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A26 341 � Aaplication Date: �rl��^-- Amount Paid: �� Receipt #: �� Person Countv Health Department Environmental Health Section APPLICATION FOR SERVICES Tax Map #: Parcei #: .� IF THE INFORMATION IN THE APPIICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED. OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested �by•(Ownerlagent/prospective owner): �� k L�f c� 1 v c' %Til !1�►�/5�.,'� Home Phone: �.6— �� —%?'�`j Address: � �' � � �� Business Phone: /�- S4� —p�7 / j � : r' 2'�.�� / 2) Name and address of current owner: �� v'�� 3) Property Description: Lotsize:l+��Township: L; �/d; (,� �wn�s%ylP �� v° / Directions to the prop��in� 4� g ros�ames and numbers):/L�p ✓'N � . r d � � � 4) :J � i i: � �✓C i L 'CO L�� I�if p-J+V\ /�/v s � �L .�2� �✓v � Proposed Use� Structure Description: answer each of the following questions: a) Proposed-� Eyx' ting ❑ b) Stick Built�!IVlodular ❑, Singfe Wide ❑, Double Wide ❑ � c) Number of Bedrooms: ,��`- d) Number of occupants or people to be served: e) Basement: Yes-� No � If yes, # of basement fixtures: O � � GarbageDispos?I:Yes�No�]'-.8�'`2't- �'- 7-�n?,�. _ _ _ g) Dimensions of Propos d tructure: Widtt�, Dep ��'y 5) Water Supply Type: Private �(new 0 or existing ❑), Public 0, Community ❑, Spring ❑ Are any wells on adjoining property? Yes,�j No ❑ If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) Conventional _Modified Conventional _ Altemative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid.l understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the H part ent if my property contains any wetlands as designated by the Army Corps of Engineers. G Jo 0 wner or Legal Representative Dat PCHD, rev. 10/12/99 , :`��,�� `iy�.`___.. ...... _._. . �� . � � ��y�,�7� , � �Y3'`p'S�t•em�,.�q0713� ��0�.1l�cJc3 SiZ'E S�TCH - .. 1Vaine cJ� %�o Sub ' ' ion Authorized State Agent Taz Map #� Z(�Patcel #-3__y __ Sectia:n/Lot#,E ____�� -��-------- Date System cumpo�ts s�e�iresent a�i,�roacimate�contours only: The coni�actor must. flaS the syste� prior to beginning the installafion �to i�sure thatlbrolbet'bmude u' maintained � �hi-h'aI S �h'1 .� ._ _ _�g��,� � Q.... . . _ / �. �.---------.. p�---- ... _ ___. _ _ . . _�.. . . . _ .. ` ZiDd � /-�CC�. � p-�ux o� se�� y ``��1, ��.s � S L 4 �. � L2 �;-�b�Qr � c��2S shau� . I b�- �a��Ce.� Pr� �1� -� cn +� i Y� 5-�� ( a�i or5 CWe�� "S �, ,.Coates � 9--62 � �,o .. � �__„� � _� .�,... _.. _ ::�.�.;�.. ,r _ � 2�3g N � �� 1`�'�' - �y�� ' 1,�� s�� cs .��'��',,c � �� . �•� a�� -,- o / ",' L�9 - o,.. C R �� CT� 1��' �� ', / �� V- , /. , d �15 �� . �°a � v `�a�,e , P'� 5ai ��.�` D=11-SO-58 R-48�.81 ARC=99.64 �� L13 s�� l,, V �o � � APR-13-2011 10:01Awi FROIA- �/�'/(� �� Sp.`r'O r-ooa P.00vuu� rorr � AppL';,ation yate: -Z Lo- I l l l � C.�, '1'au Map: � Amvunt Paid: � ,OU � /S/Z. Parcel #: --13� Receipt#: ,5 l0 � I N � 1( .5'0 � � �g��. � 6 p�,t� � 3v� �� / �3 e�llh9� �`� ._ f �� -�� ]C�'.�►riia�osrasza.Gap.�Em]L 1�-3L's�mll�]!a . Application for Services (Septic Systems and Wclls) Q! Improvement Permit (Site Ev� �� S200.00/5300.00 (if> 600 D Mobik Home Repl�cement or 5150.00 (if siu visic requiu D Wetl Permit (New/Replacema $30Q.00/5200.00/�75.00 � 1) Servioes Requested by: Name• I-lu � }-) � N�- Addmss: pa l3c�c /3 G� P�j�i'3ayro R�C. �.� s -�3 the tva� of � C�11 a � c�y �� n�� v�� c� � Mee,�- \ Repair of Existiag Septk System Applicarion: No Charge/ CA 5150.00 or 5300.OQ Phane # (home): (workkeln: _ 2) Name and address of cnrrent owner (if diit'erent than applicant): N��: J�rZ•J r'!Uo i2c Address: 3) Properey bescription: Lot Si�e: l.3 `� Subdivision: Lot #: Address and/or directions to Property: __ _ 4) i'roposed Use and Typc of Strnchire: Residential �_ Bus' essrCype: Other Number of bedroams / Number uf people served (seats/employees): __.