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Date• - -� '
Owner �
Location/D' ctions:
M�l�(
Subdivision �Name:
Drilling Contractor:�
PERSOH COUNTY ENVIRONMEKTAL HEALTH
WELL LOG
SR#
��
Lot #
. �..• r"'w'''�
'��,�� K.
• . . J
, � .
WELL CONSTRUCT'ION `-'J --
Distance from Nearest Properry Lin� �v Distance from Source of
Pollution / G� '
Total Dep.th_ �c'� Ft. Yield: „3 __� GPM Static Water Level_��=�.
Water Bearing Zones: Depth CQO _rt.o2�S Ft Ft� ��,
Casing: Dept}i: From�_to .� Ft. Diameter: Inches
TYPE: Steel - G2lvanized Sceel �_�
If Steel, does owner app;ove: Yes No
� Weight: Thic�;ness: i�A Height Above Ground:�� Inches
Drive Shoe: Yes �No
Were Problems Encountere.d in Setting the Casing? Yes No_��
If "ycs" give reason:
Grout: Type: Neat Sand/Cement ..� Coricrete
Annular Space Width Inches
Water in A.nnular Space: Yes No
_ .. Method: Pumped . .. Pr:ssure � Poured_ ,/. - � �. ..
Depth: From �_ co_ -�_n Ft. , . .
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttinos) - Ratio: �o
�ID Plates: Yes No � � .- �
�� 4 x 4 slab Yes No �
J
I HEREBY CERTIFY THAT THE ABOVE INFORM�'IZON IS CORRECT AND THAT
THIS WELL WAS CONS3'RUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Li�ITY HEALTH DEPARTMENT.
�" 4�� --
ignaturc of Contraccor D1tc
�..
. • � PERSON COUNTY ENVIRONMENTAL HEALTH
'� ` PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��� Parcel # � % TJ
Zoning
LocaUon:
Township «�%i{�%l��/�� �J'///
/�� /� � /��%
Subdivision:
Type of Water SupplV:
Requirements•
Sectlon:
Well Permit
�/ Individual Community Public
Site Approved by ���
Grouting Approved by , (D�O
Well Log ✓ 2—! a—oa
Well Tag�/,y
Air Vent �
Hose Bib
Concrete Slab �-
► � - � . . . - . : . � , /_��� , ��.i�/ ' - '
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
�l�h
��S
nc depertment
of 6ealth and
human services
� ������� ������� �' �����������
n "�._. !� �� � � N .
� ���� ���� � �a�� ����������:A�,������
For Inorga�ic Cl�emical �ontaminants
Counh'� ��r �PS c� rS , Name: /1/�.�2t 'A N�C �
Sample ID #: Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
1. Your wel i water meets federai drinking water standazds for inorganic clteinicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2. Q 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 inorganic chemical results onlv. �
Arsenic � � Barium � Cadmium � Chromium
NitrateMitrite I Selenium I Siiver
Lead Iron
Zinc uH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory leve) for sodium of
20 mg/I. 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 inorPanic cl:emical results onlv. .
❑ b. Levels over 30 mg/1 may pose aesthetic problems 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 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.
6. ❑ The following substance(s) exceeded federa) 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 � lron
Maneanese Selenium Silver pH Zinc
Fnr niore information regarding your we!! wnter resulis, please ca!! tlre Nortlr Carolina Division of Public Health at 919-707-5900.
❑
North Carolina State Laboratory of Public Health 3�12 Dist?ct Drive
Environmental Sciences Raleigh, NC 27611-8047
htta://sloh. ncaublichealth. com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH MARISSA MCCAIN
325 S MORGAN STREET
2561 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES020717-0013001 Date Collected: 02/06/17 Time Collected: 10:30 AM
Date Received: 02/07/17 Collected By: H Kelly
Sample Type: Raw Sampling Point:: Well head Well Permit #: A25-198
Sample Source: Well Temp. at Receipt: GPS #: .
