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A27 117z Person County He� th Department . � Sewage System Improv� m�ents Permit �Tb m rr'�� ' `� �r' Date: ��' �This Permit Void After 5 Y s � �� Owner. � ��*�* , - � + � , SR# Location/Directions: _ ., Subdivision Name: �'fD (l�.i ( ,/lur /-�� /I Lot # � � Lot Size: Type of Dwelling: . Water Supply: Private: Public: Community: f Bedrooms: �— Gazbage Disposal , Basement Basement Fixt • INFORMA N D BY $�1��: w�ner or representative REPAIR: REEV UATION: Size of Septic Tank: -�1�U(�- allons/ Size of Pump Tank: ---- Nitrification Line: Od X 3� Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP P�mp Remarks: Date Well Approved: Well should be 100 ft� from any sewer system -- BY Sanitarian Date Sewage System pproved: 9-3-9/ BY_ ' Sanitarian CERTIFICATE OF COMPLETION Contractor. T.�.Mr.v 1�wZr _ ►-3 ------------------------ �, Sewage System location, installauon, and : protection must meet state and local � regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained � by owner in such manner as not to create a public health_hazard. Septic tank and't3 nitrification line must be inspected and approved by a member of the Person County � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S. 130 A-335F) , �, Location of sewage disposal sewage system sketched on back. VER) �l � �!. �o n� ti lJ � , �''A , �� . � Amount paid Rece•ipt �i � H O � � � w U � a z IGp.ao ' o G � �1 0 V* � Person County Health D�pt 325 S. Morgan Str��t Rox�oro, N.C. 275?� �qurier #02-?3=15 _ G�a4�q� Date rovements Permit.(Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) Imorovements Permit (Mobile Home Replace) mprovements Permit (Addition) Repair/Replace existing Septic System _ Permit for New Well lace Existing Well mit requested by: . %prospective owner/agent: ss: .To►�►�u �- �sfG_ �ha�u� I SQ Q �r � _ ome Phone #: 5 03 - D3la 0 usiness Phone #: S 94' ��Sv Name and address < 1 or��4 d �� ux I qo q � oyo � /Vf Prooertv Descriptio 7. Dimensions�or Propose�cr�cture: Width: '� � h - )� �� Depth: 2 Co' �D' 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? iVo�-� �f current owner: 9. Water supply t}'pe: � T�iorn�w private �public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No �. ;, _ If so, identify location: : Lot size: 2• Sq �• 4. Tax Map#: �1 : 2 7 L,� � Parcel#: / I 7' r �� p�G Township: D��r. �-� . 5. Directions to property: State Road #& Road ames,�tc. .�h.,�u cS i-� C� 1� vr i-�i �� // Number of occupancs or people to be served: �_ of structurelfacility: Proposed: �Existing: Q pe of dwelling: House: ❑ Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes ❑ No 0 Basement? Yes ❑ NoL7 If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'Son County Heal�h 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. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plac of the property to the Health Dept. within GO DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfei[ed. gncc� Ow�%r or Authorized Agent � � Person County Health Oepartment Existing Sewaqe System Report For: Hobile Home Replacement _�A d d i t i o n Gwr�92 � O�c k f' 1 Requestee: ��mmv E�S��MD��n— 1� a M; ra.n�� I.�-�.