__�_ Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Ycs � No � 5) Water Sapply: Privace We11� (Proposed Exiscing _� Community e!: P.ublic Water System: Are there wells on the adjoining ptoperties? No Yes (plcase show location on site plan) Note: A comnleted aaaGeation n�ust also include: t A plat/site plan of the property lhat shows property dimensions and ihe size and location of aU proposed struclure� D� sig.red copy ajthe `Lot Preparation'form verifying thart �he property is ready [o be evaluattd I am submitting this apptication to request services from the per.�on Coanty Heaith Deparinnen� Y understand that if the iaformation provided is ineorrtct or if the site is sabsequently xlttred, or it t6e intended ase chsnges, all permits und approvals e6a11 beeome iavalid. Sigaature (Owner2e�a1 Rspresentative)s ' A�tr � ' 2 `� 10/08 Person County Environmental Health, 325 S. Morgan 5t., Suita C, Roxboro, NC 27573 (336-597-1790) � �.._.�� ,)� f �� ►-, � ~ �� 1.� � � � � � Jl� 7t7L�"717P �CD 7t'Il.7I7Y71 cF� 7t7L��A. JL 1L Jl �L a211. �L �1t� } T�x Ma� i , P�rc�el # Su�bclivision Ph�se Sect�ion Lot # Permit Valid for Type of Facility: _ # of Occupants �Y Proposed Wastew Proposed Repair: 1'� � #ofB System: �� Improvement Permit No Expiration Y� �� New _ Addition _ s 1� Projected Daily Flo�,v tl�b,_ A^ i r Permit Conditions: /ulnih-�'a�h �� S��f��+C�.S Owner or Legal Representative Authorized State Agent: _� ,' Water Supply��, g.p.d. _ � Type: � Type: - Date: �P - -�i ' � Date: ��, — Z' /, The issuance of this pernut by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and Rules far SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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. Authorization to Construct Wastewater System (Required for Building Perm�t) * See site plan and additional attachments (_). 1 Propose astewater System: ..�C;Ci'i�2ic�� ;Zr`�':J vF(/��i�Y, Type W^stewater Flow %g� g.p.d. �� air Ex a ion �� Soil LT �� g.p.d./ ft 2 New Rep p Type of Facility: rt�lG��2 �e,Si� Y. Basement _ Yes _ No � Tank Size: Septic Tank: �_ gal Drainfield: Total Area: ZOc� sq ft Wastewater System Requirements Pump Tank• —r Total Length �� ft Trench Width � ft Minimum Soil Cover: _�_ in Distribution: �Distribution Box 1/ Serial Dist�ibut gal Grease Trap: �gal Maximum Trench Depth � in Minimum Trench Separation: �_ ft D.�o�enrn Manifnlrl Specifications: / Authorized State Agent�� Permit Exnirati n Date: 1n - lo - Date: �%% The type of system permitted is ventio 1 f� ccepted Alternative. I accept the specifications of the permit. , l Owner/Legal Representative: � Date: PCH rev.11/10/OS K �� ? �� Xt \1-� �� l�.n.-n.�a �- � �-�. � �. � �.Il IHI � �.11 �1�. d�I.,L PERMIT (New ►/ 12epair� Taz Map: Z4 Parcel: Y Subdivision: Lot: Applicant's Name: %��2 �j . ��er,��/ i� oo�, Mailing Address: Phone Numbers: Location of Property: Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply.� 3) Permits expi�e S years from the date of issue. Other Conditions/Comments: - Permit issued Date: �e ' <�' �� CERT'�I'�Ct�TE OF COld�LE�Ol�t New Well Inspection: Location: Grouti.ng: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: �� Liner Inspection: EHS/Date Installer: Depth: Grout: Well Albandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: . �r'^� License #: Pump Installer: �� License#: Well Approved by: I�ate: Z�2 ( i Date Sample Collected: Date Results Mailed: '� Person County Environmental Health 325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-78Q8 Roxboro, NC 27573 3/1/08 ��,s. f ��.� �� - - ., � � �� I��a-��.��.