Sample Description:
Comment
CA Well Monitoring (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Aluminum < 0.500 3.5 mg/L
Antimony . < 0.002 0.001 mg/L
Arsenic < 0.005 0.01 ma/L
Cadmium
Calcium
Chloride
Chromium
Cobalt
Copper
Iron
Lead
Magnesiur
Manaanes
Potassium
Selenium
Sodium
Total Alkalinity
Total Dissolved Solids
Total Hardness
Total Suspended Solids
um
< 0.1
G
3
0. 002
19
8.60 250
< 0.001 0.01
< D.009 0.00'
< U.1 U
< 0.005
6
0.015
< 0.0005
< 0.010
< 0.01
< 1.00
< 0.01
11.60
< 0.50(
< 5.00
< 0.000
71
40
72
<5
< 0.000.
nc <
Page 1 of 2
0.015 mg/L
mg/t
0.05 mg/t
0.001 mg/t
0.018 mg/t
0.1 mg/L
N/A
mg/l
0.02 mg/L
20.0 mg/l
2.1 mg/l
250 mg/l
0.0002 mg/t
mg/L
500 mg/l
North Carolina State Laboratory of Public Health 3° DistrictDrve
Environmental Sciences Raleigh, NC 27611-8047
htta://slph. ncpubiichealth. com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH MARISSA MCCAIN
325 S MORGAN STREET
2561 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES020717-0014001 Date Collected: 02/06/17 � Time Collected: 10:30 AM
Date Received: 02/07/17 Collected By: H Kelly
Sample Type: Raw Sampling Point: Well head Well Permit #: A25-198
Sample Source: Well Temp. at Receipt: GPS #:
Sample Description:
Comment:
Hexavalent Chromium (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Hexavalent Chromium < 0.05 0.07 ug/L
Report Date:02/14/2017 Reported By: .�Cennet!'i y'reene
CAMA = Coal Ash Management Act
Page 1 of 1
m
Tax Map
Owner: �
Address:
Location:
Type III (b) System Inspection Checklist
Parcel # : � � � PIN
%A �(�c� i n Subdivision:
_C�4`Qn� 1�`����D Ph/Sec/Lot•
YES
1) Establishment
a) type, size and sewage flow in []
accordance with permit
2) Tanks
a) tank risers accessible and surface [,�]''
water diverted
b) tanks and access manholes structurally [.�'�
sound, watertight .
c) sanitary tee(s) in good working conditian []
d) tanks pumped, cleaned out as needed []
3) Effluent Dosing Svstem
a) effluent appears clear, free of excess solids []
b) required pumps piesent, operating properlY [„Y'
c) high water alarm present, operating
properly � �
d) floats, pipes, valves, disconnects in good
working condition, operating properly [ ]
e) control panel enclosure and components
in good condition, operating properly [v]�
fl Drawdown rate• �„�— �r► 2_
4) Ground Asorntton Fieldfsl
a) no evidence of effluent reaching surface
or surface waters [ �
b) surface water being effectively diverted
away from drainfield [v}�
c) diversion ditahes, swales, tile drains aze
well maintained [ 1
d) soil cover, vegetation adequate and
maintained as needed [�
e) protected from traffic and destructive uses [�
fl distnbution devices in good condition,
working properly [ ]
g) repair area properly reserved, maintained []
h) pressure head properly adjusted []
Summary of Improvements and/or Repairs Needed:
_ .. . _ n �
NO NOT CI�CKEU REMARKS
��
��
[I
��
• oa
;A�,ount pa�id ���• � � _ ����
Recaipt l� '�'�� Date
. , � .
