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A25 120F � Application Date: Amount Paid: Receipt #: / ai 1 C.� \ R-3-1-� l� �� DD �00 � ��f � 3 c�..�-� � 03 ( , ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 g d) L Mobile Home Replacement or Building Addition $150.00 (if site visit re uired) � Well Permit (N /Replacement/Repair) $3 00.00/�OWO�.f�O/$75.00 1) Applicant It Name:c Address: \�' ; , ) f ��'i.Y� Tax Map: /� °� � ,....�. �- � � �� Parcel#: 1 �� IE�..nn-s n.n-xnaa.v�raa,an.d.zn ll 7E`i�.esaa7l�:l� tion for Services Services ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 i ,. � : _ � � ,s,1�r ' ' • � � �' : • if' 1 � � / ..- .� � � .��.��i"�l'�" � � � 2� N^r�� aa�a �d : ess of cur: �� t otie�ner (i£ different t�an ap , ..� ..� Name: u,Q, 4! : / Address: e � � 3) Property Description: Lot Size: Y- %7��b Subdivision: _ Address and/or directions to Property: �,P.N�'n, o � 132w ' .�1� —� #: ❑ yes � no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes (X� no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes I�I 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? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: '�]Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: _ Ma�cimum number of employees: Total Square footage of Building: Maximum number of seats: 5) W er Supply: �New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring 7D/�P�i�2C i Are there aqy e isting wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no lc.t2� 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is contplete and correct. I also understand that if the information provided is i curate, or if the site is subsequentl ltered, or the intended use changes, all permits and approvals shall be invalid. ^ �J � Signat (Owner/ L al Re sentati e*) Date documentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. 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) �� s�� I�I��.� �� . �-- �--r � � �� IE��a-��.��.11 IE� �.w.Il�lEa SITE PLAN Name s+�.�� w�� Tax Map #�5 Parcel #� a� Su�in'sign Secrion/Lot vti.�c.,,.1L ` 1".1 Authouzed State Agent a e Sysrem camponents represmt appmxrmate conrours anly. The contractormusttlag the sysrem pdor to beg•ianing the insrallation ro Insure rhatpmpergradeis maintained. � .._ . l F � � �Dd'C � M �� ,� P�1Q Q� , '� r�: �"� sV L.i�L�-� � ,��'�� `�'� '�� ► � (�^a.�� , .� I'�'' .,,E t l • � �� 1914 . . . . . .. .��{�,. �1 I - . .. . . r'" . � �i� � � � . � � . �- �I�� . � . . . :y �q`, ,1 ' C� �' � � �� 'o . � ,• e� � � ':� � ?�"�4 ` ��"� �, � a�� . t'A.. e ' � e �'.� �� . '�. , J�� , tS� � _ � .. : y � , . . . � � � �V_�,/��v � {t��,�. . . � V`� . rV'rJ' �i�$ : � . �' .�� . . . . . . � �� ,; . i ��1 � .�G��.• ��a� . � :;. �, I1 � �. � �` ' ;. . w� � �'� M 1519 : . � -- _ __-- '---- `� r43,. . �� `,►+ �� 1 : 60 Fe�i �.� 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: ES110613-0021001 Date Collected: 11/05/13 Date Received: 11/06/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 2.2 Sample Description: Comment: Name of System: SHELBY RICKS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slah.nc�ublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 1325 CONCORD CEFFO RD Time Collected: 10:32 AM Collected By: Derrick A Smith Well Permit #: A25-120 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 21 mg/L Chloride 23.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 5 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 6.60 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.9 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 14.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 45 mg/L Total Hardness 74 mg/L Zinc < 0.05 5.00 mg/L Report Date: 11/15/2013 s �:��:.:��'�% � --- NOV � � 2013 ��' : _�_ Page 1 of 1 Reported By: Arnold Holl North Carolina State Laboratory Public Health 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: ES110613-0075001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: SHELBY RICKS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://siph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 1325 CONCORD CEFFO RD Collected: 11 /05/2013 10:32 Received: 11/06/2013 08:35 Sample Source: New Well Sampling Point: Well head Derrick A Smith Angela Heybroek Well Permit Number: A25-120 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent HLBRASWELL 11/07/2013 E. coli, Colilert Absent HLBRASWELL 11/07/2013 Report Date: 11/07/2013 Explanations of Coliform Analysis: Reported By: Susan Beasley � ��C� :��% ��v� NOV 1 J 2013 BY: 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. �� S. f ��$.