A24A 9��i
i������1 l�
ne deparFment
of health and
human services
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�r �~� � Y r � �`° (�� �-�� � � �� � ..{.-.� e...,�,�.� t� �' � {>-,. � �- � �'�� ip"� �..,.v
�•'j ! [ V,a �w....f' �....%� �� k j�. Lf -.1' �..• E � a E i ��/ 3 � ,i ��� E� @ \•} ! € �._l
For Inorganic Chemical Confaminants
County: rSy Name: QK i
Sample ID #: — � Reviewer: , Rr�„/
� TEST RESULTS AND USE RECOMMENDATIONS
1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2.�The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inor�anic chemical results onlv.
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
the inorganic chemical results onlv.
❑ b. Levels over 30 mg/1 may pose aesthetic prob(ems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and I S minute sample inside the house (preferably
the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the
lead and/or copper.
6. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorFanic chemical results onlv, but aesthetic problems
such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system
to address aesthetic problems.
Barium Cadmium Chromium � Fluoride � Iron
Man�anese Selenium Silver pH Zinc
Fo� more information regarding your we!! wate� results, plense call the North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: ADAM C. SARVER
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
SANDRA BIGNER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://sloh. ncaublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
804 PINESBOROUGH ESTATES RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES111915-0062001 Date Collected: 11/18/15 Time Collected: 11:55 AM
Date Received: 11/19/15 Collected By: A Sarver
Sample Type: Raw Sampling Point: Well head Well Permit #: A24A-9
Sample Source: New Well Temp. at Receipt: 4.0 GPS #:
Sample Description:
Comment:
New Well I (Profile)
Analyte Result Allowable Limit Unit 4ualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium 0.107 2.00 mg/L
Cadmium < 0.001 0.005 mg/L
Calcium
Chloride
64
Chromium < 0.01
Iron
Lead
Magnesium
Manganese
Mercury
Nitrate
Nitrite
pH
Selenium
Silver
Sodium
< 0.05 1.3
[� ' '
< 0.00;
19
0.340
< 0.000
< 1.00
< 0.1
7.s
<
< 0.05
18.00
4.00 m
0.30 m
0.015 m
m
0.05 m
0.002 m
10.00 m
1.00 m
n
0.05 m
0.10 m
m
250 m
Total Alkalinity 216 mg��
Total Hardness 240 mg/L
Zinc < 0.05 5.00 mg/L
Report Date:11/25/2015
Page 1 of 1
Reported By: Deddie .�toncol'
North Carolina State Laboratory Public Health
Environmental Sciences
f�icrobiology
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: ES111915-0085001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ���U ����� ����� ����� ����� ���� (���
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
httq://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Name of System:
SANDRA BIGNER
804 PINESBOROUGH ESTATES RD
SEMORA, NC 27343
Collected: 11 /18/2015 11:55
Received: 11/19/2015 08:32
Sample Source: New Well
Sampling Point: Well head
A Sarver
Angela Heybroek
Well Permit Number:
A24A-9
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice Owens 11/20/2015
E. coli, Colilert Absent Darneice Owens 11/20/2015
Report Date: 11/20/2015
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
/ � '�
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.
���. sf ���.� ��
� � ����
I -�"�s��aa-o�a�cn��n.�a�.Il IF-3L��.11�ll�
Applicant: (T0. dr
Location: ,
System Type (From Table Va):
Type V& VI Expiration Date:
Oueration Pern�it
Tax Map 2�� P rcel #
Subdivision i , f eQ
Phase/Section/Lot #
# of Bedrooms �
Product (IIIg): �2 �G �
Type V& VI Renewal Date: �
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
� � tiv-ei-
thorized Agent) �
'� Lew� �
(Licensed Contrac�tor� � � �
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Scale �p �
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u �s'f
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Tax Map: Parcel #•
Septic Tank System Checklist (Type II-I� System Type:
Se tic Tank itiaUDate
State ID & Date: - -1 S
S Z
Capacity: d-a-o
Tee and filter
Baffle
Vent
�Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial
Pressure Manifold �
LPP
Notes•
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alarm float (6" separation)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A proved and secured riser
Su 1 Line
Size and material: in, sch.
Length: ft.
