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A25 151�pplication Date: 7 027`�� Amount Paid: � �O , O U :�J�ceipt�#: S' 7-2 �'� 7 ci12 # 15g � TaY Ylap: /� a-� rarce? �: 1 � � _�� `��..: � i��" ; �-� _____. ��- �� 1L� �'� � �T 1.�.:,u�,.�z-:Ls-��„-.._„«r�,r:i.�z1L I£—�'�.��-..�'1v=1�:� ��g��on �o�' �e�'vie�s (Septic Systems and Wells� �ee-vic�s �'de ues�ed � �mprovement �ermit (Site �valuation) ❑ Construction Authorization ��00.00/$300.00 (if> 600 g d) (Fee is dependent on the tyoe of system ermitted) ❑ l'Tobile �3ome.Repiacement or Building .�ddition �J Permit Revision $1�0.00 (if site visit re uired) $75.00 � C�TV�iI �ermit �lacement/�2epair) fJ Repair of ��isiing Septic �ystem $300.0 /$200.00 $75.00 No Char�e Servic�s T�2equeste�l �by: Name: u r� ��x-v�e�r Phone #(home): 33(0 -�Sg�' a.a2-�p Address:`� 'r W.. ��\'rl . (work7cell): 33Co- 5 qa- (.QO�-\ ( ��5�� y.,Vx;ro V�G • Z}l�am� a�d ad€�r�ss of s�ar��at aw�aea� (s�' diiff�r�nt �h�an applicaa�t): � d Y� CO JV � Name: �Q,w,p �a C� �O r , Address: Q W el 1 10 Cai-� cc�.✓ � � - � `� i �1 �) �ro�er4y�escrflp�aon: LotSize: �d Subdivision: �ot#: � aGC� J Address and/or directions to Property: �.�lo t��.v�rc��xU.�� , 1�u'�k�crr� ��1C; 4) �roposed Use aad 'Type of Structua-e: Residential � Business/Type: Other Number of bedrooms ,�j / Number of people served (seats/employees): Basement: Yes � No e� (with plumbing: Yes � No _) Garbage disposal: Yes No �_ � ,�f Water Supplyv: � Private Well /� (Proposed Existing _) Community Well: Public Water Systein: . . Are there wells on the adjoining properties? No Yes (please show location on site plan} 1'�T�ote: �1 cornpleter� nmplacation nausE ndso inelucde: ��1 �lat/site plren of the �ar�peYfy �,�tcct s,{zotiv� �� o�er� �li��en.sions c�nd t�ae siza �pad docr�tioaa �oj`rall �roposed sPructures. � . y A sagned capy af ldze `.��o� ��sration'��rn� veri��an; that Pdae �ropeYry i� ra�cdy io be. ev�al�r��e� � ana �ubmitting #has .��polncatiou #o re�aaest 3ervac�s #'roar� �'�e �Qrson �ousniy �eaith �epa�-#pne�nt. � und�rs#a�ad tha� if th�e �ta%a-�ation provide�l is imearr��t oa- a�' #�ie :s su�ss��ue�ntiy �l�ere�, oa- if #hQ �ntenc�ed use charg�s, �� per�nats a�d appa�avais shaPb became i�tvalid. � ,_ - U�g�a��-� (Owner/Legal Representative): �` ` ICJ / �� 10i08 Person County Lnviro�l�nental. Hea�th; �"5 S. �iior?an �t.; Suite C; RoYboro, NG 2757� (336-�Q7-17°0) ��.s� I�I�� . , _ `---= �=- � � �� s��.� �� STTE PI.AN N e t V � `{� r Tas Map #�J parcel #� S- / Sub ' n Section/Lot# Authorized Srate Agent Da e System companears rrpievear appmxrmare avamrus aa1y. Tha cantracmrmust Bag t6e system pdor ro begianiag rhe iasrallation uv insvrr t6at pmpergrrde ia mamtyaed s�G �l � v�� U � �tA�c/a. � }—�• y�cGk��es l�� ( ��• � rcxn, �. os/�/oi North Carolin� Division ofPublic Healtli . . . . . .� : :: : � � : Occupational and Environmental EpidemiplogyBraach, Epidemiology Section �� • � INORGA1�tIC CHEMICAL ANALYSIS REPORT � Prlvate well water informatlon and recommendations County: -�S`" Name: Pur Qa►� 5atnpleTdNumber: ��.3 Location: � Reviewer �� . � ANALYSIS REPORT Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results wae evaluated using the federal drinking wa�r standards. The pH is a measure of the acidity of the water. Drinking water may contain substances that can occur naturally in water or can be introduced into the water from man-made so ces. (These recommendations are based on inorganic chemical analysis only.) . TE5T RESULTS AND USE RECOMIVV��NDATION5 Your well water meets federal drinking water standards. Your water can be used for drinldng, cooking, washing, cleaning, bathing, and showering. � ' The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur.