A24 9PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
Date: �,�n�,-_ .
Owner. � �o y S. C� �-vt r, 7i- SR# ��
Location/Duections:
Subdivision Name: r�� V Lot #
Drilling Con�actor: c ,� ---
WELL CONSTRUCT'ION
Distance from Nearest Properry Line Distance from Source of
Pollution
Total Dep.th: 3�_ Ft. Yield: � O GPM Static Water Level�_F
Water Bearing Zones: Depth 3/S Ft. F� F� Ft.
Casing: Depth: From_��to < ,
_� / Ft. Diameter:�_�ches
TYPE: Steel � Galvanized Steel ✓
If Sceel, does owner approve: Yes No �
Weight: Thickness: .Ig�f Height Above Ground:�_ Inche�
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No�_
If "yes" givc rcason:
Grout: Type: Neat Sand/Cement � Concrete
Annular Space Width Inches
Water in A.nnular Space: Yes No
_ Method: Punped Pressure Ro�ared ✓
Depth: From � to__ aC� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag__�
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ./ No �
4 x 4 slab Yes No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND T!
`THIS WELL WAS CONSTRUCTED TN ACCORDr��ICE WI'TH REGULATIONS
FORTH $y THE PERSON C^vUivTy HEALTH DEPARTMENT.
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S�gnature of Contractor p���
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`P�rson County°�Heaith Department
. �.�:���a je .System Impro�ements Permit
Date: 2r ' 2 This Pennit Void After.5 Years _ Permit #�=�"� — a a G:3
Subdivision Name: � % Lot # _�.
Lot Size: Type of Dwelling: _� �"-!' k`'
Water Supply:. Private:. _� Public: Community. �: -1,
Bedrooms: .� Gazbage Disposal
� Basement � Basement F' es
1NFORMATION CERTIFIED BY
Environmental Health Specialist: er o; r�ti�e
'REPAIlt: � REEV UATIO :
Size of Septic Tank: .�L� gallons Size of Pump Tank:
Nitrification Line: -�` � f �
Depth of Stone: 12 inches
Max: Depth of Trenches: -
Altemative System: Conv. Pump LPP Pump
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Date Well Approved: Well should be 100 ft. from any sewer system
BY Epvironme tal Health Specialist
Date Sewage System Appmved: �rG �N ��.Tf�� � 9•�-y'fl �
BY Environmental Health Specialist
CER
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TIFICATE OF COMPLETTON ,,.,3
Contractor. ��• ( -Qa.� � s �
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Sewage System locauon, installation, and protection must meet state and local �
regulations. Sepac tank should be pumped out every 3 to 5 years and shall be maintained
hy owner in such manner as ndt to create a• public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County �
Health Departrnent before any portion of the installation is covered and put into use. If �
the site plans or intended use change this pernut is subject to revocation. �
(G:S.130 A-335F�
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L.ocation of sewage disposal-sewage system sketched on back.
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