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A26 28Application Date: g��' �` Tax Map: � Z` �� Amount Paid: 3�0 . d 0 Parcel #: � z�l � � Receipt#: S f 6! 9-2- �� ' �� .Sf �� 6 76 _ _ — - �— �, c� � �1�T � �Y x -�-o �c��u�-��,.-,�„ ��,..�i 1��-.�n.n�� aaY�,� Application for Services (Septic Systems and Wells) 1) Services Requeste y: Name: �� ' � � '� Address: 2 � � > /YI�, f �,, " � /j, �. -� �l � �� li[�1�./n /vG .Z,%S 7'T Phone # (home): .�3 � -�� -'1�� cell): 33�' f"�Z� - ��2,Z' 3 2)Name and address of current owner (if different than applicant): Name: ,o -�-�, Address: ��j �X��Z �.tJ; l s en h/[, 2 7$�f �i 3) Property Description: Lot Size: ��G Subdivision: Lot #: Address and/or directions to Property: Za.f�1S� t 4) Proposed Use and Type of Structure: Residential ___,�__ Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: _Yes � No (with plumbing: Yes �_ No � Garbage disposa : Yes No � 5) Water Supply: Private Well � (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comvleted apnlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): � 1 � Date : 8'-S� l l 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) .`1��,�/ / ' .�1�11+� �1�Y/ V .�q- f ,�q p�y� �~ V `�../ �7��{ 1L JL � ]Lb'�9'a ][• � �rn �e-m� ,� �II.��.11 �l JL ��.� �G�L'� SI'I'E ��TC�--i Name � '1�� 5 5 � �r� Subdivis' n �� ic �, utho�ized Sta.te Agent Ta.g Map #� Pa:tcel # Z� Section/Lot# — _;Y - /� Date System components ne�resent a�iproximcate�contours only. The contructor must, flag the systemprior to beginning the installation to ans�sre that jiropergsrtde r:s maintained � _ �';�+-yi,:� `�U�S�c�S, C.c�t`i'GLi' �n�� li�`��i r'�� ?��" S�7"�7`��' �� .�� :. � � �� . e _ , �._ e � � � � � � � ' �� y�� G. ' � ,�� . � � ��o- .r s »s„�, 3 �;C1� � � � '� ; � �s �� r �� a - � z '��' � � ` w � �. , � �� - �� .� � (� �s' ` �p f/ 3 i . . %'a4. . � � t 'R� . � � I'T'i � �� -� � ,',. �' ��.e�'. , . 2 iq'�j/y� �i s! . �. / � /y. . CY _ " i4' ,' �. . ,. . " . . . f ?/J h "�`� 'y ,..�3. 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' t y,i ,�� z " �tmr� g " �� ` F _�a =�`i . .. , ��; Ny' � . �- � .. . . , � �� . �, � '�. `� �,t�; ,� �� ,: � . � � � �� , � ��- ,�, �� ; ; t, �; { �� , , , �� :� , � � � �� . �.� �� 'y �y �" iu - c�``�� , � � /� � 1 �� x" �, ' � "I % �� '� .,�� s� ti� � . ?�' i '��° 'f_��. 3 �� ' � � , �: � �%S 4r 5��' �� . � - a'�. { '" ^ � �y ��;. . . � ,�-y, �� t, ' " ` � _ � � � , w/ '; �,�{i "� '� � � '�M% � � 1 � c , � ,v'� 'F � � � z � r � � - � '� � � �� v �� i� ii �� /,�,,,,� � i'i/ � H b�� '` � �, �.� .. / ../"� f� �1, A�n a; � i i ��, Jfr i rt & , � � t �� ,� �i� `�v „ ;�i � �'% ' 1 z�`,�' � '� �` y� . . , , " � � �, fi � °� � �'` r? �r,-� �a _� , _�. :�� = �-�� . ., �� ;.� y,� �� . �� r� '�'" a�t t o '=r--��„ v. � � .. ,.� ,_. �.� . .. �. . .. . _ . `.'� � . , ,. . . , � .. �,� , �� 3 S � � � � � ,< s� �%'' � " �� 5�:�-.---'--=-> � �� 1'�t � � � � r��,�"".. «� ,�� — ., � ? yp �l, .x .. � � .� � .w.,— �: `" - ---r—�"'�""' . � � ✓Y �—�� • t+ , � Ca�.+( . _ , }.�:%-�=.�-`_.-_.`---�-- y:,�21 ii � F, ;.,, . ; �_ —. ;�--- `.