��.Il IC-33L � �.IL�7� Tax Map � Parcel # 3 f� Subdivision Phase/Section/Lot # # of Bedrooms . �� ,� ,� ,, • � r, . �� • ,. '�- t�_ _ � i_ / � Operation Permit System Type (From Table Va): t Product (IIIg): y�. x'-r,a�,�_ 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. ��,J.� �, �orized Agent) L��.� (Licensed Contractor) 5/�/ i r ��Ts � coo ��.1jAJ�� Sr' 3 3z.�. 1 � i �p."'1 � �o� ��a ,, .��. - a � � . ---� -- ,y �-,��.�- .� -�"a �L¢ST �.Ip�f� � .er'j �.� �. rv,y � �� 1 �2 �' � � �J�� _. _ _. s�ale: _�/r�� O � � /, � � � � _ (Date) , /� • �r � -�—,.✓!>l� �1�. o� ( ate) Siy►�t, �.tidd f9 �✓N�V?��f�v�� l/(r�g D�1 $% 1 ` � ! . N,� w�if•� iN ��s $u1' �i�✓f5 �� i`�`►�� j?uv�t.ltif£� �" �a/L� ��yj• Tax Map: � Parcel #: 3� Septic Tank System Checklist (Type II-I� System Type: Notes: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: •�.��,�� •. �.��/ �••_..— .`: _'___ .^- ��. .Y �^ � ^�� ^ � � �g�7T�� 'r•-]m'P37[•man��.w�B713��.L. �LJL�O��c�7L SITE S�TCH Name �e�'N l�o�ar-Q Ta.g Ma. ## . Z. . Pa:tcel 3 Sub ion � �--�-- �—�--- . � Section/Lot# ' __ � �D — �. ) • Autho�ized Sta.te Agent . F Date System camponents stepresent alb�roa�itmate�contours only: The conirrtctor must, fTag the sys�tem1brior to beginning the instaAa!'ion to insure that propergmde rs maintained � �h�-�ia ( S S�en1 .. . �.�-- _ t�gc� , �l � � Q . . � --__--__ _ � 9 p____ __ ._ _._ _ ..�.. _ _ _ _ __ 1_ — Ll oo �� r � p-b� ,� s�� o� o � '�� `�re�c� �j�a�u.S � Jr L 4 _� � �____ — `" L3 II L2 � (b � I (��25 s�lauld � b�- �Y1a�IC�.� Pr� o� -�-� �n � 1 Y� 5�iu� � ec� crS , �we�� s�p fi�� ,COO�teS I �9-62 � 1 LQ .�� . oa a�� e � .��. . , Q,�� 5�s ` � � �1 � �._ �::o _ _g� �� 3 1`� � �,Qk�. � y��- � 1, � 8 ,��`� � : � �'s � �'"��t`�u�-t� 'D a - i �� 1 �A'.ti ,� � / I D -'• . ��.� D=11-SO-58 R=481,81 ARC=99.64 � L13 ��, �,� ��a a S � � � P � ,: �:. r �� . � ^ ' North Carolina Division of Public Health �' � Occupational and Environmental Epidemiology Branch, Epidemiology Section INORGA1vIC CHEMICAL ANALYSIS REPORT Private well water information and recommendations County: Location: , `r°y Name: �Y' Sample Id Number: � 36 a�3! Reviewer �� ANALYSIS REPORT Your well water �vas tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinking water standards. The pH is a measure of the acidity of the water. Drinking water may contain substances that can accur naturally in water or can be introduced into the water from manmade sources. TEST RESULTS AND USE RECOMMENDATIONS , Your well wat�r_meets federal drinking water standards. Your water can be used for drinking, cooking; .. washing, cleaning, battung, and showering. . The following substance(s) exceeded federal drinlang water standazds. 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 want to install a household water treatment system to address aesthetic problems. Bazium Cadmium Chromium Fluoride Iron Ma esium Manganese Selemium Silver Sodium Zinc H The following substance(s) exceeded federal drinking water standards. We recommend 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. Arsenic I Barium Chromium Silver Re-sampling is recommended in months. Fluoride Lead Iron Sodium Zinc vH 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. OTHER CONSIDERATIONS 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 replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. ` For further iaformation please contact your county health department or the Occupational and Environmental Epidemiology Branch at 919-707-5900. � Revised January, 2011 ...+� North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: � Name of System: PERSON CO ENVIRONMENTAL HEALTH JUDITH BRITT P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://si�h.