� You may wattt to install a honsehold water treatment system to address aesthetic problems. � The following substance(s) exceeded federal drinking water standards: We recommend that your well water not be used for drinkin� or cooking, unless you install a water treatment system to remove the circled substance(s). However, it may lie used for washing, cleaning, bathing, and showering. I,ead Ilron Sodium � Re-sampling is recommended in months. _ Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 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. Contact your local health department for re-sampling assistance. - OTHER CONSIDERATION5 Routine well water sampling for the above substances is recommended every two to three years. Sample your well water when there is a known problem or contamination in your area, after repairs or replacernent of your well, or after a flooding event. Contact your local health department for sampling instructions. Contact your locatl Le�lth depArtment for more inforuuttion �r go to htto;//�vvw.epf.atate.ndepUoil/bsfactahee�html Marcd 10, 2009 North Carolina State Laboratory of Pubiic Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: puryear, Kevin Address: 246 Dunaway Rd Zip: County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street Ste C (336) 597-2371 Roxboro, NC 27573 Courier: 02-33-15 Collected By: J SMITH Location of sampling point: Well head Remarks: Permit # A25-151 Date: 9/28/2009 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 1:30:00 PM Parameters Results Units Date Analyzed: Silver <0.05 mg/I 9/29/2009 Alkalinity as CaCO3 70 mg/I 9/29/2009 ' Arsenic <0.005 mg/I 9/29/2009 Barium <0.1 mg/I 9/29/2009 Calcium 24.9 mg/I 9/29/2009 Cadmium <0.001 mg/I 9/29/2009 Chloride IC 44 mg/I 9/29/2009 Chromium <0.01 mg/I 9/29/2009 Copper <0.05 mg/I 9/29/2009 Fluoride <0.20 mg/I 9/29/2009 Iron <0.10 mg/I 9/29/2009 Hardness as CaCO3 (Ca,Mg) 111 mg/I 9/29/2009 Mercury <0.0005 mg/I 9/29/2009 Magnesium 11.8 mg/I 9/29/2009 Manganese ' 0.04 ' mg/I 9/29/2009 Sodium 16 mg/I 9/29/2009 Nitrite as N <0.10 mg/I 9/29/2009 Nitrate as N 3.54 mg/I 9/29/2009 Lead <0.005 mg/I 9/29/2009 pH 6.6 Std. units 9/29/2009 Selenium <0.005 mg/I 9/29/2009 Sulfate 6 mg/I 9/29/2009 Zinc <0.05 mg/I 9/29/2009 n��' Reported By: � I � Date Received: 9/29/2009 Today's Date: 10/15/2009 Report Date: 10/15/2009 Ref: 13794 Login Batch: Sample Number: A695873 Explanations Coliform Analysis: If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 r • ,. , , North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section BIOL4GICAL ANALYSIS REPORT . Prlvate well water informatton and recommendadons County: �f"�^ Name: ��r � Sam le IdNumber: /�%a� r Location: ' Reviewer� �i Your well water was tested for biological contaminaats (total coliform and fecal coliform bacteria). The results were evaluated using the fetleral drinlcing water standards. Drinking water may contain substances that can occur naturally in water or can be introduced into water from man-made sources. Total colifbrm bacteria are found in soil and fecal coliform bacteria are found in