�� ___.�= . . � � �� .�n.-wn�amnan�.�n.c��n.��.Il. �.�ce�..�.��n. WEY�L PERMIT (New,�Repair___) L��+�� Tax l�Zap: � �5 __�___ Parcel: 1 � Subdivision: � Lot: Applicant's Name: Si��l`t wt�,� Qac�.s Mailing Address: l00'1 1�1c.�5 QD .�wqY ac. a9 �a.o _ Phone Numbers: ��a. 5x5 - a'1g� (a'�s�. 5h `s- qaq�o Location of Prope�ty: C��t. � Mcc�t�sS Hi�v.. �.R d- G�a.�a� C�.�Fo Permit Conditi�ns: 1) See attached site plan for proposed well location. 2) All apnlicable State and County regulations governing construction and setbacks apply. 3) Permits expire S years from the date of is.sue. Other Conditions/Comments: At��o�r��. �lW w�.u. ; C�. Pc.t'�0 w �A,jY �snoas 33•0 - 59`1-1'� 9 �4 . Permit issue� hy: o�Q.,,,,..�. Q_ ,�, Date: y�3 CERTIFICATE OF COMPLETION New i�'+�'eli Iaspection: EHS!i�ate Location: �As 9 ao � P�yF3 G;outin � s 9 I� �"9�� '� V� ell L� : qs 9�� — Well Tag: s t _ Pum� Tag: Air Vent: _ _ • Hose Bib: Casing Height: Concrete Slab: Liner Iaspection: EHS/Date Installer: Depth: ' Grout: VVell Abandonment: EHS/Date Comgleted: Methad�'11,�aterial(s): _ WeII Driller: (�R-�.� 1£ License #: Pump Installer: I,icen:,e#: _ VVell Approved b3 :�,��,..K Q. � llRte: 011, i Date Sample Collected: i 1 13 Person County Environme:ital Health 325 S. Morgan St., Suite C� Roxboro, NC 27573 Date Results Nlailed: I1 i5 13 Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 : `�� -StATEa'. : �'� ��.ir.,:..,�\�1 j n..;�. :�r f �t , .�A.. ': �:� -��,�p; .,� RESIDENTIAL wEL1.. coNSTxuc�riorr �coRn North Carolina Depardnen: of Environment and Natural Resowces- Division of Water Quality WELL CONTRACTOR CERTIFICATION # ; 3 3��' 1. WEL CONTRACTOR: � �� ''�s ��G � � Well Contractor (Individuai) Name Bamette Well Drillina Inc Well Gontrector Company Name 611 Bamette 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#� Z � OTHER ASSOCIATED PERMIT#(ff appiicab�e) � � Z'� SITE WELL ID #{ff appiicable) 3. WELL USE (Check Appticable Box): Residential Water Supply ❑ DATE DRILLED / `� � -' % -3 TIME COMPIETED � CS C� AM p PM p-- g. WATER ZONES (depth): Top 2�� Bottom �3 %Top Bottom Top ��a Bottom / t! 3� jTop Bottom Top / 7S Bottom ��"O �i�Top Bottom Thicknessl 7. CASING: Depth Diameter Weight Material Top � Bottom�Ft. � �f�21 1%� Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Top c eottom�_ Ft. Sand/Cement Top Bottom Ft. Top Bottom Ft. Method Poured 9. SCREEN: Depth Diameter Slot Size Material Top Bottom Ft. in. in. Top Bottom Ft. in. in. Top Bottom Ft. in. in. 4. WELL LOCATION: 70. SANDlGRAVEL PACK: Depth Size Material CITY: C' P'��r'� COUNN�/ 2 2 S�-' /i% ; Top Bottom Ft. G�N�O�� C F .�D �A' L,�- �S/ Z 7� 7� : Top Bottom Ft. (Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code) . TOp BottOm Ft. TOPOGRAPHIC / LAND SEITING: (check appropriam box) ❑Slope ❑Valley B�(at ❑Ridge ❑Other LATITUDE 36 '�7' L� " DMS OR 3X.XXXXXXXXX DD � IONGITUDE��" '� 2.'� DMS OR 7X.XX)OCX)cXXX DD : Latitude/longitude source: �FrS pfopographic map (loca6on of.well must be shown on a USGS topo map andattached to this form if not using GPS) , 5. WELL OWNER Sf/� /�3� t�� /�e� R f c`GS � Owne� Name 6 /� % �'1/'C y� � Qa�-� Street Address C`'cNll�v�t/ %U �. � 7�''� O Ciry or Town State Zip Code 2( j Z 1 .��''S -� 7 c3�I Area code Phone number 6. WELL DETAILS: a TOTAL DEPTH: � � � b. DOES WELL REPLACE EXISTING WELL? YES C9/WO O c. WATER IEVEL Below Top of Casing: �' � Ff• (Use "+` if Above Top of Casing) d. TOP OF CASING IS � FT. Above Land SurFace' '7op of casing terminated aUor below land surtace may require a variance in accordance with 15A NCAC 2C .0118_ e. YIELD (gpm): %� • METHOD OF TEST BIOWII ZOfll f. DISINFECTION: Type HTH Amount � Z 11. DRILLING LOG Top Bottom � / /<> �i�^_/ �19 �/ 2c�� / / / / i / / / / / J 12. REMARKS: Fortnation Oesaiption � t� P � � -� 1� .r�s RN A� ,�•c� si. �_c��+� d C� rA I i� a�'�(< 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. � �rry,�-�9 � , � �_ �-�-� ��,...I� SIG ATURE OF CERTIFIED WE L CONTRACTOR DATE �'P� N � � c � . P��. �,�- PRINTED NAME OF PERSON CONSTRUCTI G THE WELI Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2109