Or�
cr
y
�
a
w
U
�
a
Permit requested by: . n 7. Dimensions or Proposed Structure:
�vner/prospective owner/agent: /�- A� ( � Width: � i
ddress: ►�� � �3� � i �– Depth: �-o
— � ?°°y �� ; � � �• �- � '" � � – 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
.ome Phone #: ? 6 – 4' – � � � �/
I Q�- �on4 //l �/f"�
usiness Phone #: � �'� ___
Name and addre�s of current owner: C'p- � 9. Water supply ty pe:
' � private �': public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�
If so, identify location:
3. Property Description: Lot size: f� o��'�
�
Tax Map#: �- - �-�
ParceI#: J 9 0
Townshio: G_ �,.h�-���
�
. Directions to property: State Road #& Road
.S� /3 3 6
GL � �i n � b. ,�.,.�
Number of occupants or people to be served:
10. Type of structurelfacility: Proposed: L�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: G�-Business: ❑
Type of business:
Number of Employees: ,�,�'( ;+�%�
Number of bedrooms: �- ,�°
Garbage Disposal? Yes � No ��'
Basement? Yes ❑ Nofl'If so, # of basement fixtures:
�S . A5
CLEARLY STAKE ALL CORNERS OF TH�E PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
hereby make application to the PeI'SOn COunty Health Department for a site evaluation for the on-site
�ewage disposal system for the above described property. I agree that the con�ents of this application are true
�nd represent the maximum facilities to be placed on the property. I understand if the site is altered or the
ntended use changes, the permit sha11 become invalid. I understand that before an Improvements Permit can be
ssued, I must present a survey plat of the proper[y to the Healch Dept. I understand that in the even[ I have not
ielivered a survey plat of the property to the Heaith Dept. wi[hin 60 DAYS af[er the date of the evaluation of
he site by the Health Dept., this application shall become void and all fees paid forfeited.
��� � ��
Signc� Owner or Authorized
` g 3036
. � . __..
, .; .
� � PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
, has been issued.
�
a
W
�
a
�
Tax Map # �Z� Parcel #
Zoning Township
Owner/Contractor
Location/�ddress
ivision Name
SFD
Lot#
SEWAGE SYSTEM SPECIFICATIONS
%Lot Area � ��j a'(,, Size of Tank.
Mobile Home� Size of Pu
# of Bedrooms f� Nitrificati�
Max Depth
Permits may be voided if site is altered or intended use
Well and Septic Layout by , qr �, �1}? , j �
Comments:/�/�,��{" -r1.i� � —SI . ���1
by Z- -�5 -
- � - ..
,
by
Well Permit Paid ❑ WELL S'YSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab ZS—
Public Re lacement Air Vent —
Site Approved�,�� Z ZS'��D Required Well Lo 2'/D —�
Well Head Approved � ZS`DD Well Tag �
Grouting Approved ,��/(�J11� � 2��'��
r.
Date
1
Installed by
/0�
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or mislea�ding information
contained in the application. The environmental health specialist is also not
responsible �or concealed conditio�s on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
Aaaiication Date: � z-3 v >
Amount Paid•
RecEipt #•
Tax Man #• �7�
ParcE� #• � I g
� �,���� �� ���� ��
. - - - _ -�-^ �: � g.T� � �lt.�
� aavaram�as�-TM� maa�mll �ao.m,7L-�71a
APPLlCAT10N FOR SERVIC�S �
CONSTRUCT SHALL �ECOAflE INVALID.
1) Permit requesiec�b : (Owner/aE
Home Phone: ��
Business Phone:
Add�ess:
2) Name and address of currerrt owne� �(��� �
C��.��
3) Property Description: Lot size: � � Township: ubdivision: Lot #
Directions to the property (including road names and numbe .
4)
5)
P'roposed Use and $truc#ure �scription: answer each of the foliowing questions:
a) Proposed . Exis�ting t/ TYPe of Structure: 1lyidth: � Depth: �,
b) Number of 8edrooms: �� �. Number of occupants or people to be served: �_ :
c) Basement Ye�_, No _�Will thgce be plumbing in the basement?�i'C
d) �arbage Disposal: Yes ��. No V '
Water Suppiy� Type: Private v(new _ or exis�ng�; Pubji�_, Community , Spring _
� Are any welis on adjoining property? Yes_ No � If yes, piease indicate approxima#e lacation on the
'site pian. � . ' �
fi) Does your property c�ntain previously identified jurisdlciional wetlands? Yes No_
PLEASE NO'TE THE FOLLOWING: �
➢�► PLAT OF THE PROPERN OR SITE PLAW MUST BE SUBMITTED WITH THIS APP�iCAT10N.
