : �� \��R � /Y C � ��'o So � E ,, l _ � _ ., �� i�-��. � �� ( lU�:, , � - -�..,; -: - _ Powerpla t wi�,` �� (\y� '1 � ��i \ �� [ . `l .- ,� '� � � � ., i--,�s �� ) = 5� \�� ; ��/�'SON � � � ` i � _��(� � � C✓-. � � � / o[.e.n.�7 � � a � � , � � � / �--• � �. . �7 �� '• �� d II - � � ,•�✓ �/ ' \\ � \ ` �J �� \\\\ p \ �,.�� ; � � �U 2 � i � 444 . 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'� _ - --- ` i� '� � _ � �/ . . -- •.� , � � _�1 • � � . . - - � � Q � �.. �� , \ % �1 _ � ' 1 / '� ` / _ -% ! �. �1 / �� \ " �� J Ce� �� •�. �\ \, ( , � � - �' �� \ • �., I - �� , �-� _ � �: V - �; `' � �_ .� � ��`i � ��`'/ -- .. __ �� _- __ <.aKE n `.;, �'1 �� 1/ � 4%� �.7 �i i -� ;�� ; . j 5tn �'°ncord � — i % _ . �i-! �, �, :. _� - . �� 'J •Cem �� -�-__ .'! . , c r��, r- � � � �-. !(�, '�_ �� ` ;�582 � � _ - _ . i �� " �_ BM 6a6�`I� � � � i� V C _ n( r ..� / � �t /� � � - -�- _� .'' • �° � � - �i � __ e ��i� ( /��`�� J\j' j. _ _ - - � ' 1, \ �, I � S \ �. /_��>.� f�� / �_ �a '," ,�^ , '; � � � `.� /- _ _� _ f.' _ '+ �� c� 'i ' • ��' ,�:/ ''7'( .` i�,, _ � _ ' , \ _,. i�.-= , „ _ 1....ti�<� . . _ • STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL MANAGEMENT CERTIFICATE OF COVERAGE GENERAL PERMIT NO. NCG550807 TO DISCHARGE DOMESTIC WASTEWATERS FROM SINGLE FAMILY RESIDENCES AND OTHER DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standazds and regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the Federal Water Pollution Control Act, as amended, Tripp Garrett is hereby authorized to construct and operate of a wastewater treatment facility that consists of a septic tank, dual primary sandfilters in parallel, a secondary sand filter, chlorinator with chlorine contact tank, cascade aeration, and associated appurtenances with the discharge of treated wastewater from a facility located at the Gazrett Residence Munday-Oakley Road north of Roxboro Person County to receiving waters designated as Hyco Lake in the Roanoke River Basin in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II, III and N hereof. Thic certificate of coverage shall become effPctive February 6: 1QR6 This Certificate of Coverage shall remain in effect for the duration of the General Pernut. Signed this day February 6, 1996 Ori�inal �is�n�d By David �. Goodrich A. Preston Howard, Jr., P.E., Director Divisioo of Environmental Management By Authority of the Environmental Management Commission � • State of Nor�h Carolina Department of Environment, Health and Natural Resources � • � Division of Environmental Management � James B. Hunt, Jr., Governor Jonathan B. Howes, Secretary �� H N I� A. Preston Howard, Jr., P.E., Director February 6, 1996 Mr. Tripp Garrett 1417 West Pettigrew Street Durham, North Carolina 27705 Subject: Permit Issuance/ Authorization to Construct Permit No. NCG550807 Garrett Residence Person County Dear Mr. Garrett: In accordance with the application for discharge, the Division is forwarding herewith the subject Certificate of Coverage to discharge under the subject state`- NPDES general permit. This permit is issued pursuant to the requirements of North Cazolina General Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental Protection Agency dated December 6, 1983. If any parts, measurement frequencies or sampling requirements cont�: ..ne� in this permit are unacceptable to you, you have the right to request an individuai permit by submitting an individual pernut application. Unless such a demand is made, this Certificate of Coverage shall be final and binding. A letter of request for an Authorization to Construct was