A24 77Application Date: ��' � G+�� Tax Map: �
Amount Paid: � 00 • � Parcel #: �
Receipt#: �@ ��� 0
C.�- � ����. ) � ���� �/�
��.� 1 � - -_--�. � � ����
11_✓�ca s u�c-�ca7tasc�-n�ea_ �a�:..�n.� �"�ae:_, w.�d�a.
Applieation for Services (Septic Systems and Wells)
C Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
C Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (Ne placement/Repair)
$3oo.oqi$2oo.0 $�s.00
c�,1i �o
� e ` �M ��
! "
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s stem ermitted)
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Services Requested by:
Name: ,� r �,�� �l� GC� S _
Address: e ` L.LV _
t�.l%'/e�rfm,�E? S�� b i Cl �S�
Phone # (home): z 7C5 — �Z O %
(work/cell):
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Properly:
Does the property have previously identified jurisdictional wetlands: Yes
No
4) Proposed Use and Type of Structure:
Residential Business/Type: Other
Number of bedrooms , or Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
Lot #:
5) Water Supply�/
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparaiion' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall6ecome invalid.
�
Signature (Owner/Legal Representative): � � , .�` Date : —�6✓��
08/11 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�"��, ; ,.1,� ���� ��
�.,,, �{ � � � � � �
1� ��. �- � �� � � � �. ll 1L-33L � �►. ll �.Il�
. W�+ I��, PERIV�T (New�itepair�
Rc�olacemen-�
Taz Map: Parcel: �%7
Subdivision: Lot:
Applicant's Name: LT a I5
MailingAddress: �7� �A� �wS Ln
Phone Numbers: Z"l,t'y - � Z6�
Location of
7
_>
Permit C'onditions:
1} Seg attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply. �
3) Permits expire S years, from the date of issue.
Other Conditions/Comments: L! u F� -
PLrmit issued
I�ate: 9—/� -�/
CER�'�T�CATE OF CO1dIPLE'1�IOI�T
New Well Inspection:
HS/Da
Location: � z< <<
Grouting: 2 l t I
Well Log:
Well Tag:
Pump Tag: „ !^�) �1i
Air Vent: � � ��
Hose Bib:
Casing Height:
Concrete Slab:
Liner �spection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: 13c(�v�"{-� License #:
Pump Installer: License#:
.... -
Well Approved by: I)ate: �� 2(t -( �
�J'Z��IZ �
Date Sample Collected: Date Results Mailed: '"
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 Pubiic Heaith
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: ES032712-0057001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID: 35361
GPS Number:
Sample Description:
Comment:
Name of System:
LT MATTHEWS
474 MATTHEWS LN.
Col lected: 03/26/2012 11:15
Received: 03/27/2012' 08:27
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http:!/siph.ncqublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
J. Smith
Angela Heybroek
' Well Permit Number:
A24-77
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte
Test Result
Analyst Date
Total Coliform, Colilert Absent .1oy Hayes 03�28/2012
E. coli, Colilert Absent Joy Hayes 03/28/2012
Report Date: 04/03/2012
--_,-
� .. : __ ,_._�_ .. �_. j
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�,� �, _
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 Carolina State Laboratory of Public Health 306 N. W?m�ngton St.
Environmental Sciences Raleigh, NC 27611-8047
htta://siph.ncpublichealth.com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES032712-0035001 Date Collected: 03/26/12
Date Received: 03/27/12
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 2.0
Sample Description:
Comment:
Name of System:
LT MATTHEWS
474 MATTHEW LN.
Time Collected: 11:15 AM
Collected By: J. Smith
Well Permit #: A24-77
GPS #:
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 99 mg/L
Chloride 18.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.21 4.00 mg/L
Iron 0.76 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 21 mg/L
Manganese 0.23 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 22.00 mg/L
Sulfate 15.00 250 mg/L
Total Alkalinity 345 mg/L
Total Hardness 330 mg/L
Zinc 0.38 5.00 mg/L
Report Date: 04/12/2012
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Page 1 of 1
Reported By: �e�ie �%loKeol
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l�,�m�u-�,Y„ ,�„-„ ��.��.11 1E���.11�Il-�
Natne _ _ �T f � G � �'t,�'�
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vuv��i`J�
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uthorized Sta.te Agent
�I'I'E ��'I"C�i
Ta� Map # J� Pa:�cel #�7,�
Sec�uu; �,Gt�
_ �-�� --,�,
Date
System corr�ponents represent appraxistaa�e �contours only. The contrnctor rraust flug tjae ,ys�tena prBor to
beginning the insi`adlation io ansure that pm+fljierg�srede as nraintained
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I
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departmen: of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # � � 6 % _�'
1. WELL CONTRACTO �
�� .