-e � 01C1�� , n� L z�5� �..—_ �-� �! "-i � n M � ., � Location/Uirections: Original Permit Located � Septic Syste�a Uesigned ror: ltesidential v k3usiness Home Phone# 'JU_ 3�f�0 Businessn 'Pax Hap# � Other (speciEy) # I3edrooms 3 # �mployees Other llate '1'nstalled �-Sr� � Water supply (,� �'�� Type of 5ystem �i�n�1 �� a��\ Nitrification Line �vV\�� Tank size l��P� Certified Operator Required �i� On site uastewater disposal system showes no visually apparent malfunction on � ��q q Yermission is granted to: According to the attached site plan. Environmental Health .$�C.. ��, /Vl��' ��' � � � C DATE 0 �pplicatioa Date:. � 2 6 _ �� Amonn�Paid: 7 5, va Receipt #: °� 3- - C�-# l0�7 � Fmprovement Permit �200.00/�300.04 (if> 600 L Ntobile Home iteplacement or $130.00 {if site visit requin � WeIl Permit (NewlReplacemei �� ,� IL �� `U�l � Tag Map: ��_. Y' �. � � � �� Parcel#: _[�Z_. ]E��,-z�.,�-.,,,,�..�.�.Il 7[�[��.il�. fOI' �8�'V1C�'S C� Constructioa Ant�orizatton lFee is dependent on the e of pair of Existing Septic System Applicatioa: No Chargel CA 5150.00 or $300.00 1} Appiican� Inifor�mafion: Name: Jal�s� �F�,-� �f,�%��' � � zc.rd�� Address: .Q�i �:r : li �. �� u: x�..�_�, � �� u 2)1Yame and address oi cw rent owaer (if different tban �ppIicant): Name: Address: ' r+ Phcne (home): �33L,�`�� " WyLL (worklcell): �'�'�&Z 5"�3�•' L��3� Phone: r.e'�� 223� l'/ fG� Ql 3) �'raperty 33escription: Lot Size: Z• Sr--- Subdivision: Lc�orr�o. �t ��.--- Address and/or directions to Pmperty: L�.., ��.�.t %ix� �, �? y/� yes ❑ no Does the site contain any jurisdictional wetIands? D yes 0 no Does the sita coniain any ex+stinS wastewater systems? ❑ yes � no Is any wastewater goina to be generated on the site other than domestic sewage? ❑ yes � no ?s the site subject to approval by any other public agency? • . t7 yes 0 no Are there any easements or right of tivays on this property? � o� p �4.'��• ('� `yes' is ch�cked, please provide supporting documentation) �: /�_+ L� V�"" �) Proposed iJse and Tyge of �tructure: �Residentia[ ❑ New Single Family Residence Maximum number of bedrooms: � Expansion of Existing System If expansion: Current number of bedmoms: ❑ Repair to Malfuncdoning System WiII there be a basement? ❑ yes C] no �th plumbing fixnues? C! ye� 0 no �Non-Residentiai ' Type of bnsiness: Totai Square footage of Building _,_. Maximum number of empIoyees: Ma�timum number of seats: 5� �Yater SuppIy: Cl New well [� Existing Well I] Community Well D Public Water 0 Sprina Are there any existinD we1Ls, springs, or existing waterlinss on this properly? � yes ❑ no 6) if apglying for `Authoriz�.tion to Canstraci', please inc�icate pre%rred §ysfem type(s). CI Convenrional ❑ Accepted D Innotrarive C1 Alternative 0 Other 0�Y I certify that the information provided above is complete and cof�ec� I also t�tdetstand Ihal if'tYte In.foPmutton provlded is inaccurate, or if the site is subse�ue�eily attered, or the intended zise charcges, all permits and approvals shall be invalid. . � Supporting documentation raquired. s-ZG-I.5' Date Permiis are vaIid for eiitier 60 mantl� or are nnn-expiriug ��en �ccomp�uuied by �► approved plat ,�i cotapleted `�ot Preparation' form must accompany artp applicat�o�. �eQu�ring a site evaluaiiou. ...,,. „„�__ n_.._... �..