; �.��. ��;��� : ���.� ��
� � �' ����T���
,� �
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�63��H�ES�Oflfl: P�aes r�a� 6� �s« E ��$:
��pfln�ant'� i�iasaae: (Z,ofSE.ltc' F� rS�ER.S � �A�! '�o�aOEx'�f�
�'�aIl�HIlY� �sd�Q�➢'�53:
��o�ae �ufl�a��a�s: 335.- So�l- 34�0
�I.,�sa�a�n ���'r����y: Aariac,�-r 'To 8��. P��S�s (�eNo�►h�1 �sv3�S
j�op►O
:��ep�i� C'o�adi�do�as: .
�) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks ctpply.
3,� Permits expire � years ft•om the date of isszre.
�Pher �''�n�z�i��a�/�"�om�e�a�s: Ma►�r�q ��5, A� �'bACKS : K�EO ���.�
A-r t.EAsr 1co �Q�r �Mor� SEP�r�� SYstTcln .
���auna� is�u�s� �y: d�1Qw..L' . Q. .�.1�.. ��$�: � 8 �3
��g3�'��+'����� ��' t��1b�L�'�t'��1� �
Nd�a� �1��� g�ns��es:�`a�a�:
EHS/Date
Location: s
Groutin�: 8- lg-lS
Well Log:
V41e11 Tag:
Pump Tag:
Air Vent: ,�_�s
Hose Bib:
Casing Height:
Concrete Slab:
�Ilffi�&' �ICda�D�C$Il�Bfl:
EHS/Date
Installer:
L7epth:
Grout:
���� Aba�d���a���:
EH5/Date
Completed:
Method/Material(s): _
��fll Da�nfl���: t u�v�n � n a t �a�e�a�e #: 2S 37
Pump Installer: '` '' License#:
.
'�'���� t°���a-���s� b�: u ,_� �9�$�: �-25=(S
�
Date Sample Collected: —�$ � 7
Person County Environment�] Health ��
335 S. Nlorgan 5t., Suite C
Roxboro, �iC 3757.i
Date Results Nlailed: . 2 2 ��j
Phone: 336-�97-1790 Fax: 336-�97-7�08
8/1i08
WELL CONSTRUCTION RECORD
'Ihis form can be used for single or multipie wells
1. Wdl Cantnctor Informaflon:
Dennis Cummings
VVell Contractor Name
2537A
NC Wcll ConvactorCcrtificationNumbcr
Cummings Developments, Inc.
Company Name
2. Well Cunstracdon Permit #: N( �
Liat a/l applicable wellpennifs (?.e. Caa�ry. Srare, b'ariance. lnjection, etc.)
3. Well Use (check well use):
R'ater Suppty Well: "
❑Agricultural ❑Mwiicipal/Public
OGwthermal (Heating/Cooling Supply) OResidential Water Supply (single)
�IndustriaUCommacial sidential Waur Supply (shared)
Non-Water Soppiy Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑AquiYer Storage and Rccovery ❑Salinity Barrier
�Aquiter Test OStormwater Drainage
❑Experimental Technology OSubsidencc Convol
❑Geothermal (Closed Loop) ❑Tracer
❑Other (explain under #21
4. Date Well(s) Cumpleted: t'i'�/—'� Well LUtI
Sa. VVell Locatioa:
�dv'� ��av� r
Facility/Owner Name Facility IDtI (if applicable)
+w� ( 1'�✓1ZS�06✓'Ot.c(� ��5, SCwtOr� KC
Physical Addcess, City, nnd Zip
�e�sc�
Counry Paral idcntification No. (PIN)
56. Laritude and Longitnde in dcgrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
-� G ° Z°l . �� 1 � x �`�l'v b�� • �S a � w
6. Is (are) the weU(s): 6germanent or ❑Temporary
7. Is thLv a repair to An eiistlng well: OYes or �.elvo
If Ihis is a repair, fip oul known wdl con.ttruclion ir{farmalion and explain [he nature ojrhe
repair under #Z/ remarkt seclion or nn !he back of thia form.