animal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well may ' have structural problems or that the well was not pmperly disinfected. BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR PRIVATE WELL WATER (Thesc recommendations are based on biological analysis onl , No coliform bacteria were found in your well water. Your water can be used for drinking, cooking, washing dishes, bathing and showering. Total coliform and/or fecal coliform bacteria were detected in the sample which indicates that hazmful bacteria &om human or animal waste could enter the well. Do not use the water for drinking, cooking, washing dishes, bathing or showering unless you boil it for at least one"minute. If you have been drinking the well water and are pregnant, nursing, have a child in the household under 5 years of age, or immunocompromised (such as an individual with AIDS, cancer, hepatitis, dialysis or surgical procedures) inform your phystcian of these results at your ne�ct visi� There may be a problem with the construction of the well, the groundwater source, or operation of the well. The well needs to be inspected by the local health department or a local well contractor to determine the problem with the well and to give guidance on how to correct the problem. You should re-sample your water after proper well inspection and disinfection to make sure that the problem does not continue, If the contamination continues, you should investigate the possibility of drilling a new well or installing a point-of-entry disinfection unit which can use chlorine, ultraviolet light, or ozone. Contact your IocAl heAlth depArtment for more ipformatiop or go to htta://www.eai.statanclepVoti/hsfactsheet.html. March 10, Z009 Report To: North Carolina State Laboratory Public Health 3 6 N W�m�ngton St. Environmental Sciences Raleigh, NC 27611-8047 httq: //slph. state. nc. us M i c ro b i o I o Phone: 919-733-7834 g y Fax: 919-733-8695 Certificate of Analysis - � ��-' � f ;' .--. '; .� ,.-;. J;=�` o� r.``.',� ; �` R�'LO� .i PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Name of System: Kevin Puryear 246 Dunaway Rd \�i StarLiMS Sample ID: ES092909-0019001 Collected: 09/28/2009 13:30 J Smith IIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIII'IIIIIIIIIIIIIIIIIII'IIIIIIIIIIIIIIII Received: 09/29/2009 08:55 Angela Heybroek ES Microbiology ID: 9706 Sample Source: New Well Well Permit Number: GPS Number: Sampling Point: Well head A25-151 Sample Description: Comment: Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Darneice Lyons O9/30/2009 E. coli, Colilert Absent Darneice Lyons 09/30/2009 Report Date: 10/05/2009 �' i Reported By: JoyHayes /� Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. ._ � Inorganic Analysis: Recommended limits for drinking wat�r. Sample should not exceed levels listed below. � Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 � oP�RSON COUNTY HEALTH DEPARTMENT 355A S. MADISON BLVD. ROXBORO, NC 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant Keviv� ��..�,� Address �� [e 1�wr�,,,.��u ��, County �ers�,n _ Collected By �ti S Date Collected /6 -27 -o� Time Collected /: 2S Source: C�'Well ❑ Spring �"Well Tap ❑ Other �� Qe-Sar�p�e LI No Charge � 0 Charge �**��*�**:�*****x�**��*�*��x**�x�*�*x******��****�***�t�*��********��*x** xx�*�x****��**��*��t�****��****x�******�****�**x�**x��*****��x*�t�*�***��x Total Coliform Fecal/�. Coli. Results Present Absent p �" ❑ GY Reported By Date ��-�'�� , ., �--� � � � � 1L � I�.