�,;,...,,*,,,o„+fll APs�lth �7�i 4 ZVlnrssan St_ SuitE C_ Roxboro. NC 27�73 (336-597-1790) ........ ,,.. .__.�_ .__.. .. .. . . . ..... __... ______�.__._-___- -- r ��'., 22-141 i0 Si1FET5 ',^M1+�'•'''� Z2•142 100 SIfEEtS 22•144 200 SNEEiS a � `� � �� . � <_; W � \ � �P f/ y � � �t �-- � � �. �"s. � \_� n /� � _ _�: `�, � � � . � �. �j o -�-.._ -... .' _._ ,.,.... `�--� �� ' 1' ., � � -� c� � � "�� , � �� r n :� ��-�••`'r-_�_h` � % J1i!%.I,� � �_ �j / ♦A�~ �\ J.�--�. � � . '�� k + � l� . ..� � � i � � s � '..., � " .'� ;' /; � \ � o � _I � � �� -�'d-�� I �` � �$ \ { � � � r -- � �� . � c� ��-�o / �� W�J� � �. ._ � / / 6, s � „8 � ' � �t _� .�� o 9 � � � — � -- � � — � T' � �___- � �� i � y Z � � . N h e t l 'S'6 �' ' ' � �h'f� �' -- ------ .-(_'�„Z _,b_�,, Q�_____. __... _ . _ _. _ . s —.,_._ ----�----. . ` . _ _ __ _� ----- - � -��O-S_--�� -_ . , � � s ��.sf ��.�� - � � �� rav�n�c�na�rxa��ra��.Il ��ce,ei.Il�Jia WELL PERMIT (New_ Repair e�) Tax Map: �'% Parcel: // % Subdivision: /�.�� Lot: _� Applicant's Name: ^Tc Mailing Address: � ' ��,��,��_�� -�21�I��a c�. �1C'_ Z�S'Z� 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 expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: ___ Permit issued by: QNew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Certificate of Completion Depth Grout Date: � L�1L,iner: EHS/Date . �' �.7 �d DAbandonment: Date: Method/Materials: ��L„� � � _�� j� � � License #: License #: Date: Additiona! Comments: Date Sample Collected: Date Results Mailed: EHS: Person County Environmental Health �� 325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 11/26/13 \ � `� . �'� ! c�� nc dapartment of healfh and human services �� °�`�� '-�� "��°�"��'�� ' �� _ � 'r � �� Sample ID #: y.7— / For Inorga�ic C�emical Confaminants - 'LG/�, �./ ` � TEST RESULTS AND USE RECOMMENDATIONS 1. 0 Your wel l water meets federal drinking water standards for inorganic cl�e�nicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. 0 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 inor�anic chemica[ results onlv. Arsenic � I Barium I Cadmium I Chromium NitrateMitrite I Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc nH 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level 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 innr�anic cl:emical results onlv. ❑ b. Levels over 30 mg/I 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 federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic 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 � iron Magnesium Man�anese Selenium Silver pH Zinc For nrore information regarding your we!/ water results, please ca!! tlre Nort/e Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3�2 Dst?c�Drve Environmental Sciences Raleigh, NC 27611-8047 htto://slph. ncpublichealth. 