8. Number of wells cons/ructed: One
For multiple injactlon or non-waler supply wells ONLY with the soma eonsbvetion, you can
submit one jorm
9. Total wdl depth below lxnd sarface: � J � ([t.)
For multrple we!ls Ust alldepths jfdiffnent (example- 3Q100' m�C2Q100')
l U. Static water level below top of casiog: �� (ft.)
lJwaicr leve! is abme casn�g, use •,+'•
For inamal Usc OHLY:
22. Cc ' ►ca on:
� -� � g �/ �
S' nawre ofCertified Well Con to Date
By signing lhrs jorm, I hereby certify lhat the well(sJ wa.f (wereJ constructed in accardance
wilh f SA NCAC 01C .0I00 or 1 SA NCAC 01C .0200 Well Conalruclion Slandards and (ho1 a
copy oJthrs recor•d has bern pro�•ided io the well owner.
Z3. Site diagram or addiHonal well details:
You may use the back of this page to provide additional well site details or well
consttuction details. You may also attach additional pages if necessary.
SUBMiTTALiNSTUCTTONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the f'opowing:
DivIsion ofVValer Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 6 (in.) 246. For Iniection Wells ONLY: In addition to sending thc form to the address in
Air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12. Well constractlon method: ry construction to the following:
(i.c. augcr, rotary, cablq dircct push, ctc.)
Division of R'ater Resourcea, Undergroand inJection Control Program,
FOR WATER SUPPLY WELIS ONLV: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yidd (gpm) � Method of test: Air Rotary Z4c For Water Supply & Injecfion Wells:
Also submit one copy of this focm within 30 days of completion of
13�. D�«�on m,�: HTH Amoont: ��t• 2. . well constntction to the county health department of the counry where
cuns[ructed.
FOSII7 GW-I Nnrth C:ar�lina Denartmenf �f Fnvirnnmrnl arvi NahRal Rna�nrcree _ Ilivici�m nY War.r R.c�nr�.e G..�.<..d e,.a�<� �n i n
���.sf ������
�_ � � ����
)C�+esrn�n��arn�•--+•-T ��rn��.Il 7L—���.II�I�n.
Tax Map: Aa4A Parcel: �
Subdivision p����rt,oy�N Es�^[�
Phase/Section/Lot # I�T �
Improvement Permit
Permit Valid for: Five Years i� Non-expiring
Type of Facility: 3�� PR«� �S. New � Addition _
Number of: Bedrooms �/ Occupantsip� Employees / Seats:
Proposed Wastewater System: Atc�ptEp t,,i� 01.5'lo Kl�qperoa
Proposed Repair: (l£pa4�� �1c�Et+1[�t
Permit Conditions:
s.�
Water Supply: �Q�Y1�Et� �A1El.�-
Projected Daily Flow: 3�o gallons/day
Type: � �_
Type: ~
. 1990
Authorized State Agent: � Date:. oZ 13
(X) Owner or Legal Representative: � �/t( Qt_� Date. —3fl.
�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
and Rules for Sewa�e Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �C,c��,p t� 01$ °1v I�i9►1t�tvcl
New x Repair _ Expansion _
Type of Facility: 30�R PRWa'L'� RE�StOE�C£
�R
Illb, Illbg, IV, and V,
(*)Type �_ Design Flow 3�0�_ gal./day
Soil LTAR: O. 3� gal./day/ft2
Basement: X, Yes _ No
W/Plu►,�b�n,
ey the Person Counry Hea[th Department.
Wastewater System Requirements
Tank Size: Septic Tank �o0p gal. Pump Tank "" gal. Grease Trap "—' gal.
Drainfield: Total Area q 00 sq. ft. Total Length �1�1 ft. Ma�c. Trench Depth ia'� in.
Trench Width 3 ft. Min.Soil Cover $ in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution i� / Pressure Manifold
Specifications: SE£, Srt�, P�,qt�j ORylwtt��o :$�� Sw�. �A�E.t. iZEQ41�K£�
Authorized State Agent:
Issue Date: o'�,I $ � �3
Permit Expiration Date:
Ti�e system permitted is: Conventional /Accepted x/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: �- - 30 •(�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
50
PROPEERTY SKETCH
PINESBOROUGH ESTATES
LOT 9
CUNNINGHAM TWP., PERSON COUNTY, NC
MARCH 2O01, HAMLETT—JENNINGS & ASSOCIATES
0 25 50 ,00 ���
BAR GRAPHI inch = 50 ft.
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S`T.S:�M .