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 325 S MORGAN STREET SEMORA RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573 EIN: 566000331 EH StarLiMS ID: ES092811-0030001 Date Collected: 09/27/11 Date Received: 09/28/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 9.0 Sample Description: Comment: Time Collected: 2:15 PM Collected By: J�S � � Well P mit #: A26-34 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 29 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.32 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese 0.32 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.8 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 11.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 110 mg/L Total Hardness 88 mg/L Zinc 0.38 5.00 mg/L Report Date: 10/07/2011 Page 1 of 1 Reported By: �e�ie r%%loKeol .�. . . � ._ . .. . . ... . -. . :c ... . North Carolina Division of Public Health ,• • Occupational and Environmental Epidemiology Branch, Epidemiology Secrion ' BIOLOGICAL ANALYSIS REPORT Private well water information and recommendations , County: �-�f� Name: Y� Satnple ID Number: ;3 d? Location: Reviewer _�!''��. Initial Sample Confirmation Sample BIOLOGICAL ANALYSIS RESULTS AND RECONIlKENDATIONS FOR USES OF YOUR PRNATE WELL WATER ('These recommendations are based on biological analysis only.) No coliform bacteria were found in your well water. Your water can be used for all purro es including drinking, cooking, washing dishes, bathing and showering. � Total coliform bacteria were detected in the sample which indicates that hannful bacteria from human or animal waste could enter the well. Do not use the water for drinking or cooking unless it has b n boiled for 3 minutes. You may use your water for all other purposes including washing dish , bathing or showering. Your well water needs to be re-tested to verify that the result is accurate. Fecal coliform bacteria were detected in the sample. Do not use the water for drinlcing, cooking, washing dishes, bathing or showering. If the re-test shows contamination by bacteria contact your local health department for assistance. 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 problein. Your well water was tested for biological contaminants (total coliform and fecal coliform bacteria). The results were evaluated using the federal drinking water standards. Drinking water may contain substances that can occur naturally in water or can be introduced into water from man-made sources. Total coliform bacteria aze found in soil and fecal coliform bacteria aze 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 properly disinfected. 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 physician of these results at your next visit. 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. For further information please contact yow county health department or the Occupational and Environmental Epidemiology Branch at 919-707-5900. Report To: North Carolina State Laborato Public Health P•O. Box28047 � 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 http://sl�h.ncoublichealth com M i crob i o logy Phone: 919-733-7834 Fax: 919-733-8695 _�_._ _-----,-- ----CertificateofiAnalysis -___ ____ -_ __._._ __ _._ ______ __ PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES092811-0076001 � �� (�� ES Microbiology ID: 30779 GPS Number: Sample Description: Comment: Name of System: JUDITH BRITT SEMORA RD. ROXBORO, NC 27573 Col lected: 09/27/2011 14:15 Received: 09/28/2011 09:00 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A26-34 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Total Coliform, Colilert E, coli, Colilert Report Date: 09/29/2011 Test Result Present Absent Explanations of Coliform Analysis: � ..z � � , :� R .