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 TERRY 8� JODI LABOMBARD 325 S MORGAN STREET 189 MIRANDA LN ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES100317-0032001 Date Collected: 10/02/17 Time Collected: 11:00 AM Date Received: 10/03/17 Collected By: H Kelly Sample Type: Raw Sampling Point: Well Head Well Permit #: A27-117 Sample Source: Well Temp. at Receipt: 3.5 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifer(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 6 mg/L Chloride Chromium Copper Fluoride I ron Lead Nitrate < 5.00 < 0.01 < 0.05 0 0.58 < 5 1 < 0.03 < 0.0005 < 1.00 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m 10.00 m Nitrite < 0.1 1.00 mg/L pH 7.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium Total Hardness < 5.00 32 20 250 Zinc < 0.05 5.00 Report Date:10/16/2017 Page 1 of 1 Reported By: Deddie .r�toncol � J ! � �a� � �..�� 1J � �.! �. V � � ��a�nson�an�nca��a��o.Il ��Il��a Date: �_/ �/1� Name: Tax Map:�2 Parcel: /� Address: • � Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on /D / Z/� and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: X No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are natura.11y found in tl:e soil. Fecal coliform bacteria are associated with animnal and/or human was�e. The, presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may not be safe for use. Young children, the edderly, and the individuals x�ith compromised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A well that tests positive for total or fecal coliform bacteria shotsld be nroperlv disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Fiealth Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, ✓� Environmental Health Specialist Person County Health Department (rev. 4/20i 16) Person County Environmental Health; 325 S. Morgan St.: Suite C, Raxbora; NC: 27573, Phnne: 336-579-1790; Fax 3?6-59?-780R North Carolina State Laboratory Public Health Environmental Sciences il�icrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES100317-0075001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: TERRY 8� JODI LABOMBARD 189 MIRANDA LN ROXBORO, NC 27574 Collected: 10/02/2017 11:00 Received: 10/03/2017 08:23 Sample Source: Well '` Sampling Point: Well head H Kelly Angela Heybroek Well Permit Number: A27-117 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 10/04/2017 E. coli, Colilert Absent 10/04/2017 Report Date: 10/04/2017 Explanations of Coliform Analysis: Reported By: Susan Beaslev / � '' 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. � ��"�o- � ' GEO-THERMAL WELL .CONSTRUCTION RECORD ��,d �rn..,, �� l � r� � .�ON �ESIDEN�'IAL wELL corrsr�vcTiort x�coRn *� � North Carolina Departinent of Environment and Natural Resources- Division of Water Qualily �`�«;:�;<,�• tiVELL CONTRACTOR C�RTIFICATTOH #{ 7 - �} 9. WELLCONTRACTOR: --��d�� l,J M�i� �s Well Contractor ndividual) Name _ _ Yat�kin Wt�ll C'�� nG_ Well Contraclot Company Name STREET ADDRESS 7 9f1R Ham� fnnvi 1 1 a Rc�ac3 Hamptonville NC 27020 City or Town State Zip Cafe 3L 36 �_ 468-4440 Area Code- Phone number 2. WELL INFORMATIdN: ��` � / /� S{TE WEILIOit(I(applicable) ��r STATE W ELL PERMIT#{it appli�ama) DWQ ar OTHER PERMIT {i(ft applicabie) ��_� �.:i ��`t`'/�� WELL USE (Check Applicable Box) Monftaing p Municlpal/Public q Induslriaf/Commerclal p Agrioullural ❑ Recove`ry p InJeclion Q/ Irrigation❑ Other�'(list use) ��! Guc� .