� Do t�ocS' iris��. ot�t►e,�
1rJE'� t�Ct�,t��-��t'�:a .
� Q� s,urs3 A s �rm-� AS
j�o�,��b�.E ��t5.
c,�.n+�.t�6
C„aT .
� MA�t`t��tJ �a-�� ,�c
(��-�-tvt�►s.
LOT 8
.;� l.A�t o�,-� Fvt+L. 'ii'+&�:�
�fl�o� �r��
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P
0
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420' CON70UR
CAROLINA P0�'VER & LIGHT COMPANY
HYCO LAKE
�
`'\
X
HAMLETT-JENNINGS
& ASSOCIATES, P.A. w '
PROFESSIONAL LAND SURVEYORS „
212 S LAMAR S7REET - PO 80X 1266
ROXBORO NORTH CAROIINA 27573
�' (336) 599-8742
L
Lot 9 Pinesborough Estate
Tax Map & Parcel #: A24A 9
LAYOUT FOR 3 BEDROOM HOME
FLAG
LINE # COLOR
1
2
3
4
S
PINK �
YELLOW
ORANGE
RED
BLUE
LINE LTAR
LENGTH GPD/FTZ
System 300 0.300
SOIL
SYSTEM LTAR
TYPE GPD/FT2
IIIg 0.300
FLAGGED
LI1VE LENGTH
40
70
70
70
SO
300
DISTR[BUTION
SERIAL
Notes: **All measures in feet.
**Nitrification lines are demonstrated on contour via colored pin flags.
** REPAIR EXEMPT LOT
February 8, 2013
DESIGN
LINE LENGTH
40
70
70
70
SO
300
Application Date: � z.2� I
Amount Paid: 2s� �—
Receipt #: -�',�} 11'�i
� t� 5�
��} 6.26�(
� 3�_�y ��� s ��
�{�0 .00 � �... � .J.0 11e11�1 �
! S ' �. � �V � 1L �
IE:�rnv aa-�cnr*,•�„ �aan9:,mll IHL�,s.11d,lln
A
�Improvement Permit (Siie Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
�i5G.00 fifsite visitreauiredl
0 '1Weli Permit (New/Replacem
$3 OO.OQ/$200.00/$75.00
1) Ap
Services
� ��
s (�tdr�
for Services
Tax Map: A a� A
Parcel#: �
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
� Permit Revision
�75.00
❑ Repair of Existing Septic System
Application: No Chazgel CA $150.00 or $300.00
�1I�,(,f5 `s �ph�� ome): �T• ��IIUU
� �
�
(work/cell): 33 � .-- �jp - p
2) Name and addr f c�urr�qt o er if di�erent thaa applican
Name: _ -t–
Address
(� 1
3) Property Description: Lot Size: ��� Subdiv�siorz�I�.Q/�
Address and/or directions to Proaertv; �YI �) ,.Ir(��.
. Phor.e:�GL E�-
��
#: � - u►-� �,�
s _ �.in 1�-.A � ��
❑ yes .l�o- Does th�te contairi any j6risdictional wetlands? U �''i "-;- �{�� �I.c� 1►ePs
❑ yes � Does the site contain any existing wastewater systems? �bw� t/'� �,� �
❑ yes m-rt� Is any wastewater going to be generated on the site other than domest�c sewage. �
❑ yes C�no� Is the site subject to approval by any other public agency? S�i�'����t �� 1
❑ S�es �o Are there any easements or right of ways on this property? �
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑ esidential
ew Single Family Residence Maximum number of bedrooms:
� Expa�sion of Existing System If expansion: Cu�ran� r►•�nberj� f bedrooms:
❑ Repair to Nizlfunciioning 5ystem Will there be a basement? �'yes ❑ no With plumbing fixtures7 6�es ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maxim4m number of employees: t�aximum numb�r o: seats: _
�) Water Supply: YJ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring _�
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes Gd'no
6) If lying `Authorization to Construct', please indicate preferred system type(s):
Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � 1�- �ny
I cert� that the infof•mation provided above is complete and correct. I also understand that if the information provided is
ina curate, or if e site is subsequently altered, or the intended use changes, all permits and approvals s all be invalid..
y� �
Sig a re O ner/ Legal Representative*) Date
* S orting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A campleted `Lot Preparation' form must accompany any application requiring a site evaluation.
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