� _ � .,�. �..- . . , ? � ___.__._____...__ _y r ' � OCT ._ 4 201I � - �...___._.,.� _� �; .� 1 '� :,.1. ..., �;yti,C 'rj`_: . . _., o.'a ..i�i�Vi�'vi �1 a ' .ri� li�.:;i � ..r `. .�,.. � . ..!j �ii:.� �� b�� L�1 - ` , '`' �' — Analyst Date Darneice Lyons 09/29/2011 Darneice Lyons 09/29/2011 ported By: Susan Beasley 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. : -�.;a ST/\Tf„ �, , ; � Pr`+ ��'.;Z+�n: � ;� ;> .� � A � '�I'` /cQ. :_� •..�.:.'' �:- �,�� RESIDENTIAL wELL corrs�ucriorr �coRn c North Carolina Departmen. of Environment and Natural Resources- Divisio of Water Quality WELL CONTRACTOR CERTIFICATION # �� b� PT" 1. WELL CONTRACTOR• 1 q � � �/6n Well ConVactor (individu I) Name Bamette Well Driliina Inc Welt Contractor Company Name 611 Barnette Tinoen Rd Street Address Roxboro NC 27574 City or Town State Zip Code . 3c 36 � 599-0015 Area,code Phone number 2. YVELL INFORMATION: �� WELL CONSTRUCTION PERMIT# R OTHER ASSOCIATED PERMIT#(if applicable) � SITE WELL ID #{rfapplicaWe) 3. WELL USE (Check Applicable Box)_ Residential Water Supply p" DATE DRILLED_ �'� 2 ' � � TIME COMPLETED ( v 30 AM �PM ❑ 4. WELL L ATION: CIN: p / O COUNTY C/ r1 (Street Name, Numbers, Community, Subdivision, Lot No_, Parcel, Zip Code) TOPOGRAPHIC / LAN SETTiNG (cheGc appropriate box) ❑Siope ❑Valley lat ❑Ridge ❑Other LATITUDE 36 ^�� DMS OR 3X.XXX)OIXXXX DD LONGITUDE�_° �� `r DMS OR 7X.XXXXXXXXX DD Latitude/longitude source: PS Qropographic map (location of.well must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OWNER C � �G � �i � Owner Name - � % �V CpT ��N/?p �'/uc /'t'(�I Str�oXb��t� - Ql. C. d� 757�1 City or Town State Zip Code 3r 3 C, S�`rs- ev �y Area code Phone number 6. WELL DETAlLS: �J /� a. TOTAL DEPTH: �L � T '� b. OOES WELL REPLACE EXISTING WELL? YES ❑ NO � c. WATER IEVEL Betow Top of Casing: v2 S' FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS � FT. qpove Land Surface' 'Top of casing terminated aUor below land surtace may require a variance in accordance with '15A NCAC 2C .011 S. e. YIELD (gpm): _ l� METHOD OF TEST BIOWCI ZOfll f. DISINFECTION: Type HTH Amount 1/2 CU D g. WATER ZONES (depth): Top�� Bottom tZ Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom Thicknessi 7. CASING: Depth Diameter Weight Material � TopQ_ Bottom�_ Ft. ��v SD'P-21 Q V� ' �_ LLJ1L• _ Top�� eottom� 2_ Ft. � . Top Bottom Ft. 8. GROUT: Depth Material Method Top�_ Bottom � � Ft. Sand/Cement Poured Top Bottom Ft. Top Bottom FL 9. SCREEN: Depth Diameter Stot Size Materiat Top Bottom Ft. in. in. Top Bottom Ft. in. in. Top Bottom Ft. in. in. 10. SAND/GRAVEL PACK: Depth Size Materiai Top Bottom Ft. Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bottom /,�— / S /� � � / 325' / / . � / / / 12. REMARKS: FormaUon Desaiption %,b So: 4 S nC I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AIYD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. �'�Z-�' �� CER IED WEL�,CONT�TOR DATE �� y PRIN D NAME OF ERSON CONSTRUCTING THE WELL Submit within 30 days of compietion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Maii Service Center, Raleigh, NC 27699-961, Phone :(919) 807-6300 Rev. 2109 � Z � /r� ��, �� D�t.P � � l � ��% . � � �� 'c��, ��{— �-a�� -�.�2 �� tc� o � ly �2� t ��` "� r�_ �n � b(�( �� W � � � � �a ��'S �- :,�� .- � � _ � ��r � .��,,,�,.,��,. ��,�-� w�� f�� E�� f�. �'�e � ' �►`s �r4 S ��e �--� ► S l22��-,Q c� �.-�C� �`' n bs S�t,. � � i U� � r.e s� �-� . �� S �� ; .� � � �r�:�� ,�� , �� 1a.�� . �-�-,� �.�.�. �'� c� � �drr; �e.� ��-'- G � 7 Y�, -� � C �_�^., , � �-�,a -� ��5 ✓�� e ��G,e�.Q �,�- , -��.� S �, l �s 4 _� 1 .� cv �- ��e-�-► �ad�,�w, ex��.,s; � � �' £ _ .�+ q � �,, -� �, �..�Y..Q. ` � �