>• l�l''I�C�-t DATE DRILLED ,. —cl � � I TIlNE COMPLETED �n `3d AM ❑ PN�,Q 5. WELL LOCATION• ��n: n� �-�� a-,� COUNTY�C��J4'�'\ -- f � � %'4 v�i.c c� t� �,... (Sveel Name, Numbers, Communtty, Suhdiviston, Lot No., Parcel, Ztp Coda) TOpOGRAPHIC / LAND SE'i71NG: �lope ❑Valisy ❑Fla� pRldge ❑ Olher (check appropda�e box) � IATITUDE 3�a L-�'•� `��+� May bc in degrus, a minutes,seconds or LONGITUDE �, �, B,;L ,� j`.j' In a dceimal format I.atitude/longitude source: rr3uPS ❑Topographic map pocation ot we7musl be shotvn on a USGS topo map and atfached fo fhrs lomt ifno( using GASj 4. FAC1LlTY- ts ttw nama ol the Dvslne:s where Ihe well Is 1oc�ted, FACILITY ID #(if applicable} tJAME �i�/4�6itIYY j CJ�+'v'y L-a ii �+, �s n.� � STREE7ADDRESS _��+? /✓(�.�hn,��4 i� . -;�u y [�'� , /�/.�C/. 2% ) 7S`L Ciry or Town 5tale Zip Codo �ONTACT PERSON�I Etev��1 �-r�Ch j�.ov+i ,�.:,:� MAILING ADDRESS_ C l �i C'F�.� �(+t�- �-�- Dc�,rhu•y. �c:,, 2`t�o1 Ciry or Town State Zip Coda �'u��- _ 3�� - � y�s' Area code - Phona number 5. WEtL OETAILS: a, TOTAL DEP7H: 3:� .Sl b, DOES WEIt REPLACE BXISTING WELL? YES Q NO [] c. WAT�R LEYEL 8elow 7op oi Casing: F'(, {Usa '+• it Above 7op o[ Cas(ng) , �c��ad� D �� ; d. TOP OF CASINO IS F'T, Above Land 5urfaca• '7op of casing terminafed eVor below land sur(ace may require a varlance In accordance witf� 15A NCAC 2C .Ot'18. e. YI�LD (gpmJ: �_ NfETHOD OF TEST f. D(SINFECTION: Type � Amount «,� g. WA7ER ZONES (deplh�: �roml ( � To,, f�_ Fran To From To From 70 From To From To 6. CASIHG: Oepih biametai From ' To Ft. Fran To Ft. From o Ft. 7hlckness/ Welght NSalerial � 7.OROUT: Deplh Matorial Method From �� To � Ft. s�.N /� c{�+*y� From To Ft. —T �rom To Ft. 8. SCREEN: OepYh Diameter SlolSrze Malerlal From To �l. in. En. From To Ft. .� in. In, From 7o Ft. In, in. 9. SANDIGRAVEL. PACK: . Depth • •••- • -• g�Za Materfaf Fran To Ft. From To Ft. From To Ft. ---�_. 'E0. DFtILLIHG LOG From To G -• '7b' -?-:� •' ;��r. �?rJ - 35S 1�, RTf�dQRKS• ` � � v�� ?:.�:r � rl, l � f�� ,� , 1 DO NERESY CERT1Fy 7�iAiT!{IS WEtI WAS CONSTRUC7E0 W ACCORWUtCE WfJH 15A NCAC 2C, W ELL COHSTRUGilON STANOAR�3, AND 7}IAT A COPY OF TWS AECORD BEENPROMDEDTOTHEWELL �� l� 7'� �3�L'!�� 1-9-J� TURE CER7IFIED WELI CONTRACTOR DATH �_T a �:l w �% 1�'1 s � ( � PRINTEa NAME OF PERSON CONS7RUCTING TNE WELL Submit the ariginal to the Dlvision of Water Quafity w(thin 34 days. Attn: Informatlon Mgt,, T617 Maii Servlce Center- Ralslgh, NC 27699•9817 ,�P,Zione No: (919) 733-7015 axt 568. Date site visited: �� ZG , U� by t.a<J�'� pe�� required- Yes No ��-^,l� t,�lt G � /�cu� � �� ' �-��vcr �4 ��-� � ��;,, �- � -� � � ,�,.. � Fam GW1b Rav. 7105 1w��-��-'y fG'�v1u�1 L':v c�n � y .�/l,t! � t � � G��l � ��r�r� -- �'v� ��1 � oi� t z-�:,� �t�r� �� ''� � `� c f� �'�� l-, � l/ - Z 7/.5". � � f �i � � �-� �. ,c-� , 0 " ! �; , _.� �.�.� V Llr ! �� - . .�....