��a� � �.��.�..�.I1 .IL��L � ��,►.]l �1�. W�LL P�RMIT (�Tew�Repair� Tax 1VIap: o�� Subdivision: Parcel• s Applicant's Name: t -�9l 1Vlailing Address: Phone Numbers: Locataon of Property: Lot: Permit Condations: ' I) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. � 3) Permits e�pire � years frorrz the date of issue. Other Conditions/Comments: Permit issued by: I)ate: ? � g � CERT'�FICA�'E O� C�MPLETI011�TT New Well Inspection: I�iner Inspection: EHS/Date EHS/Date Location: J s �f 2� p� Installer: Grouting: Depth: Well Log: Grout: Well Tag: Ts Pump Tag: V6�e11 Abandonment: Air Vent: g_ 2c� � 0`1 EHS/Date Hose Bib: Completed: Casing Height: Nlethod/Material(s): Concrete Slab: � � Well Driller• � K� License #: Pump Installer: � License#: �Vell Approved by: � I�ate: �j- Z�{ l D�% Date Sample Collected: 9 �Zg'0� Person County Environmental Health 32� S. Vlorgan St., Suite C Roxboro, NC 37573 Date Results Mailed: 0- S' a Phone: 3�6-597-1790 Fax: 336-597-7808 8/1/08 WELL CONSTRUCTION RECORD North Carolina - Dcpartment oF Environment and Natural Resources - Division oF Water Quality - Groundwater Section WELL CO�TRACTOR (INDIVIDUAL) NAME (print) WIL BEET JONES CERTIFlCAT10N q 2 309 ��'ELLCO,�'fRACPORCOhiPANYNAD1E_RANKTN WTTLTAM4nN�TN(` PHONe q { ) S'fATE ��'ELL CO�STRUCTION PERMIT# ASSOCIATED WQ PER�11Tq _ (ifapplicable) (ifapplicable) I. 1VELL USE (Check Applicable Box): Residential � Municipal/Public ❑ industrial O Agricultural ❑ Monitoring � Recovery ❑ Heat Pump Water [njection ❑ Other � If Other; List Use 2. WELL LOCA Q• a � N L`i 7'own�.� U1JAS A t�J' ��2.On�Y �D (Strre� Name, Numbers, �ommunity, Subdivision, Lot No., Zip Cafe) 3. OWNER: "V�N U � Address 1 j � - C�0 �'�°�1�'°.' �( � � � �t 3 Ciry or Town State Zip Code ( )- Area code• Phone number 4. DATE DRILLED "IO �Oq 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTlNG WELL? Y �NO ❑ 7. STATIC WATER LEVEL Below Top of Casing: � F'I'. (Use "+" iCpbove Top of Casing) 8. TOP OF CASING 1S F'f. Above Land Surface+ 'Top o( casing terminated aUor betow tand sur(ace requ[res � v��i�nce in accorda c Ith ISA NCAC 2C A118. 9. YIELD (gpm): � � METHOD OFTEST 10. WATER ZONES (depth): _ � �^ l:s � O I I. DISINFECT(ON: Type � Amount L 12. CASING: Wall Thickness �Dept t, ia�ygt,er or ' hdFt. avr'al From To � Ft. 7�� . From To Ft. From To Ft. 13. GROUT• Dep Matcria M�c�— From_� To� Ft. � l� From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. 1�. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: I DO HERELiti' CERTIFY THAT7'HIS WE�c L WAS CONSTR CONSTttUCTION STANDARDS, ND FfA COPY 7' SIGNATURE OF PERSON Topographic/Land setting �Ridge OSlope ❑Valley ❑Flat (check appropriate box) Latitude/longitude of well location (degrees/minutes/seconds) Latitude/longitude source:�GPSOTopographic map ' (chcck box) DEPTH DRILLING LOG Fr m � F • io c jp�ipn �ti �� . " 7 � ��, ' ' LOCATION SKETCH Show direction and distance in miles from at least two State Roads or County Roads. lnclud� thc road numbers and common road names. t 336 �~ �� IN ACCORDANCE W1TH I SA NCAC 2C, WELL :ORD HAS BEEN PROVIDED 7'O THE WELL OWNER r NG THE WELL — � —DATE Submit the uritiinal to the Division of 1Vater Quality, Croundw�ter Section, 1636 Mail Scrvice Centcr • Ralcibh, NC 27699-1G36 Phonc No. (919) 733-3221, within 30 days. GW-I REV, 07/2001 / i ► !� 1 •