received December 12, 1995 by the Division and final plans and specifications for the subject project have been reviewed and found to be satisfactory. Authorization is hereby granted for the construction of a 360 gpd wastewater treatment system consisting of a 1000 gallon segtic tar.::, u �i::tribution box, two (2) primary sand filters nZeas�ring 1�C squar:; �� .uc �, L:�•.. �:; secondary sand filter measuring 180 square feet, a tablet chlorinator, a chlorine contact tarik with a 30 minute retention time, effluent pipe, and cascade aeration with discharge of treated wastewater into Hyco Lake, a Class B water in the Roanoke River Basin. 1n addition, the system components must be located above the 100 year flood line on the property. � This Certificate of Coverage shall be subject to revocation unless the wastewater treatment facilities are constructed in accordance with the conditions and limitations specified in Permit No. NCG550000. Please take notice that this Certificate of Coverage is not transferable except after notice to the Division of Environmental Management. The Division of Environmental Management may require modification or revocation of the Certificate of Coverage. The Raleigh Regional Office, phone no. (919) 571-4700, shall be notified at least forty-eight (48) hours in advance of operation of the installed facilities so that an in-place inspection can be made. Such noti6cation to the regional supervisor shall be made P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone 919-733-5083 FAX 919-733-9919 An Equal Opportunity Affirmative Action Employer 50% recycled/ 10°% post-consumer paper NCG550807 Garrett Residence February 6, 1996 Page 2 during normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through Friday, excluding State Holidays. Upon completion of construction and prior to operation of this permitted facility, a certification must be received from a professional engineer certifying that the permitted facility has been installed in accordance with the NPDES Permit, this Certificate of Coverage and the approved plans and specifications. Mail the Certification to the Permits and Engineering Unit, P.O. Box 29535, Raleigh, NC 27626-0535. A copy of the approved plans and specifications shall be maintained on file by the Pernuttee for the life of the facility. The sand media of the sand filter units must comply with the Division's sand specifications. The engineer's certification will be evidence that this certification has been met. A leakage test shall be performed on the septic tank and dosing tank to insure that any ex filtration occurs at a rate which does not exceed twenty (20) gallons per twenty-four (24) hour per 1,000 gallons of tank capacity. The engineer's certification will serve as proof of compliance with this condition. This pernut does not affect the legal requirements to obtain other permits which may be required by the Division of Environmental Management or permits required by the Division of Land Resources, Coastal Area Management Act, or any other Federal or Local governmental permits that may be required. If you have any questions or need additional information, please contact Susan Robson, telephone number 919/733-5083, ext. 551. Sincerely, Original Si�n�d B� David A. Go�dr��h A. Preston Howard, Jr., P.E. cc: Central Files Person County Health Department Raleigh Regional Office, Water Quality Permits and Engineering Unit Facility Assessment Unit r � _. � .� � U tr C� a • PERSON COUNTY HEALTH DEPARTMENT � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �' ,�� Parcel # �' � � �1 , Zoning - �'"LL�,� y Townshi 4� �� ' ��t� Owner/Contractor �' �T_�(,�Y�' D� r ' Location/Address Si��l.