ConUacior (Individuap N��
Bamette Well Drillina Inc
Well GonVector 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. YYELL INFORMATION:
WELL CONSTRUCTION PERMIT� �
OTHERASSOCIATED PERMIT#(itapplicabie)
SITE WELL ID #(dappiicaWe) '
3. WELL USE (Check Applicabie Boxj: Residential Water Supply p
DATE DRILLED q� Z O"' ��
TIME COMPLETED lI V C7 AM �PM ❑
4. WELL LOCATION:
cmr: �oX �,� 2a couNnr �e 2se�
�'�S� � �f�ec�rs �../i% ���'�'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, L'p Code)
TOPOGRAPHIC / IANU SETTING: (check appropriate box)
❑Slope ❑Vailey at pRidge ❑Other
LATITUDE 36 "�� ,'���C • DMS OR 3X.XXlOCXXXXX DD
LONGITUDE�_"�' '7 � • DMS OR 7X.X)0000000c DD
Latitudellongitude source: �PS Qfopographic map
pocaSon of.weil must be shown on a USGS topo map andattached to
ihis form if not using GPS)
5. VYELL OWNER
L r a��-�,��
O,/wner Name
T�� i%7f3�"1. C c% �./V 4�/s+e�S1��
Street Address `
�c�xbo�n� �L9C. 7S7 i�
City or Town State Zip Code
�L� _Z �'D — � Z n 7
Area code Phone number
6. YVELL DETAIIS:
a TOTAL DEPTH: � g b
b. DOES WELL REPLACE EXISTiNG YVELL? YES �O ❑
c. WATER IEVEL Below Top of Casing: � FT,
(Use '+` if Above Top of Casing)
d. TOP OF CASING IS �_ FT, qbove Land Su�face'
"Top of casing tertninated aUor below land surface may require
a variance i� acxordance with 15A NCAC 2C .0118.
e• YIELD (gpm): ��. METHOD OF TEST BIOWn ZO171
f. DISINFECTION: Type HTH Amount Z� / CU D
g. WATER 20NES (depih):
: Top,�O Bottom l���op Bottom
: Top !b S Bottom��Top Bottom
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
� Top_� Bot2om�� Ft. t4' �$ ,SGi�2( PvG
Top�� eottom 6''L Ft. 6-26' 1 b" 3' G A('� �
: Top Botiom Ft.
: 8. GROUT: Depth Material Method
= Top�_ Bottom ?.f� Ft Sand/Cemeni Poured
: Top Bottom Ft
: Top Bottom Ft
9. SCREEN: Depth Diameter Stot Size Material
Top Bottom Ft. in. in.
Top 8ottom Ft. in_ in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth S'ize Material
Top Bottom Ft
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
_ l�/ 1�
/o /�_
�l J d
/
/
/
/
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/
/
�
/
: 12. REMARKS:
Formation Description
� vCR� w2�e�
a�2 ,C c� � �c
---�.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER �
�'�l"'�— =- � A� ..�e�r�./.i - ��/f
SIGNATURE OF CERTIFI WELL CONTRACTOR DATE
L(�i�t� i`-s 6�Rrve��
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - tnformation Processing, Fotm GW-1a
1617 Mail Service Center, Raleigh, NC 2T699-161, Phone :(919) 807-6300 Re,,,�tpg
C � ��
!�� The District I�ealth ;Departn
� t �., �-��.. � :.- �,.... �_ __..; . ._ _._. _-._._ --�---��..�..:.
CASWE�L. CHATHAM; LEE PER OS N;COUNI
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,
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