•�_ "' _.._-- - ;. .,; . {�G� �''t .;;;�.,---- 1, ;:;, �� y �� _ �� _�,., ��{'" � �.f ).L �� `�' � � � �LT�� I�.��a n- � �� .�, ll IE-3L � ,�.11 -� I.I�. � W�+ �L PERMIT (New�p2epai{�� Repiqee sha�ed well o� ,��;�(�bors la�' Taa Map: Z� ?arcel: 2-.� Subdivision: Lot: Applicant's Name: („� a h d Ya,� �O ,� W 0.V '�� E� . L� Mailing Address: o � � � a � Z� Phone Numbers: 331� - S$ 3- $131 �' ►f � - 2 23 I.v rermrt t,�onainons: 1) Se� attached site plan for proposed well location. Z) All applicable State and County Yegulations governing construction and setbacks apply. 3) Permits expire 5 years from the date of issue. Other Conditions/Comments: � A , �. , . , - i P�rmit issued r— I�ate: � '8�— �L CERTIFICAT'E OF COIVIPLE'1'IO1�T lYew Well Inspection: L'nner �spection: EHS/Date EHS/Date Location: 5�� Jd�� I/ Installer: Grouting: Y� 5��, }—�i Depth: Well Log: �� %4 ��% Grout: Well Tag: � �- �1C� Pump Tag: � 1 Well Abandonment: Air Vent: .��5 EHS/Date Hose Bib: ✓' Casing Height: Concrete Slab: Completed: Method/Material(s): _ Well Driller: _ �a�tZ ,_ License #: Pump Installer: License#: Well Approved by: � �� Date: _ Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: ' � Phone:336-597-1790 Fax:336-597-7808 8/1/08 1iESIDENTIAL vvEI,I, coNsrxucrtoN �coxn x North Carolina Ikpartrnen; of Environment and Nahusl Reso�uces_ Division of Water Qua];ty �;'ELL CONTRACI'p12 CERTI�CATION # ��G � -/� '1• WELL CONTRp,CTOR: Wefl Contractor Indi ' � � � � fia .�a�, ( v�dual Name Bamette Well Drillin Inc. Wefl Contractor Company Name 611 Bamette Tinaen Rd Street Address _Roxboro NC 27574 Ciry or Tovm State Zip Code . 3�3_6.� 599-0015 Area code Phone number 2 WELL ItVFORMATION: WELLCONSTRUCTIONPERPof(7'� G� � Ap�(, OTNERASSOCIATEQPERMIT�{i�applicabie) i .2Ff SJTE WELL ID �{dapplicabte) 3• V11ELL USE (Check F,pplicahle Box): Residentiai Water Supply (� QATE DRIi t Fn_ �- ( �- ( ( T1ME COPdPLETED_3 30 At� ❑ pM � 4• WELL LOCATION: cmr. _ �oX bo,,� cour„-,r P �S• � a�77% f�o.�D�l �/lia.n � (Str�t Nane. tvumbers. Comrrwniry. Subdmsion. Lot No.. ParZel. Ztp �e) TOPOGRAPHIC / LAN SETTING: (cherJc appropriate box) + +Slape QVailey Flat GRidge QQ�er lA'fITUDE 36° `�• �{�.�( ^ DMS OR 3X.)ooOUppppc DD LONGf t IIDE �� 3f, (, _• DMS OR 7X.)OOOOOpppc DD Latitudetlongitude sourca: � S (]Topographic map (location of ►iell musf be shovrn on a USGS topo map andattached to this form ii not using GPSJ 5. VYELL OWNER _ i�L-�r/s /�o��.zSo.� Ocmer ►vame � %� % /�0/�bn ��1�/q.►.� � Street pAddress f�o x�o.� - ( a ?� r�-! Crt}r or Tovm State Zip Code t��—? �93-$(3� F+rea code Phone number 6. VYELL DETAILS: r a TOTAL DEPTH: oZ Z(� `�'% b. DOES WELL REPLACE EXIST►NG WELL? yEgv; NO p c. WATER LEVEL Below Top oE Casing: pZ5 �- N52 "+" if Atrove Top of Casing) d. TOP OF CASING t5 � FT. qbove Land Surtace• 'Top of casing terminated aUor below land surtace may require a variance in accordance vhw �5q NCAC 2C _0118_ e. YIELD(gpm):-- '� NlETHODOFTESTBIOW() Z011l f. DISINFECTION: Type HTH Amourtt �/2 CUI� � 9• WATER ZONES (depth): = Top S�O Bottom jS 2 = Top�l�_ gottom l L � : Top Bottom Top Bottom Top Bottom Top Bottom rnick ssl : 7. CASING: Depih Diameter Weight Materiai = Top D Bottom�_ Ft�� D� 2� L ToP� Bottom � 6 Fk ��_ � �$'�f ✓� : Top Bottom Ft 8. GROUT: Depth Material Top_� aonom� D Ft Sand/Cemenl Top Bottom Ft Top Bottom Ft Method Poured 9. SCREEN: Depth Diameter Slot Size Materiai ToP Bottom �_ in. i� Top 8ottom Ft. in, �n_ Top Bottom Ft in. in. 90. SAND/GRAVEt PACK: Depth Size Materiai Top Bottom �. Top Bottom F� Top Bottom Ft. 11_ DRILLING LOG T—�Bo�tpm � 5 _��[u i� ---�—� Z� / / / 1 / . � / / 12. REMARKS: Forrr�tion Description _ v Sd. n�.�. 4 S� � � 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION S7ANDARDS, ANO THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO E WELL OWNER. • � -- �-� 7 � SIG R OF C � IED WELL CONTRACTpFt�� DATE qn C� PRINTED N E F PERSON C NSTRUCTING E WELL Submit wrthin 30 days of completion to: Division of Water Quality - Information Processing, '16'[7 Mail Service Center, Raleigh, NC 27699-161= Phone :(919) 807-6300 Form GW-1a � Rev. 2/09 Report To: North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis . PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: CHRIS ROBINSON P.O. Box 28047 306 N. Wilmington St. Raieigh, NC 27611-8047 htto://sloh.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 2777 MORTON PULLIAM RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES092811-0029001 Date Collected: 09/27/11 Date Received: 09/28/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 10.0 Sample Description: Comment: New Well I (Profile) Analyte Time Collected: 2:00 PM Collected By: J. Smith Welf Permit #: A26-28 GPS #: 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 3 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 020 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium < 1.0 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L _ ---- ... _ _--- --__ - __ Nitrate 1.60 10.00 mg/ ��I Nitrite < 0.10 1.00 mg/ pH 6.6 N/A OCT 11 2011 Selenium < 0.005 0.05 mg/ Silver < 0.05 0.10 mg/ By. Sodium 7.80 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 20 mg/L Total Hardness 10 mg/L Zinc 1.50 5.00 mg/L Report Date: 10/07/2011 Page 1 of 1 Reported By: �e�Gte �%laKeal North Carolina State Laboratory Public Health 06 N. W?m� gton St. Environmental Sciences Raleigh, NC 27611-8047 htto://sloh.ncpublichealth.com M i c ro b i o I o Phone: 919-733-7834 gy Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH CHRIS ROBINSON 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES092811-0075001 � �� (�� ES Microbiology ID: 30778 GPS Number: Sample Description: Comment: 2777 MORTON PULLIAM RD. ROXBORO, NC 27574 Col lected: 09/27/2011 14:00 Received: 09/28/2011 09:00 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A26-28 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 09/29/2011 Test Result Absent Absent Explanations of Coliform Analysis: Analyst Date Darneice Lyons 09/29/2011 Darneice Lyons 09/29/2011 Reported By: Susan Beasley ��G:�-�I � � �� .,_�.i 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.