�3� �, s�t�- 133G � .s�r� /3/6 �o /�- ��e ��, � Subdi Name " _�'+''1 "�"�r %in,,�,r SEWAGE SY5TEM h S.R.# As Installed TIONS �" NC G .epair Lot AreaTy79T�.f Size of Tank ' FD Mobile Home Size of P p T �usiness # of Bedrooms�_ Nitrif' tion Lj.� � Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. � Permits may be voided if site is alter in nde use anged. Well a�c Layout by Comments: Date Installed by Approved by, Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved Comments: Date Installed by pproved by. Q91 6 T'his report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. 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 application. Neither Person County nor the environmental health specialist wamants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permitsam Ol/95 rev.1.0 � '�„`. tS} 'm n, � � � � �� \ �e' . ... ;.. A :_- •�� s �� (�'`��5�a r —�" ��° � � � �� .�� _F_, � . a� �%�1� �� _ ��e � ��.�� ,.l . a. � � �ti �.� . ; ,\� �, W� � �, , .. � � � / � ��N�uNtL t�Nts� � tt 2 E�{- Fa �2 t/�l � i�i/� LL � S Page 1 of 1 http://gis.personcounty.net/connectgis_v6/DownloadFile.asl-ix?i=_ags_mapb 1 fc285f544248... 6/ 1/2012 Application Date: I 7� Amount Paid: O Receipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 if site visit re uired Well Permi �vvllt�qplacement/Repair) ��, f II�'IEI��I�T 1 " �� ILsav�nn-onnIIaacIIi�raIl �c�aIl1�a Services for Services Taa Map: � Z�f Parcel#: �_�/ �. � b� � I � q ��-f,� �: cor►� Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of Ezisting Septic System Application: No Chazge/ CA $150.00 or $300.00 1) Applicant Information: , Name: ��Im U E 1 ��D0�0 �� y ��. � E LL Address: !86 /1'1 u►� o�,i -Oq KLE`� fZo Sem c�2q NC'_ 2�34�� 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3�- 5c c- 5�53 C ��t-rt) (work/cell): �I / �I -3Z �- d 1£; �'1 h e-yr� E 9' / ci - 3 a �'i - O 2 58` ��c �� -��, 'c�nfac�- !hF , Phone: 3) Property Description: Lot Size:,C� Subdivision:�i�Q�c ��U�![.T'.Zq/✓(Lot #: f-) 2� 3! (�42C'E � T�-#� Address and/or directions to Property:-r..� y 2��Kr Pe��oad �d Cn,C�-s7�,, ��c �-r T ean�a�cP �F-fF� �., LE�T iL1CChEFSfGf�LL y7� CE�T �tra�e- D,2i vE ��c-rrr�no�et ��2�i'.U,�� ei�r�� iL1vNPhv-D�ir•c.�y y��/, ❑ yes � no Does the site contain any jurisdictional wetlands7 '� yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes � no Is the site subject to approval by any other public agency? � yes ❑ no Are there any easements or right of ways on this property? t A K� FizCy� T�ii��w7 �iv I� — (if `yes' is checked, please provide supporting documentation) ��rz�oi� -�l15 DlI �LL L/I!i t/�rir/y pR � rj 4) Proposed Use and Type of Structure: �Residential C.I,E / l /ZE� /GCFrr7 En � . ❑ New Single Family Residence Maximum number of bedrooms: 2 ❑ Expansion of Existing System If expansion: Current nutnber of bedrooms: Q Repair to Malfunctioning System Will there be a basement? � yes � no With plumbing fixtures? ❑ yes � no ❑Non-Residentiai Type of business: Total Square footage of Building: MaYimum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well ❑ E�cisting Well � Community Well 0 Public Water ❑ Spring Are there any existing wells, springs, or existing waYerlines on this property? � yes ❑ no i2 i�uN�r�<<-o�r��Ei rc�', ��o��r,,u � C�E�ev� 5 3 h�mFS� 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I certi, fy that the information provided above is complete and correct. I also understand that if the inforntation provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �� Signature (Owner/ Legal Representative*) * Supporting documentation required. C��/o I Zo ! � Date Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved pla� A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) :.. . . . . . . . _. 