9 PROPERTY LlNES AND CORNERS MUST BE CLEARL.Y MARKED. �,.
➢ THE PROPOSE� LOCATION OF ALL STRUCTURES MUST BE STAi�D OR FLAGGED.
➢ YHE SITE MU$T BE READILY ACCESSiBLE FOR AN EVALUATION 8Y THE HEALTH DEPARTMEiVT
STAFF: �
( hereby make appEication to the Person Caunty Heaith Department for a site evaluation for the on-siie sewage disposal
sysiem for the above-described property. I agree that the cantents of this applicatio� are trve and represent the maximum
faciliiies ta be piaced on the property. I understand if the siie is altered or the intended use cf�anges, the permii shali
hec:rmdiE± invalid_ �. �n � /1
�l
or
� 6��
Date
PCND, re�. 06J27102
Person County Health Department
Environmental Health Section
Tax Map #: � 2� Parcel #: �� �
Zoning: Township: G%�-G1V11 f/y,j�GL�M
Subdivision: Section: Lot: ,��j��✓
Applicant: YJ�(��l� ����L�4'll�i'��
Location: LU(� � ,�� IV1l �� �. � I Dll� /!/d%) ��1I �Dl� �VC �� �%{�D�G�` `�
Operation Permit
System Type (In Accordance With Table Va):
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.
�,���.�� • ��/1�i1'�1��'�(J�'' � J �� �d
Authorized State Agent Date
I'ov���,y Co�f �-�
Tax Map #: �}"2� Parcel #: ���
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Townshlp: � l R 6'YI
Subdivision: Section: Lot:�,'' J
Appiicant: F�u,b�Q.,�( 7VIDl1��
Location:� � �P S��
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �
B) Distance from system to any welfs 7/00'
C) Distance from septic tank to foundation �'
D) Distance from system to property lines =lo'
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank t/
B) Visually inspect the interior walls, ffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture '��' !-5
D) Tank serial number S� bC0 - 2
E) Liquid capacity of tank I� I?DD gallons
3. SUPPLY LINE TO 7RENCHES
A) Grade ��C�{'�GLlUq�1/8 inch per foot minimum)
B) Material supply line s constructed from �'.l�l 4f� pUL
C) Diameter 2'�
D) Length �eP
E) Distance from tank to ainfield/distribution device e� II'�ij
✓
4. DISTRIBUTION DEVICE(S)
A) TYPe u ti ��L� , .
B) Is Device water tight ��
C) Distance from the distribution device(s) t� trenches S�� G'�rQiliUll�la
D) Is the device on a level foundation
E) �oes the device perform according to its desi n specifications N��
F) Record the inlet and outlet elevations ��i�G{�Wl�l�
5. NITRIFICATION FIELD
A) Trench depth I� inches
B) Trench width � inches
C) Distance between trenches 2q' D�l Cel�l%
D) Number of trenches 5
E) Length(s) of trenches ��10', �f7�,7�!' , 67'
F) Aggregate depth � inches �
G) Aggregate material and size
H) Record septic tank outlet elevation �
I) Trench gradeS��A�lll�i_ _(< 1/4" pe 10')
J) Step downs
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down
a Solid pipe used ✓
d. Elevations of step downs � (Record elevations and show on as built)
See "as built"�p al 1n on attached sheet.
PCHD, rev. 10/12/99
�/��/C� `7 �iyl� fir� ✓/`�''��f'��� � /l�r, . �'G/,r��
� �ll
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