�,�we�F16 � � �d�`�"�� q ' GEO-THERMAL WE�L .CONSTRUCTION RECORD ,�n�, ,�� r�'� `�; � 1 Y ON�ESIDENT.If�L WELL COI�ISTRUCTION RECORD � � -� ^'� North Carolina Dcpartmenl of Environment and Natural Resoutccs-Division of WaterQuality •� W+4 �AV� �VBLL CONTRACTOR C�RTIFICATIOId €l � �7�--/� 1. WELLCONTRACTOR: � � �� y �i� 'i�'1�\ � .3 Well Con[ract r Ondhridual) Name . Ya�7kjn WP11 r�� 7nc Wel1 Contraclu Company Name STF2EET ADDR�SS 19nR Hamntnnvi 11 e Rnar� Hamptonville NC � 27020 City w Town State Zip Code 3c 36 �_ 468-4440 Area code- Phone number 2. WELL INFORMATIDN: � ,(�—`��y S{TE W ElL 10 #(I( applleable) { �L � STAFE W ELL PERMIT#(if aPplicable} DWQ or OTHER PERMIT tl(if applicable)�'/-f dS C�� /S� WELL USE (Check Applicable Box) Monftoring ❑ MuniclpaflPublic O fnduslrial/Commerclal ❑ Agricutlura/l p Recovery p Infecl'ron ,p/ Irrigation❑ Other�7'(listuse) C(�J[c� �a� �� 'h�.{'%�� DATE DRILLED 0 ' ��' I { TIME COMPLE7ED �- 3� AM ❑ P1�¢ �. WELL LOCATION}• C�TY: I�.� .J�b:> t'c� COUNTY C��JL "'� --f_�'�I /�/�t,-Lt�C� L�,. (Sveel Name, Numbers, Community, Subdivtslon, Lot No., Parcal,Ztp Code) TOPOGRAPHIC f LAND SE'fTiNG: '�lope pValley ❑Fla� ORldge ❑ Olher (check appropriale box) � LATITU�E 3 � ��vy2 Maybeindegrea, "' — minutec, seconds or LONGITUDE ,Z, � �.2 , � �''f Ina decimal format Latitade/longitude source: p�uPS ❑Topographic map (local'an of we7mus! be shotvn on a USGS lopo map and attached to fhis lorm ifnof usTng GPSj 4. FAC►L�TY• Is the name ol P-0 bvsiness where Ihe Wcll Islotated. FACILITY ID #(if appiicabie} NAME pP-Fit9}EITY 1(�3'j^�/ L..a 1�.,,r++ � nv a STREE7 AODRESS _��7 /✓i�Yon.�iu ��_ �."!! _Yx�►'� �c:.�. �% S ! � City or Tam 5tale Zip Codo �ONTACT PER50N�.rLk ��-'r,Pth l.�ov+i Z,,.:� MAiLING ADDRESS_ G( GI �i�S �'Q►" ST- Oc,�,�h �.:,►,.. � c:, 2� Z a t City ot 7aNn Staie Zip Code ,C , JZl � � 76 �r Area code - Phone number 5. WELL DETAILS: a, TOTALDEPTH: _S:�„� b, DOES WEL� REPLACE EXISTING WELL7 YES ❑ NO � c. wAT�R LEY�L BeloyY7op oi G05f�g: �, (Use '+• if Abova 7op of Casing) , d, TOP OF CASINO IS FT, Above Land 5ur(aca• '7op of casing terminated aVor below land surfece may require a varfance fn accordance with i5A NCAC 2C .0718. e. YIEID (gpm): ��_ N►ETHOD OF TEST f. DISINFEC7�ON: Type HTH Amount �� Ck g. WA7ER ZONES (deplh}; From ra� To l(6 Fran To �rom To From To Fran To From To 6. CASIHG: Thickness/ Depth btameler Welght Maleriai From ' To Ft. From To Ft. From o Ft. 7.OF�OLtT; Dep�h Matorial Method From�� To � FI. t;/�n/ �"«✓h,yi Ftom To Ft. 7 From To Ft. 8. SCREEN: Oepth Diameler Sbl Size Material From To pl. in. (n. Fran To Ft. .� tn. In, From 7o Ft. fn. in. 9. SANOIGRAVEI. PACK: . Deplh . .... . .• Size Material Fran To Ft. From To Ft. From To Ft. i0. DRILLIHG LOG From To D � $c)' �U � . '� 1'1, E3E�IRKS� I DO kEREBY CERT1Fy T}{qT1NI5 W Ell WRS CpNSTRUCTED FI ACCOAWU2CE W fIH 15A NCAC 2C, W ELL C6NSTRUGiION STANOAR0.4,/W D THA7 A COPY OF hG5 RECORD EENPROVIDEOTOTHEWELL04VH — t � �' .� /�-(/ URE 0 ER7IFIED WELL CON7RACTOR DATE � � c�d�I G� � ��✓�/� PRINTED NA E 0 PERSON CONSTRUCTING TNE WELI 5ubmit the original to the Dlvislon of Water Quality wlthln 34 days. Attn: lnformatlon Mgt., 16i7 Matl Sarvlce Centar— Ralelgh, NC 27699•9617 ,�P,�ione No: (919) 733-7Qi5 ext b68. Date site visited: �� ZG, U,� by i��i�� permit required- Yes No , ,� � i,�,, ��•� � �-t�.- � I 't 9 � �'�- �am GW1b Rev. 7l05 h,., •�- � � ��,vrv� �v�en�y �v� �� E��r�-t��f •- �'v�e�h ��oi�t �� '�'� ��1- ��-27/.S" � � �.�� .. �.� �. ��t' Cs+"'h�, � � _ .� , d �� 1'�`� 4. . , � 2 ' � ,_ . . ,� �.--- (�� v �� j S'c� ��