1 . ,� . . . .r � . , d. % � �^/. e /�n1! J � � ry ' -- . - � � � � �� C�P�� s�.�� -p��,�� ------- --� ---------------- --��--- • � 0916 � � � PERSON COUNTY HEALTH DEP MRN ME�N� WELL AND SEWAGE SITE, LOCATION IMPRO Tax Map #_� � Parcel # `� � �',r,y�o Zoning � . Owner/Contractor_ Location/Address � I � , , Subdivisio�'f Name � i. '' ilr r. � � , . " � , . _ . • • . �,1 � ,�,F� S.R. Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. - • � � ----a Permits may be voided if site is Well � Layout by stalled by ' Approved by. .�_ � Comments: Date Installed by Approved by This report is based in pacc on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleadiog informa'ion�onfaioed i�� rt Phatamav have resuited om false oh ��, ; � �� ..r "` � � �� I��a-��.��,ll IE3I��.11-�I.I� W��,i, l'ERNIIT (New �/ I2epair� C�ep �aCerv�eh�) Y Taz Map: Z. Parcel: 3� Subdivision: ,Shd�-a. �rive, Lot: 20 1} Seg attached site plan for proposed well location. Z) �11 applicable State �nd County Yegulations gove-rni�zg construclion and setbacks apply.� 3) Permits expire S years from the date of issue. Other Conditions/Comments: i� ,n � i'a G� ._ f- � v. 1�{e� 1-� n��c�e i,1 rf� l V P�ranit issued by: I�ate: (� - / Z - / 2 CERTIFICATE OF CO1dIPLE�'IO1�T New Well Inspection: S/Date Location: .S�Z �irouting: �(Z �Well Log: Well Tag: — Pump Tag: Air Vent: �- �� Z Hose Bib: Casing Height: Concrete Slab: Well Driller• �� Pwnp Installer: Lnner Inspection: EHS/Date Installer: Depth: Gro�:t: Well Abandc►nment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date: `7- � l� - I � Date Sample Collected: �-' � G�" � 2 Date Results Mailed: 'I Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 North Carolina State Laboratory Public Health 06 N. W?m� gton St. Environmental Sciences Raleigh, NC 27611-8047 htta://slqh.ncpublicheaith.com M icrobiolo Phone: 919-733-7834 gy Fax: 919-733-8695 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: ES071712-0113001 � �� ES Microbiology ID: 38233 GPS Number. Sample Description: Comment: Name of System: SAM & DOROTHY BELL 186 MUNDAY-OAKLEY RD. Collected: 07/16/2012 13:15 Received: 07/17/2012 08:40 Sample Source: New Well Sampling Point: Well head : J. Smith Angela Heybroek Well Permit Number: A24-31 Environmental Microbiology - Colisure Profile Method: SM 92236 Test Name: Water - Colisure Analyte Total Coliform, Colisure Test Result Present Analyst Darneice Lyons Date 07/18/2012 E. coli, Colisure Absent Darneice Lyons 07/18/2012 Report Date: 07/19/2012 Explanations of Coliform Analysis: Reported By: Susan Beasley 71Y�r\TT< 7-1��. 1'•.:'-'vLi V �•� e JUL 2 4 2012 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 Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES071712-0056001 Date Collected: 07/16/12 Date Received: 07/17/12 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.5 Sample Description: Comment: Name of System: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htt�://siqh.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 SAM 8� DOROTHY BELL 186 MUNDAY-OAKLEY RD. Time Collected: 1:15 PM Collected By: J. Smith Well Permit #: A24-31 GPS #: New Well l (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 89 mg/L Chloride 24.