A25 36I' ,
.,;
�'``'= ' � 0 8 4 2
� PERSON COUNTY HEALTH DEPARTMENT ' �--�
� WELL AN SEW GE STI'E, LOCATION IMPROVEMENT PERMIT
Tax Map # � Parcel # ��
Zoning Tow s ip _ r�: n ��'j
Owner/Contractor l�iS Da� �/_?� �
Location/Address _ ��'l tf' / 3 � � �o S/Z �' / � �; /,� � a � ,-.,�,f- L�.o�.-�
�
a�
Subdivision Name
��
�
_ �� , .,
z�- -
�f �<�
?►�'vc�e tl,�Q� f
C„c� yqp`� � �
0
�
S Q�,kr� /��-i
6
,,
/�
i � -'
�'
� �o<<
� �
`� c
, �
�
`� S.R:
Lot#
�
: ..
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area lS6 a cv�s Size of Tank �����
SFD S/t.,�Mobile Home_� Size of Pump Tank i
Business # of Bedrooms� itrification Line
ax Depth Trenches �� `'
Permit Void after 60 nt s. Permit,Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or i n d u cha ge� d•
Well and Septic Layout by
Comments:
� l 2� �/(o Installed by `� �m Lp.��� Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Weil Log
Well Head Approved Well Tag t�
Grouting Approved
�
�
�
✓ G�'�_
�
� i- y�
This report is b�sed in part on information provided the homeowner or his/her reprccentative in the application submitted for this permit. The �'
environmental health specialist is not responsible for false or misleading information contained in the application. The enJironmental health
specialist is also not responsible for concealed conditions on the property or for statements in this repon 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 01/95 rev.1.0
North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone(919)733-3221
��
ti
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
FOR OFFlCE USE ONLY,
QUAD. N0. SERIAL N0.
Lat Long. RO
Minor Basin
Basin Code
Header Ent GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Sho sketch of the location below)
NearestTown: Q���DPn County: �25�-
(Road, Communi ofj S�ubdivision and LoLNo.) DEPTH
2. OWNER ��P ,�) I1 S From To
ADDRESS I c��Li
� (street or oute No.) �'„� L� � 3 D
�n n�,�,
City or Town State Zip Code
3. DATE DRILLED USE OF WELL `
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO❑
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
7. STATIC WATER LEVEL Below Top of Casing: �_ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS�_ FT. Above Land Surface*
* Casing Termfnated aUor below land surface Is illegal unless a variance is issued
in accordance with 15A CAC 2C .0118
9. YIELD (gpm): METHOD OF TEST G 4
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING:
DRILLING LOG
Forma6on Descrip6on
u.` �
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diarr�e er or Wei UFt. atenal (Show direction and distance from at least two State
From—�--To � Ft. Ja--�� ��� Roads, or other map reference points)
From To Ft.
From To Ft.
13. GROUT:
Depth Mater'al Method
From _..�._ To �� 3 Ft. � ���'' ��
From To Ft.
14. SCREEN:
Depth
From To
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To —
From To—
16. REMARKS:
Diameter Slot Size Material
Ft in
Ft. in
Ft. in
Ft.
Ft.
Size
in.
in.
in.
Material
I 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.
v�i�-J i�Gi�� q-��-��
SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 REV. 9/91 Submit original to Division of Environmental Management and copy to well owner.