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.27 4.00 mg/L Iron 0.25 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 19 mg/L Manganese 0.10 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 7.3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 35.00 mg/L Sulfate 120.00 250 mg/L Total Alkalinity 209 mg/L Total Hardness 300 mg/L Zinc 0.07 5.00 mg/L Report Date: 08/07/2012 Page 1 of 1 Reported By: �e�ie �okeol RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Departmenf of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # '� �{ r� 1. YVE�L CONTRACTOR: ti Weli ConVactor (Individu t) Name .. �3,�mette Well Drillina Inc Well Gontractor Company Name 611 Barnette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2 WELL INFORMATION: � WELL CONSTRUCTION PERMIT# /7 � �' OTHERASSOCIATEDPERMIT#(ifapp�icab�e) A/LL� g. WATER ZONES (depth): q �,..� : Top�� Bottom_1�_� Top Bottom � Top�_ Bottom �5� (2w��op Bottom ; Top Bottom � Top Bottom Thickness/ : 7. CASING: Depth Diameter Weight Materiai : Top'�` _ Bottom� Ft. L r 4' ��_ Top Bottom Ft. : Top Bottom Ft. 8. GROUT: Depth Material Meihod � Top rU sottom Z.� Ft. Sand/Cement Poured : Top Bottom Ft. : Top Bottom Ft. SITE WELL ID #(if applicable) 9. SCREEN: Depth Diameter Slot Size Material 3. WELL USE (Check Applicable Box): Residential Water Supply � Top Bottom Ft. in. i�. DATE DRILLED �riY'(� Top Bottom Ft. in. in. TIME COMPLETED ,)0� AM ❑ PM'Q : Top Bottom Ft. in. in. 4. WELL LOCATION: CITY: SeMDi�� COUNTY e/ N� —Oa�l ,Qo� (Street a e, Numbers, Commw ity, Subdivision, Lot o., Parcel. Zip Code) TOPOGRAPHIC / LAN ETTING: (check appropriate box) ❑ Slope ❑ Vatley lat O Ridge ❑ Other LATITUDE 36 °� 1iS " DMS OR 3X.X)CX)UWCXX DD LONGITUDE ��' O; ' DMS OR 7X.XXXXXXXXX DD Latitude/longitude source: PS QTopographic map pocaSon of.well must be shown on a USGS topo map andatfached to this form if not using GPS) 5. WELL OWNER / � �P� �� L � Owner Name � l�l� M. ��-- Ia(�(��.; str�Te'ss �� '��c. �73�3 C�i y or Town State Zip Code C�� Are- a code Phone num r 6. WELL DETAILS: �,�, a TOTAL DEPTH: �'?`� � � � b. OOES WELL REPLACE EXIS7ING WELL? YES ❑ Nc.vlB� c. WATER LEVEL Below Top of Casing: 2r FT. (Use '+' if Above Top of Casing) d. TOP OF CASING IS �_ FT. Above Land Surface' ''1 op of casing terminated aUor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): � METHOD OF TEST BIOWtI ZOtll f. DISINFECTION: ry� HTH Amount 1/2 Cuq 10. SANDlGRAVEL PACK: Depth Size Material Top Bottom Ft. Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bottom / : � ��— �_�.�i— / / 1 / i � � / . 12. REMARKS: �r ation Description r 'oDse�/ fLriC ,o C 1 DO HEREBY CERTIFY THAT THIS WEL� WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDAROS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVI D TO THE ELL OWNER. ei r„ �! ! % � SI AT�E OF C T D W CONTRACTOR DATE �{t 9 � PRIN D NAME OF P RSON CO TR TING THE WELL Submit within 30 days of completion to: Division of Water Quality - InfoRnation Processing, Fortn GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09 . . .�� J�� . �1.� �i�� • ' ^� t/ V �� JL IE�•�y�,.,,,.,.,,��.�.11 ]H[�� . .. . ;, � SITE S]E�ETCH - . Name �� rv� ue � � e, ( I Taz Map #� 71� . Patcel # 3( Subdivi ' n �i _ � Section/Lot# 2 d Ce-IZ-IZ � � . Authorized State .Agent . � Date . System components nepresent appraximate�contours only.� The coniractor must, fTag the system prior to begissning th� ir:stalla�ion to i�sure thut propergrade is maintained �M�� n�liln � D0� -�owl q �� ,p G rf"5 � S��G S�(S� Vl�l / ID �Ue5{�on5 � oVI�GC-� �n �� ii ea ��I� ��e, � 3��- S� 7-17g0 � .a � , I . � � � � � , s� t � � � � � � � �t �� ; <; � � i �' { M �` � " ; E� _ _ � . '`�;.,. ` � ��-�� :